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VOLUME 10 NUMBER 3 • SEPTEMBER 2013
ADA WATCH
SA JOURNAL OF DIABETES & VASCULAR DISEASE
positive metabolic consequences, includ-
ing a decrease in numbers of white blood
cells, neutrophils and lymphocytes, and
HbA
1c
levels. Another target is the nuclear
factor kappa-B, or NF-kB, a pathway that
acts as a master regulator of inflammatory
signalling in both adipose tissue and skel-
etal muscle. Pharmacological intervention
in this pathway appears to have beneficial
effects on the metabolism and inflamma-
tion.
Targeting glucose absorption and
excretion
One of the approaches to targeting glucose
absorption and excretion is to enhance the
activity of sodium glucose co-transporter
2 (SGLT-2) in order to boost renal glucose
excretion. Dapagliflozin and canagliflozin
have been approved for use by the Federal
Drug Administration, and positive phase
3 data on empagliflozin were presented
at the meeting. These agents can be
used with other antiglycaemics but safety
questions remain.
Look AHEAD: lifestyle intervention
in type 2 diabetes offers microvas-
cular benefit but does not lower
risk of cardiovascular disease
Look AHEAD (Action for Health in Diabetes)
is the longest and largest randomised,
controlled trial to examine the effects of an
intensive lifestyle-intervention programme
in overweight and obese participants with
type 2 diabetes. Investigators presented
11-year results of lifestyle interventions
designed to achieve at least a 7% weight
loss, and increase physical activity to 175
minutes per week, implemented through
group and individual sessions.
In terms of cardiovascular effects of
intensive lifestyle interventions in type 2
diabetes, the trial was stopped for futility
reasons after a median follow up of 9.6
years. The primary outcome was a com-
posite of death from cardiovascular causes,
non-fatal myocardial infarction, non-fatal
stroke, or hospitalisation for angina during
follow up.
An intensive lifestyle intervention focus-
ing on weight loss did not reduce the rate
of cardiovascular events in the study popu-
lation. However, it did show benefit of a
31% reduction in the risk of advanced
kidney disease and a 14% reduction in the
risk of diabetic retinopathy. Also of note
was a 20% reduction in new incidence of
depression in the intensive lifestyle-inter-
vention arm.
Improvements in fitness levels saw
improvements in other markers of meta-
bolic risk, such as HbA
1c
levels and systolic
blood pressure. LDL cholesterol levels were
not improved with the intensive lifestyle-
intervention programme.
The Look AHEAD research group. Cardiovascular effects
of intensive lifestyle intervention in type 2 diabetes.
N
Engl J Med
2013;
369
: 145–154.
/ 806816?t=1
Exercise may be the best medicine
for diabetes patients
Dr Samuel Dagogo-Black, professor
and director of Endocrinology, Diabetes
and Metabolism at the University of
Tennessee Health Science Centre, said
‘A preponderance of evidence mandates
lifestyle change, principally exercise and
diet, as the pre-eminent and primary
consideration for any and all purposes
where the goal is to improve insulin
sensitivity, reduce obesity and prevent
diabetes. The vast majority of overweight
people who are insulin resistant will benefit
greatly from a 5 to 10% weight loss.’
Dr Dagogo-Black is also of the opinion
that there are very limited roles for drugs
and surgery. ‘Pharmacotherapy can help a
very select cohort of patients who fail to
respond to exercise and dietary changes,
whereas bariatric surgery is appropriate for
an even smaller and targeted cohort’.
Dr Barry Braun, associate professor
of Kinesiology at the University of Mas-
sachusetts, stated that insulin sensitivity
is improved dramatically by a single exer-
cise session, and even more by a three-
month training programme. Research into
the effects of exercise and metformin in
patients with pre-diabetes indicate that
while exercise plus metformin is not better
than exercise alone, the combination is
better than metformin alone.
Dr Paul Coen, assistant professor of
Health and Physical Activity at the Univer-
sity of Pittsburgh, says that exercise pro-
vides additional benefits to cardiometabolic
risk following bariatric surgery. Experts rec-
ommend 150 minutes of aerobic exercise a
week; however any amount of exercise is
better than none.
New perspectives on type 2 diabe-
tes risk factors
Epidemiological research continues to
uncover a growing list of novel risk fac-
tors that include environmental elements.
Metals, plasticisers and air pollution are
not typically considered risk factors for type
2 diabetes; however recent research sug-
gests they should be. Epidemiological data
have implicated environmental exposure
to arsenic and phthalates, both common
compounds used as plasticisers across the
globe, as risk factors for the development
of type 2 diabetes.
