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Type 2 diabetes in young people puts their eyes at risk

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Sixteen-year-old Karl is seen for the first time in my optometry practice. He was referred to me for a fluctuating vision problem. During his examination, I saw signs suggesting he may have diabetes, which could have explained the fluctuating vision. This suspicion became a reality when his family doctor confirmed the diagnosis. Karl’s world was turned upside down.

As an optometrist, I invite you to dive into a reality that should concern us all.

What is diabetes?

Diabetes is an insidious disease. Its symptoms (thirst, need to urinate often, fatigue, weight loss, darker skin areas on the neck and underarms) often go unnoticed, at least in the early stages of the disease.

Diabetes affects the lives of one in 14 people in Canada (7 per cent) and one in 10 in North America (10 per cent).

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Two types of diabetes can be diagnosed:

  • Type 1, which is insulin-dependent and develops when the body cannot produce the insulin needed to metabolize the sugars we ingest and which feed our tissues
  • Type 2, which develops when insulin is produced, but in insufficient quantities. Sometimes the insulin that is produced is ineffective in doing its job.

Type 1 diabetes is usually associated with the development of the disease in childhood and adolescence. Type 2, the most common, usually develops later in life, often after age 50.

A counter-intuitive diagnosis, but not a rare one

From this definition, it would have been logical to conclude that Karl was affected by Type 1 diabetes, the course and treatment of which are well controlled by physicians. However, in his case, and after the required testing, his doctor identified Type 2 diabetes. This diagnosis is counter-intuitive and poses significant challenges. The speed of onset, the initial severity of the disease and the mechanisms of resistance, or of reduced insulin secretion, may be different in patients who develop the disease at a younger age than in adults.

In addition, treatment options, involving trial and error, become more complex due to the much longer duration of this type of disease when it starts at a young age. Both major and minor changes that affect the blood vessels in the Type 2 diabetic patient can have serious consequences that are difficult to predict since the course of treatment can continue for 40 to 60 years.

However, Karl’s situation is not exceptional. More and more young people and adolescents, especially those who are overweight, obese, and sedentary, are affected by Type 2. Almost 75 per cent of them have parents or siblings with diabetes.

While at first sight, this confirms genetics as a risk factor for developing the disease, in this specific case, it was more a consequence of poor lifestyle habits, especially dietary habits, and lack of physical activity, which are often shared by the whole family.

Impact on vision

The fact that Karl developed Type 2 diabetes earlier, rather than later in life also puts him at a higher risk of developing eye complications. An article about this topic recently caught my attention. This study looked at the records of 1,362 people with diabetes living in Minnesota, so, in North America and then extrapolate to Canada. The data was compiled between 1970 and 2019, which also allows us to measure the evolution of the situation over the last decades.

The results are astonishing: young people with Type 2 diabetes (compared to Type 1 diabetics of the same age) are 88 times more likely to develop retinopathy (abnormal blood vessels and/or hemorrhages in the retina). In addition, the risk of this retinopathy becoming “proliferative,” and therefore threatening to vision, is increased 230 times. There is also a 49-fold increase in the risk of fluid accumulation in the retina (macular edema) and a 243-fold increase in the risk of developing a mature cataract at a young age. The latter requires surgery which is riskier in young people than in the case of age-related senile cataracts.

 

Vascular and metabolic complications of diabetes visible on the fundus (hemorrhages, exudates).
(Langis Michaud), Fourni par l’auteur

What should we remember from this? That the major problems, which often require surgical interventions to save vision, occur much more rapidly in young Type 2 diabetics than in those affected by Type 1. These patients must therefore be followed more closely. Indeed, almost one in two Type 2 patients will develop some form of retinopathy within one to eight years of diagnosis. In comparison, one in three Type 1 diabetics will develop retinopathy between six and 10 years following diagnosis.

Significant repercussions

Already having increased significantly in the last 10 years, the prevalence (number of cases) of Type 2 diabetes in young people is predicted to quadruple by 2050. This prediction is most alarming for health professionals, but also for policymakers and managers of public health agencies. The lifetime cost of direct medical care for a single diabetic patient aged 25-44 years was US$125,000 in 2013. These costs have since increased and many more dollars need to be added to cover the period between 15 and 25 years, which is not taken into account. Indeed, if 20 per cent of the youth population develops diabetes by 2050, millions (perhaps billions?) of health-care dollars will have to be spent on their care by our governments.

The long-term quality of life of people with diabetes is also reduced. Another study, this time of young people with Type 1 diabetes, shows that their disease has a negative impact on their life. They have to devote a lot of time to their care (missing activities with their friends). And the burden of their disease on their relatives weighs heavily on their shoulders. The fear of hypoglycemia (lack of sugar that can lead to coma) or of developing serious complications of the disease also affects them. Achieving autonomy is more difficult for these adolescents, and their quality of life is proportional to the freedom they can or cannot exercise.

Eat well, exercise and visit your optometrist

Type 1 diabetes is difficult to prevent, mainly because we don’t know all the reasons why it occurs and to proactively screen for it. The situation is different for Type 2 diabetes, which is strongly associated with unhealthy lifestyle in young people. Eating a healthy diet, exercising regularly, and combating sedentary lifestyles, including limiting screen leisure time (to less than two hours per day), are good ways to avoid or delay the onset of diabetes in young people. Screen time is also associated with insulin resistance and obesity in young people. In other words, healthy lifestyles must be encouraged and especially shared within the family unit.

young children ride bikes

 

Healthy habits are good ways to avoid or delay the onset of diabetes in young people.
(Shutterstock)

As far as eyes are concerned, regular visits to the optometrist or ophthalmologist can detect early signs of diabetic complications (signs are seen in up to 30 per cent of patients shortly after diagnosis). These health professionals can also detect other oculo-visual problems arising from the disease, such as loss of ability to focus up close (accommodation), partial paralysis of certain muscles of the eye resulting in double vision, delayed healing of surface corneal changes, dry eye or glaucoma. Testing should be done at the time of medical diagnosis of diabetes, or in anyone with a high-risk profile (heredity, obesity, sedentary lifestyle).

Since healthy lifestyle habits are an integral part of the treatment of the disease, it is not too late for Karl to enjoy a happier future. But it is important not to neglect regular follow-ups by his medical doctor and frequent visits to his family optometrist.

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ER closure for Seaforth’s emergency department due to COVID-19 outbreak

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Starting on Feb. 1, Seaforth’s emergency department will be closed in the overnight hours.

The Huron Perth Healthcare Alliance said due to “sudden health human resource shortages related to COVID-19,” the Seaforth Community Hospital’s emergency department will be closed from 5 p.m. to 7 a.m., from Feb. 1st to Feb. 6, when regular hours are expected to resume.

On Jan. 28, a COVID-19 outbreak was declared in Seaforth’s inpatient unit, closing all admissions to the unit. On Tuesday, a COVID-19 outbreak was declared at the Clinton General Hospital’s inpatient unit, also closing it to admissions.

In total, 10 people are in Huron-Perth hospitals dealing with COVID-19.

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Two long-term care homes in the region are also dealing with COVID-19 outbreaks at the moment. Since Jan. 1, eight Huron-Perth residents, most of them over the age of 75, have died due to COVID-19, according to the Huron Perth Health Unit.

“I extend my condolences to the loved ones of these individuals,” said Dr. Miriam Klassen, medical officer of health for the Huron Perth Health Unit.

She added, “COVID-19 remains a serious illness for some people, especially those who are older. While we are seeing signs of improvement, it is important to keep taking actions to protect those who are most vulnerable to severe outcomes from this virus.”

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GLP-1 Agonists Protected Kidneys in T2D With Advanced DKD

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Researchers published the study covered in this summary on Research Square as a preprint that has not yet been peer reviewed.

Key Takeaways

  • In patients with advanced diabetic kidney disease (DKD; estimated glomerular filtration rate [eGFR] < 30 mL/min/1.73m2), treatment with a glucagon-like peptide-1 (GLP-1) agonist had a neutral effect on cardiovascular outcomes but significantly linked with preservation of kidney function and improved survival in a propensity-score matched, retrospective analysis of observational data from more than 2000 people with type 2 diabetes in Taiwan.

Why This Matters

  • Cardiovascular disease is a leading cause of mortality in people with type 2 diabetes and among those with chronic kidney disease.
  • GLP-1 agonists reduce all-cause mortality and cardiovascular death in people with type 2 diabetes, but their role in patients with advanced DKD is controversial.
  • Research on the effect of GLP-1 agonists on cardiovascular outcomes in patients with advanced DKD is limited. Trials that have assessed GLP-1 agonists in people with type 2 diabetes have generally excluded those with advanced DKD and completely excluded those with end-stage kidney disease (eGFR < 30 mL/min/1.73m2).
  • Treatment with GLP-1 agonists has been associated with a significant reduction in composite cardiovascular outcomes in people with type 2 diabetes and relatively fair kidney function (eGFR > 30 mL/min/1.73m2), but among people with type 2 diabetes and lower levels of kidney function, research has shown neutral composite cardiovascular outcomes levels. However, limitations of previous studies include being mainly based on subgroup analysis or including a limited sample of patients.

Study Design

  • Retrospective analysis of observational data from nearly 9000 people in Taiwan with type 2 diabetes and an eGFR < 30 mL/min/1.73m2 who received a first prescription for a GLP-1 agonist or dipeptidyl peptidase 4 (DPP-4) inhibitor in 2012-2021 and had the data necessary for this analysis in their records.
  • The data came from the largest multi-institutional electronic medical record database in Taiwan, which includes two medical centers and five general hospitals and information on more than 11 million patients, from 2001 to 2019.
  • Researchers used propensity scoring to match 602 people treated with a GLP-1 agonist with 1479 people treated with a DPP-4 inhibitor.

Key Results

  • During a mean follow-up of 2.1 years, the rate of the composite cardiovascular outcome (cardiovascular death, myocardial infarction, and ischemic stroke) did not significantly differ between the GLP-1 agonist and DPP-4 inhibitor groups, with incidence rates of 13.0% and 13.8%, respectively, and a nonsignificant hazard ratio of 0.88. Rates of each of the three components of the composite endpoint also did not significantly differ between the two groups.
  • Progression to end-stage kidney disease with dialysis was significantly lower in those treated with a GLP-1 agonist compared with a DPP-4 inhibitor, with incidence rates of 23.4% and 27.5%, respectively, and a significant hazard ratio of 0.72.
  • The incidence of a greater than 50% drop in eGFR from baseline was 32.2% with GLP-1 agonist treatment compared to 35.9% with a DPP-4 inhibitor, with a significant hazard ratio of 0.74.
  • Median time until patients needed new-onset dialysis was 1.9 years with GLP-1 agonist treatment and 1.3 years with DPP-4 inhibitor treatment, which was a significant difference.
  • The rate of all-cause death was 18.4% with GLP-1 agonist treatment compared with 25.1% with DPP-4 inhibitor treatment, a hazard ratio of 0.71 that was significant.

Limitations

  • Because the study was a retrospective analysis of observational data it cannot prove causality.
  • The study could be subject to residual confounding despite propensity-score matching.
  • The data came from health records that could have included coding errors.
  • Treatment compliance was unknown.

Disclosures

This is a summary of a preprint research study, “The cardiovascular and renal effects of glucagon-like peptide 1 receptor agonists in patients with advanced diabetic kidney disease,” by researchers in Taiwan on Research Square and provided to you by Medscape. This study has not yet been peer reviewed. The full text of the study can be found on researchsquare.com.

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Research by UBC professor lays groundwork for life-saving breast cancer treatment

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A drug originally designed to prevent osteoporosis is now expected to save and improve the lives of millions of people with breast cancer, thanks in part to decades of foundational research by Dr. Josef Penninger, a professor in UBC’s Faculty of Medicine and director of the Life Sciences Institute.

The achievement highlights how UBC scientists are developing effective new treatments — and unlocking the full potential of existing drugs – through research into the fundamental biological principles behind disease. By advancing scientific discoveries from the lab to the clinic, UBC researchers are bringing life-changing treatments to patients everywhere.

The drug, called Denosumab, was recently shown in a long-term Phase 3 clinical trial to improve survival among postmenopausal women with hormone receptor-positive early breast cancer receiving aromatase inhibitor treatment. Moreover, the drug markedly improved patients’ quality of life by reducing broken bones by 50 per cent, a common side effect of breast cancer treatment. The results of the trial were recently reported in The New England Journal of Medicine.

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Denosumab is a monoclonal antibody developed by American biopharmaceutical company Amgen to prevent bone loss. In the early 2000s, research by Dr. Penninger and his team revealed the therapeutic potential of Denosumab, as well as the drug’s surprising connections with breast cancer.

“More than two decades ago we started the experimental groundwork that revealed Donosumab’s potential as a treatment for breast cancer patients,” says Dr. Penninger. “These results are incredibly exciting and will help improve the lives of millions of patients. I am very proud of all the people in my lab over the years who did that work and helped pave the way for this achievement.”

Discovering the link between osteoporosis and breast cancer

Denosumab works by binding to and inhibiting the activity of a protein called RANKL, which plays a key role in bone-resorbing cells called osteoclasts. By blocking RANKL, denosumab reduces the activity of osteoclasts and slows down bone resorption, helping to increase bone density and preventing osteoporosis.

Dr. Josef Penninger

Dr. Josef Penninger

Dr. Penninger and his team began to draw the connection between osteoporosis and HR-positive breast cancer when they generated the first RANKL “knock-out” mice in the late 1990s.

A knockout mouse is a laboratory mouse that has been genetically engineered to have certain genes deactivated, or “knocked-out”. Dr. Penninger’s team engineered mice that lacked the genes necessary to produce the RANKL protein in an effort to study the protein’s essential function in bone metabolism.

However, to the researchers’ surprise, they discovered that the RANKL-deficient mice failed to develop a lactating mammary gland in pregnancy – a process that depends on sex hormones.

“This proved an evolutionary link: showing how bone loss is regulated by sex hormones, and how pregnant mammals activate RANKL to form breast tissue for lactation among other functions,” says Dr. Penninger.

Based on this initial finding, Dr. Penninger’s team went on to show that RANKL played a key role in progestin-driven breast cancer, as well as breast cancer driven by BRCA1 mutations.

“Further researcher revealed how RANKL controls the stem cells in the breast that respond to sex hormones and thereby drives growth of the breast tissue at every menstruation cycle and in particular in pregnancy and lactation,” adds Dr. Penninger.

In the case of breast cancer, RANKL spurs mammary epithelial cells to divide, and helps to maintain the stem cells that give rise to breast tumours.

A dual benefit drug

One in eight Canadian women will be diagnosed with breast cancer in their lifetime according to the Canadian Breast Cancer Network. An estimated 70 to 80 per cent of these breast cancers are hormone receptor-positive (HR-positive), making it the most prevalent breast cancer subtype.

The current standard treatment for HR-positive breast cancer involves surgery and radiation, followed by treatment with aromatase inhibitors for 5 to 7 years. While aromatase inhibitors diminish sex hormones that drive new cancer growth, they can have serious adverse effects on bone health, including increased risk of osteoporosis and fractures.

The now-published clinical trial, led by the Austrian Breast and Colorectal Cancer Study Group, was conducted to see if Denosumab could help in two ways: by reducing these negative effects on bone health, while also improving breast cancer survival outcomes.

“These results are incredibly exciting and will help improve the lives of millions of patients.”
Dr. Josef Penninger

The results reveal that 6 mg of Denosumab every six months — the recommended treatment level for osteoporosis — improved disease-free survival, bone metastasis-free survival, and overall survival among participants. It also effectively reduced bone fractures over the long term.

“Blocking RANKL in breast cancer patients reduces broken bones by 50 per cent, massively improving their quality of life, and even at a very low treatment dose,” says Dr. Penninger. “We now know that RANKL drives breast cancer cell growth, is the critical mechanism behind bone loss, and has also an effect on anti-cancer immunity and immunological rewiring in pregnancy. These clinical results in patients show how blocking RANKL could save the lives of 50,000 women among one million women with the diagnosis of breast cancer.”

Based on the data, the researchers behind the trials are recommending that Denosumab be considered for routine clinical use in postmenopausal breast cancer patients receiving aromatase inhibitor therapy.

These trials were largely based on the foundational research published by the Penninger laboratory, including Kong et al. Nature 1999, Fata et al. Cell 2000, Jones Nature 2006, Schramek et al. Nature 2010, Sigl et al. Cell Research 2016, and Paolino et al. Nature 2021.

Dr. Penninger is now part of a large international prevention trial evaluating Denosumab in young women who carry BRCA1 mutations.

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