Published on 24 February 2020

DRWF Research Manager Dr Eleanor Kennedy reports from the second day of the 13th International Conference on Advanced Technologies and Treatments for Diabetes in Madrid, Spain.

The second day of the ATTD conference dawns bright and sunny and today there is a full programme of talks and seminars.

I start the day in an area that is an emotive one to many – type 2 diabetes and cognitive decline.

The link between dementia and type 2 diabetes

Cognitive decline is a precursor to dementia and Professor Elizabeth Selvin’s work is based on identifying risk factors for cognitive decline that could perhaps help to identify people to target for early intervention strategies.

Professor Selvin’s research group conducted a study investigating the association of diabetes assessed in middle age with subsequent 20-year cognitive decline in a community-based population of white and black adults.

This long study started with a baseline visit between 1990 and 1992 and looked at cognitive testing at three different time points.

The tests of cognitive function used were:

  • Delayed word recall – to assess verbal learning and recent memory
  • Digit symbol substitution – used to monitor response speed, sustained attention, visual spatial skills and task switching
  • Word fluency test – to assess executive function and language

Professor Selvin’s conclusions were that there were trends in cognitive decline that mapped baseline HbA1c (blood sugar levels) values – the higher the average HbA1c value, the greater the cognitive decline – which could have implications with regards not just to diabetes prevention but also to glycaemic control.

Elderly person with a jigsaw.

Poor blood sugar control linked to decline in brain health

In a follow-up study to this, in older patients aged between 66 and 90 years of age, diabetes, poor glycaemic control and a longer duration of diabetes were associated with incident cognitive impairment.

Finally, Professor Selvin reported on the long-term neurological consequences of severe hypoglycaemia (low blood sugar levels) in people with type 2 diabetes.

Professor Selvin’s research group found that severe hypoglycaemia was associated with smaller total and frontal brain volume and that severe hypoglycaemia was strongly associated with prevalent and incident dementia leading her to conclude that assessment of cognitive function is important in older adults especially those with a history of hypoglycaemia.

My next stop was a varied session on emerging therapies for type 2 diabetes. It wasn’t one that I was expecting to be busy given a parallel track on decision support systems in diabetes running in the next-door auditorium. However, I am pleasantly surprised. It is full to the brim and there is standing room only.

Treatment recommendations for people living with type 2 diabetes

There was much debate around the new guidelines coming from several clinical associations around the world and their recommendations to start dual or even triple therapy at a much earlier stage. It is well known that people with type 2 diabetes will usually move onto just metformin as and when their initial dietary and lifestyle management fails.

But what if this initial therapy with metformin also included one of the newer classes of drugs that are proving to be so effective in clinical trials namely SGLT-2 inhibitors or GLP-1 receptor agonists? Could this simultaneously improve glycaemic control and decrease clinical inertia?

This latter issue is just that. It’s an issue and a huge one for healthcare professionals and patients alike – the move from one therapy to more than one is often met with resistance.

Resistance to prescribe and resistance to comply with treatment. Maybe by prescribing more than one drug at an earlier stage could overcome these barriers and any potential side effects should not be increased as combined doses may be lower than for each individual component alone.

An empty hospital bed.

Complications of diabetes on the rise

The session ended on a less positive note – a much quoted recent paper on the resurgence of the complications of diabetes.

For many years, the incidence of all the complications related to diabetes, including eye disease and cardiovascular disease, has been decreasing. But no more.

For a number of hotly debated reasons, the rates of these complications are now on the increase and, of course, the question that everyone is asking is why?

And the conclusion was interesting.

Improvements need to be made, of course.

  • Registries need to be more robust.
  • Case management needs to be better.
  • Innovations are desperately needed particularly to reach underrepresented minorities. And, arguably, a shift in focus away from HbA1c to time in range.

But, whilst all of this debate rages, it’s important to recognise that mortality in people with diabetes is also diversifying.

Quality indicators and intervention strategies need to focus on areas where people with diabetes are dying. And it’s not all in areas that you might have, at first, thought – sepsis sometimes caused by chemotherapy, flu, liver disease and amputations are now all leading causes of death.

So, by focussing all our efforts on one area and firefighting on a narrow range of complications, have we left the door open to other causes of death to sneak up on the diabetes community?

It is a sobering thought to end Day Two with.

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