By: Jessica Cook MS RD LD CDE (Director of Education)
Fall is in the air and nothing can compare to the amazing produce it brings. This season offers fresh apples, kale, Brussels sprouts, cauliflower, spinach, potatoes, acorn squash and everyone’s favorite, pumpkins! Pumpkins have such a great reputation to provide health and wellness, plus are much lower in carbohydrates than sweet potatoes! Here are a few reasons to indulge in pumpkin:
*Try substituting pure canned pumpkin for butter or oil in recipes when baking to help lower fat content and boost vitamins as well as minerals!
Please enjoy this month’s Living Well with Diabetes Newsletter and take full advantage of everything fall has to offer!
By Gary M. Pepper, M.D.
The following is the opinion of the author. Only you and your own doctor can decide which medications are best for you.
Numerous new diabetes medications have become available over the past few
years raising questions for consumers regarding their effectiveness, cost
and side effects. These
medications include three new classes of medication referred to as GLP-1 analogs, DPP-4 inhibitors and most recently SGLT-2 inhibitors. The focus of this discussion will be the most widely prescribed of the newcomers, the DPP-4 inhibitors.
The first thing consumers will notice about these new diabetes medications are their TV friendly names, Januvia, Onglyza, Tradjenta, and Nesina. Mix these newcomer drugs together into a single pill with the venerable low cost generic metformin and the names becomes Janumet, Kombiglyze, Jentadueto, and Kazano.
The next thing a consumer will notice is the price tag. At the local pharmacy in Jupiter, Florida the retail price of a 3 month supply of Januvia, Onglyza or Tradjenta are all about $1100. A three month supply of the established generic drug, glipizide, is $9.99 and metformin is between zero and $41.
The new drugs are produced by the biggest names in the pharmaceutical industry including Merck, Bristol-Myers Squibb, Lilly, AstraZeneca, Boehringer Ingelheim and Takeda. The growth of these medications has been impressive with the percentage of diabetics receiving treatment with the new drugs rising rapidly. Data Monitor, a company tracking pharmaceutical trends reported in 2014 that DPP4 drugs now dominate the diabetes care market with 40% of sales in dollars, (http://www.datamonitorhealthcare.com/files/2014/07/Sample-package-Type-2-Diabetes-Forecast-3.7.2014.pdf), with Januvia leading the pack.
The effectiveness of this new drug class has been examined. The primary measurement of the effectiveness of diabetes medications is their ability to reduce the 90 day average of a person’s blood sugar known as the glycohemoglobin A1c measurement. A glycoA1c of 7% or less is considered the healthy goal although a level of less than 8% is now being advocated for those over 65 years of age. After more than 40 years of observations and numerous scientific studies the glycoA1c lowering achieved with metformin and sulfonylureas is recognized to be about 1.5% and even greater under certain conditions. DPP-4 inhibitors lower A1c by 0.4 to 0.7% in most studies.
In Europe, the German equivalent of the FDA reviewed the DPP-4 drugs and referred to a “minor” but “unproven” benefit of the DPP-4 agents over the established generics. (http://www.epgonline.org/news/2013/oct/galvus-novartis-fails-german-g-bareview.cfm#sthash.RyIuup4t.dpuf) . Studies organized by the pharmaceutical industry appear to show equal or superior glucose lowering ability of their products over the established generics, but in 2012 the WHO declared available studies showed evidence of “serious” bias. (http://www.who.int/selection_medicines/committees/expert/19/applications/Oralhypoglycemics_18_5_A_R.pdf).
Finally, the issue of medication safety needs to be addressed. When looking
for indications of side effects due to a medication, newer medications
have an obvious advantage since the appearance of negative outcomes may
take years to be recognized. A recent example of this is the diabetes
drug Avandia which was approved in 1999 but withdrawn in 2010 when
cardiovascular safety concerns surfaced. Januvia was the first of the DPP-4’s to reach the public and has been available since 2006 and the latest drug Nesina, since 2013. In contrast metformin has been prescribed in the U.S. since the 1970’s and sulfonylureas since the 1950’s with the newest agents of this class approved in the 1990’s.
The package inserts of the DPP-4 inhibitors note that these medications can cause an inflammation of the pancreas known as pancreatitis. Since diabetics have a higher incidence of pancreatitis the true incidence of drug related pancreatic inflammation is hard to determine. An increase in hospital admissions for congestive heart failure (fluid on the lungs) with DPP-4 medications has been reported. At present the evidence for this is still being evaluated. Growing experience suggests that, as a class, the DPP-4 inhibitors are well tolerated by most people. Additionally, they don’t cause weight gain or low blood sugar (hypoglycemia) as some other diabetic medications do.
Metformin causes frequent but relatively minor gastrointestinal side effects which may limit its use in susceptible individuals. An extremely rare but potentially fatal complication of the drug is lactic acidosis but it is thought that only those with significant kidney or liver disease are susceptible to this. Sulfonylureas can cause weight gain, low blood sugar, and there is some evidence indicating an increase in cardiovascular death with earlier generations of this class but this last and most serious side effect is still debated. Critics of sulfonylureas refer to a possible “burning out” of the insulin production of the pancreas caused by these drugs but scientific evidence of this is lacking. Because these drugs work by very effectively increasing insulin production by the pancreas there is a risk of hypoglycemia if a diabetic takes this medication and fails to eat or takes too strong of a dose. The treating physician must know their patient before prescribing any medication, and individuals who cannot care for themselves properly or who have significant kidney or liver disease are not a good candidate for sulfonylureas due to their potency.
Finally, it must be acknowledged that most Type 2 diabetics will go on to require insulin due to the natural history of the disease resulting in complete loss of insulin production by the pancreas. Of all the treatments, insulin causes the most weight gain and hypoglycemia but is the fail safe choice and extremely effective when used properly. We are fortunate to have so many choices for treating diabetes. It is universally recommended that those with diabetes work closely with their own physicians to find the most effective, practical, affordable and safe approach to their disease.
By: Gail Starr LCSW, CDE
What did one person with diabetes day to the other?
You sure are sweet!!!
It’s good to have a sense of humor about most things, diabetes included,
but out of control blood sugar is no laughing matter. October represents
the beginning of the season that heralds in all
kinds of “tempting” celebrations, such as Thanksgiving, Chanukah, Christmas, Kwanza, and The New Year. Many holidays close together make for loads of fun, but at times can seem overwhelming to the person who is trying to be in control.
Several factors at this time of year can affect blood sugars. One of them is having enough time to do all the things that need to be done. Shopping, cooking, packing of presents, decorating houses, writing cards or sending E-cards may all affect schedules. There may not be enough time to take care of oneself by perhaps not eating appropriately, or not making time for physical activity, or by being “tempted” by the various foods that will help create the festivities of the holiday season. Stress levels may be high also, and stress also may cause blood sugars to rise.
Since this is the month of Halloween, let’s focus on the trick or treating that occurs. We want to hear the laughter of children when they come to our homes and as they get their treats. However, that means that our pantries will be filled with the myriad bags of candies that are on sale and advertised by the various venders. “Good excuse,” the mind says, “for having candy in the house.” Of course it is! But what happens when fewer children come knock on our doors? What happens to the bags of candy that are left over. The mind, the incredible controller of what we think and do, says, “We can’t waste it, can’t throw it away.”
So we have a quandary – what can we do? Can you believe that we have options? Well, we do!!!! First of all, find the adult part of the mind and balance the inner child. Let the adult part use the word “moderation” in its internal conversations. Secondly, give the candy away, as quickly as you can, because if it’s in your refrigerator, kitchen cabinets or hidden in the back of the closet it will call to you until resistance is futile. Who to give it to? Try the police and fire departments, senior residences, Children’s Shelters, or you can try returning unopened bags to the store in which they were purchased. Thirdly, instead of buying candy to give away, give the trick or treaters some coins. Everyone loves money!
There are always options. It’s a question of choosing the option that is the one that will allow Halloween, and all the other holidays of the season, to be enjoyed healthfully for many years to come!
At Healthy Living with Diabetes we want to ensure that you are satisfied with all services received. We also would like your input on educational workshops that you would like us to offer, information you would like to read about in Healthy Living with Diabetes Monthly or feedback on any workshop that you may have attended.
You can contact the director of education personally by email jcook@PBDES.COM or leave a message at (561) 513-5100. We would love to hear from you!