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Daily News: Disease

Study to look at depression-diabetes link


Dominion Post (Morgantown, WV)

11-25-13

Nov. 24--Diabetes research, treatment and prevention surge forward every year.

Charles Ponte, professor of Clinical Pharmacy and Family Medicine at WVU, talked to The Dominion Post about advances in medications -- but made an important point about all the efforts by researchers, providers and educators.

"The adage that it takes a village -- it does," he said. "The most important person is not the provider, it's not necessarily the service that's provided. It's the patient. If we collectively can't get you to buy into your own self-care," none of the educational programs or other outreach matters.

"You might as well take it all and flush it down the toilet. If I can't get you to buy into your self-care, everything I do is for naught."

One of the biggest obstacles to self-care is depression, said Guy Hornsby, associated chairman of WVU's Department of Exercise Physiology. Having diabetes doubles a person's chances of becoming depressed, and 1 in 4 patients with diabetes is depressed.

It can become a vicious cycle, Hornsby said.

"If the person is depressed and they're sad and they can't function properly, they can't take care of their disease," he said. Diabetes requires daily management of diet, exercise and medication. The patient must make regular doctor visits. It can be overwhelming, and feed the depression.

Hornsby and the WVU Human Performance Lab are part of a team working in three states to study and treat diabetes patients with depression. WVU is into its third year of a five-year study. "We are trying to look at what is the best way to care for people who have depression and diabetes, and that's a lot of people," he said.

Their project is called Program ACTIVE (Appalachians Coming Together to Increase Vital Exercise). Eligible volunteers are placed in one of four groups: Exercise therapy, cognitive behavior therapy (talk therapy), exercise plus talk, and "usual care."

It's proven that exercise and talk therapy can help depression, he said, and the idea of the study is to see if the combination gives better results for the depression and management of the diabetes.

Hornsby said it's well known that depression increases a person's chances of heart trouble. A depressed person who suffers a heart attack has a reduced chance of survival. Heart disease is the biggest killer of people with diabetes.

Potential participants are screened to see if they have symptoms of major depressive disorder, Hornsby said, if they're healthy enough for the moderate exercise program, if they've had Type 2 diabetes for at least a year and haven't had a heart attack in the past two years.

The program runs for 12 weeks, with follow ups at six months and one year. All treatment is free during the 12-week period, and participants in the exercise portions receive a gym membership.

Hornsby said the project began with a pilot at Ohio University. Two-thirds of the initial 50 subjects became free of symptoms of a major depressive disorder. A site in Indianapolis just launched a program.

WVU is seeking more volunteers, and needs 26 more people to fill its study slots.

Once the study is complete, he said, and the results are in, researchers hope other treatment centers will join the bandwagon.

Along with the benefits to patients, he said, insurers may find the financial motivation to cover exercise therapy -- something most don't do now. The program could wean patients off expensive medications and reduce complications, saving the insurers and patients money.

"Diabetes is the most expensive disease in the c o u n t r y, " Hornsby said. One of every five health care dollars goes toward diabetes treatment. "Yo u would save everyone a lot of money. I think it would be cost effective."

Hornsby is a medal-winning weightlifter who also has Type 1 diabetes and has earned a bronze medal from the Joslin Diabetes Center, in Boston, for successfully managing the disease for more than 50 years. When he was diagnosed, in the mid-1960s, he said, his projected life expectancy was 25 years.

The Joslin Medalist Program, Joslin said, began in 1948, with a 25-year victory medal. As science advanced and people began living longer, it upgraded to a 50-year medal: 2,905 people have received one. In 1996, it awarded its first 75-year gold medal and has given out more than 720 since.

Diabetes medications

Ponte said 1995 was a pivotal year for treating diabetes through medicines.

Before that, there was only insulin and some oral medications, such as Diabinese, that lowered glucose levels by stimulating pancreatic cells (called beta cells) to secrete insulin. The pancreas doesn't produce any more insulin, it just releases it into the body.

From 1995 on, he said, medications flourished -- each a different class addressing different conditions or "defects" contributing to the disease. "We have a lot of new medications to treat Type 2."

Glucophage, for instance, addresses a problem where defective beta cells don't secrete insulin when they're supposed to when glucose increases following a meal. In Type 2 diabetes, the liver makes excess glucose and glucophage tells the liver to stop glucose production.

Another class of drugs has been less successful than desired. Alpha-glucosidase inhibitors inhibit an enzyme in gastrointestinal tract that breaks down complex carbohydrates. This slows the digestion of the carbs and reduces post-meal glucose elevation, improving glucose control.

Unfortunately, it has unpleasant side effects, such as increased gas, cramps, nausea and diarrhea, so it hasn't been as well received as once hoped, Ponte said.

Another class of drugs addresses insulin resistance. Insulin is a hormone for metabolizing carbs, fats and proteins. But insulin-resistant cells resist the hormone's operation, requiring higher levels to operate and overtaxing the pancreas over time.

Actos -- pioglitazone -- is an oral drug that goes inside the cell and programs the nucleus to make proteins; one protein goes to a cell's surface and brings glucose inside, to help overcome resistance.

Another drug mimics the activity of a hormone called GLP-1, which offers beneficial effects for sugar control, curbs the appetite (Type 2 is often associated with obesity), shuts off a hormone that causes the liver to produce glucose, and can repopulate or preserve beta cells. The down side of this drug is delivery -- injection, anywhere from twice a day to once a week.

A new oral GLP-1 drug inhibits the enzyme that breaks it down, so it can do its job.

A final group, Ponte said, targets the kidneys, which reabsorb glucose. The drug inhibits that absorption so excess glucose can be expelled from the body.

Often, Ponte said, a patient requires a combination of treatments, what he calls a "therapeutic soup."

But for the care providers, he said, all these drugs provide a toolbox of choices. "It's challenging from the standpoint of patients, providers, to keep it all straight." Also in play are the patient's willingness to accept treatment, other conditions and drug interactions, and insurance coverage.

But overall, the advances are positive, he said. "It's been a blessing."

Doctor, pharmacist and patient need to work together to manage the disease, Ponte said. "It affects everything from head to toe; there's nothing in a person with diabetes that's spared when it comes to a potential adverse effect or a potential complication."

But he values what he does, he said. "Some of the best and most rewarding activities that I've had as a practitioner have been trying to help people that have diabetes. You can make a huge difference to these people. Sometimes you can't, but "you always try, and do the best you can."

Prevention efforts

The state Bureau of Public Health is working with the U.S. Centers for Disease Control and Prevention (CDC) to offer the CDC's National Diabetes Prevention Program across the state, said Jessica Wright, director of the bureau's Division of Health Promotion and Chronic Disease.

The program targets people with pre-diabetes -- in which a person has a blood sugar level higher than normal, but not high enough for a diagnosis of diabetes.

The CDC estimates that 1 out of every 3 U.S. adults had pre-diabetes in 2010 -- 79 million people -- and most d o n't know they have it.

The prevention program emphasizes lifestyle changes. Wright said it's a 16-week group training program, with follow-ups, where participants learn strategies for coping, eating healthy and incorporating physical activity.

The CDC said research shows that modest weight loss and regular physical activity can help prevent or delay Type 2 diabetes by up to 58 percent in people with pre-diabetes. Modest weight loss means 5 percent to 7 percent of body weight, which is 10 to 14 pounds for a 200-pound person. Getting at least 150 minutes each week of physical activity, such as brisk walking, is important.

Monongalia General Hospital and WVU Extension Service offer CDC-recognized programs.

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(c)2013 The Dominion Post (Morgantown, W.Va.)

Visit The Dominion Post (Morgantown, W.Va.) at www.dominionpost.com

Distributed by MCT Information Services

Copyright Dominion Post (Morgantown, WV) 2013

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