A word of advice for Boston Mayor Thomas Menino from a top specialist: Diabetes is no reason to retire. And another bit of wisdom: When you’re back in the office, schedule exercise into your day as you would a demanding constituent.
Mayor Menino’s doctors disclosed last week that during his recent weeks-long hospital ordeal of infection, blood clot and fractured vertebra, the mayor was also diagnosed with Type 2 diabetes. (That makes him a rarity in American politics; lists of famous diabetics abound, but the only other politician who has been open about Type 2 diabetes that I can find is Mike Huckabee of Arkansas.)
Mayor Menino is now recuperating at Spaulding Rehabilitation Hospital and sounded very much like himself in a recent press conference (Retire? “I checked my retirement. It wasn’t good enough.”) and a public letter about the fiscal cliff. But his ailments triggered calls for him to retire in Boston Globe columns and elsewhere.
We’ve written repeatedly about the explosive rise in Type 2 diabetes prevalence, now at 26 million Americans and expected to rise by another 50 percent in the next decade or two.
But I suddenly realized that I didn’t actually understand what it means to have Type 2 diabetes. Both my grandfathers had it. One, a stocky former boxer, was felled by its complications, first knocked down to a wheelchair and then into an early grave. The other didn’t seem bothered by it at all. So how hard is diabetes? Is it in fact relevant to any decision the mayor might make about his next political move?
According to Dr. Martin Abrahamson, chief medical officer of the Joslin Diabetes Center, the answer is an emphatic “No.” I spoke with Dr. Abrahamson just after he gave an overview of the current state of diabetes treatments to some 500 doctors as part of a Harvard Medical School continuing education course. Our conversation, lightly edited:
So we’ve just learned that Mayor Menino has Type 2 diabetes. What does that mean, both physiologically and in terms of — well — living?
Well, it means that his ability to metabolize glucose is impaired, and the glucose levels in his blood have risen, and probably for two reasons: Firstly. he has less ability to dispose of glucose in the cells compared to people who have normal metabolism, and that comes about because the insulin in his body is less effective. And secondly, he is not producing as much insulin as normal people do. Insulin, as you know, is a hormone that pushes glucose into the cells, and the cells use the glucose for their energy on a daily basis. So it means that he has elevated glucose levels.
However, there’s a lot that he can do about it. He can treat his diabetes through a variety of ways, the first of which is modifications in lifestyle, increasing exercise, watching his diet and losing some weight. And second, there are medications that can be taken, either by mouth or injectable ones, that can either help the body use insulin more effectively to dispose of glucose, or enhance the amount of insulin that the body produces to promote glucose uptake into the cells.
So the first-line treatment tends to be lifestyle changes — diet and exercise — and then it sounds like very typically you prescribe Metformin, which is just a pill, right? And then, I believe you said, by about six years out, about half of people with diabetes need insulin?
Metformin is for most people the first-line therapy, providing they can tolerate the medication. Every medication can have a risk of some side effects. If Metformin is not tolerated or people cannot take it, or it’s not effective alone, there are other medications that can be added to Metformin. And what I was saying in my talk is that after about six years of diabetes, there are many people who would require insulin in addition to the other medications they are taking.
Historically, people with Type 2 diabetes have looked upon insulin treatment as a last resort, a punishment because they’re not following their diet and exercise program. But the point I was trying to make was that it’s a reality for many people even if they are adherent to other treatment approaches. And that if you need insulin, you should take insulin. The most important goal is to control your blood sugar, and if you control your blood sugar you can lead an absolutely normal life, and there isn’t anything that you can’t do.
So the people who are saying, ‘Oh, well, the mayor has a progressive chronic disease, he should retire,’ how do you react to that?
I would say if the mayor looks after himself and controls his diabetes there’s no reason to use diabetes as an excuse to retire.
However, in your lecture just now, you spoke about a study that showed that very tight control of blood sugar had some disappointing results.
There are interesting studies that have come out recently in people with longstanding diabetes and who either have established cardiovascular disease or multiple risk factors for cardiovascular disease. These studies show that if you very intensively manage your diabetes, and that’s really getting the glucose levels as close to normal as possible, there was no difference in cardiovascular outcomes. There continued to be some benefit in reducing risk for what we call microvascular complications — that’s kidney disease, eye disease and neuropathy, which is the disease that affects the nerves of the feet.
But having said that, if you’re someone who is newly diagnosed with diabetes, there is strong evidence that good glucose control, in the short term, reduces microvascular complications, and the longer you can maintain that control, even if it’s not quite as good as it was in the beginning, there is good evidence that long term, there is cardiovascular benefit, and continued reduction in risk for the development or progression of the microvascular complications. That’s what we call the legacy effect. So for the majority of people, it makes a lot of sense to control their diabetes well and keep glucose levels as close to normal as possible, provided they can do this safely.
So if I were newly diagnosed, what would be the chances that I could control it with just diet and exercise?
That depends on how high your glucose levels are. So if you’re newly diagnosed and your glucose levels are only marginally elevated, it may be you can get yourself well controlled with lifestyle modification. But for the majority of people, it’s usually a combination of lifestyle modification and some medications.
And, as you put it, what’s coming next to a theater near you? What comes next in treatment?
For people with Type 2 diabetes there are new medications that work through different mechanisms than those we have already, that may be approved by the FDA in the near future. One class of drugs are medications that promote excretion of glucose by the kidney by exaggerating the renal tubular release of glucose. There are also newer insulins coming to market which appear to be safer than the ones we have in terms of the risk of hypoglycemia. We still are waiting for further outcome data from some of the longer-term studies to see if they are overall as safe as the current insulins we have.
And there are new developments in what we call GLP1 analogs. These are drugs that promote insulin secretions but in a glucose-dependent manner so when used alone or even with Metformin, they will not cause a low glucose or hypoglycemia. These are drugs that can currently be given once a day or even once a week, and there are some clinical trials of drugs that may be able to be given even once evert few weeks or even evert few months.
And those are approved?
There are two on the market that are approved and there are more in late clinical studies.
So if we look forward for the mayor, and given that you’re not his doctor, we know that his program will include lifestyle changes and possibly Metformin; would it include new drugs?
It’s difficult to say, but my hope is that the mayor will look after himself — I’m sure he will — and that will enable him to continue to do the wonderful job that he’s already doing as our mayor.
Readers, comments or burning questions about Type 2 diabetes?