Tagged Diabetes

It’s Not Just Insulin: Lawmakers Focus on Price of One Drug, While Others Rise Too

Michael Costanzo, a Colorado farmer diagnosed with multiple sclerosis in 2016, has a well-honed ritual: Every six months, he takes an IV infusion of a medicine, Rituxan, to manage his disease, which has no cure. Then he figures out how to manage the bill, which costs thousands of dollars.

For a time, the routine held steady: The price billed to his health insurance for one infusion would cost $6,201 to $6,841. Costanzo’s health insurance covered most of it, and he paid the rest out-of-pocket.

But last fall the cost for the same 20-year-old drug and dosage jumped to $10,320, even though he was covered by the same insurance.

“Why does it have to increase in price all of a sudden?” wondered Costanzo, who lives in a small town about 50 miles north of Denver.

“I think greed is a huge problem,” he said.

As drug prices spiral upward, politicians in Washington, D.C., and in state governments across the country have sought to address the problem in limited ways, focusing mostly on one drug: insulin, a drug more than 7 million Americans rely on to manage diabetes and whose price tag more than doubled from 2012 to 2017.

With comprehensive drug price legislation stalled in Washington during the COVID-19 state of emergency, seven states in the midst of the pandemic enacted insulin payment caps of less than $100 per month, bringing the total to eight; five more have proposed legislation. In March, President Donald Trump’s health officials announced a Medicare test project limiting seniors’ monthly out-of-pocket costs to $35. In July, he signed four executive actions targeting insulin and a handful of other medications, boasting, “It’s going to have an incredible impact.”

Insulin took center stage last year, after moving demonstrations by mothers who caravanned to Canada to buy lifesaving medicine for their children at a tenth of the U.S. price; they swarmed the halls of Congress.

The measures that have resulted so far have not solved a far more widespread problem: escalating drug prices across the board — a problem that voters, left and right, say Congress must fix.

Underlying the problem is that lawmakers spent much of last year at loggerheads about whether the federal government should have the power to set prices or limit price increases. Prospects of comprehensive legislation already in the works slipped away this spring as Congress turned its focus to the COVID-19 pandemic that has killed more than 150,000 Americans and tanked the country’s economy.

So state lawmakers played whack-a-mole, targeting the drug with the most notoriety, and tackled insulin’s cost to patients. But patients like Costanzo — among the millions who rely on other vital drugs — struggle evermore to afford unchecked price increases for everything from HIV/AIDS and depression to asthma, autoimmune disorders and Type 2 diabetes.

A 2019 survey from the Scripps Research Translational Institute published in the Journal of the American Medical Association found that the costs of 17 top-selling brand-name drugs more than doubled from 2012 to 2017. Many of the drugs that made the list are household names: Lipitor and Zetia for high cholesterol, Advair and Symbicort for asthma, Lyrica for pain and Chantix for smoking cessation.

“The general public doesn’t realize this is happening with all sorts of drugs,” Costanzo said. “We’re all suffering from increased prices.”

***

Insulin was a natural poster child for pharmaceutical greed, encapsulating America’s problem with high drug prices in a neat package that few, if any, other medications do as effectively.

“You have an illustration of the problem — politics gone awry and capitalism gone awry,” said Celinda Lake, a veteran Democratic pollster. “They think of it as being emblematic of everything that’s going on with the system.”

Three pharmaceutical companies dominate the market for the diabetes treatment that has essentially the same formula as when it was introduced in the 1920s. Not taking insulin can quickly turn fatal. In 2017, Minnesota resident Alec Smith died at age 26 after rationing his insulin because he couldn’t afford it.

People dying “is what it takes for Congress to actually commit money and act, and then we solve these problems eventually,” said Andy Slavitt, who was acting head of the U.S. Centers for Medicare & Medicaid Services in the Obama administration.

Yet proponents of lowering drug costs say an effort centered on a single drug could backfire, and it did when COVID captured center stage.

“Everywhere in this country people are angry about their drug prices,” said David Mitchell, founder of Patients for Affordable Drugs Now, a Washington, D.C.-based group that lobbies Congress and runs campaign ads in support of lower prices. “The people with cancer, the people with autoimmune problems, the people with multiple sclerosis, the people who are taking a variety of drugs that are wildly overpriced, are going to say, ‘Now, wait a minute, what about me?’”

In early March, University of Pittsburgh researchers published research finding that, without discounts, list prices of brand-name drugs were rising about 9% a year. Late last year, House Democrats passed a bill that would let the federal government set prices for hundreds of drugs and cap seniors’ out-of-pocket costs for medication at $2,000. Trump opposed the bill, calling on Congress to send him a drug pricing bill that has bipartisan support.

“Let’s be clear — these price hikes aren’t because the medicines got better or there was a significant increase in research and development,” said Sen. Chuck Grassley (R-Iowa) in a March 5 floor speech. The chairman of the Senate’s powerful Finance Committee spearheaded a bipartisan drug pricing bill with Oregon Sen. Ron Wyden, a Democrat. “No, this was because the pharmaceutical companies could do it and get away with it.”

While Congress dithers and the topic periodically becomes the subject of a presidential tweet, patients continue to fend for themselves.

Tara Terminiello has seen the total underlying cost of her son’s anti-seizure medication, Topamax, skyrocket to about $1,300 a month, hundreds more than when he started taking it over a decade ago.

In Texas, Joseph Fabian, a public school teacher in San Antonio with health insurance through his job, has relied on inhalers since childhood to manage his allergy-induced asthma. In February 2019, he paid $330.98 for a three-pack of Symbicort inhalers, which he typically uses twice a day but more frequently during allergy season.

A year later and after a change in his health insurance plan, Fabian’s costs tripled, to $348.95 for a single inhaler, he said in an interview. According to the Scripps’ drug pricing study, the median cost of Symbicort rose from $225 in January 2012 to $308 in December 2017.

“There’s no way I can keep working out $350 every month and a half,” Fabian said.

***

Chances that Congress will pass comprehensive drug pricing legislation before the 2020 election have slipped away as lawmakers focus on additional COVID-19 relief. Moreover, the Trump administration, Congress and the public are now hoping for pandemic deliverance by the very same drug companies that have been raising prices as they develop potential virus treatments and vaccines. PhRMA, the powerful industry trade group, has seized the moment with ad campaigns emphasizing the sector’s enormous value.

The stalemate provides little solace for patients like Costanzo, whose medicine, Rituxan, made by Genentech, was first approved by the Food and Drug Administration in 1997 to treat lymphoma and can be used off-label for MS. It is one of seven medications with price increases unsupported by new clinical evidence, according to a report from the Institute for Clinical and Economic Review. ICER noted that over 24 months, the net price — the price after any discounts from drug companies are factored in — “increased by almost 14%, which results in an estimated increase in drug spending of approximately $549 million.”

In a statement, Genentech spokesperson Priscilla White said ICER’s analysis was “significantly limited” because it didn’t account for “meaningful, high-quality, and peer-reviewed evidence supporting the clinical and economic benefits of Rituxan.” White said the company did not increase Rituxan’s price during the period in which Costanzo’s bill rose and wouldn’t speculate on the change without knowing “other factors” that may have contributed.

“We take decisions related to the prices of our medicines very seriously, taking into consideration their value to patients and society, the investments required to continue discovering new treatments, and the need for broad access,” she said.

Costanzo was prescribed the drug by two neurologists and hasn’t had any acute relapses since he started the infusions. He eventually did get a financial reprieve, not thanks to Washington, but by enrolling in a patient discount program operated by the very drug company that sets Rituxan’s price, a program he said was an “absolute lifesaver” financially.

Genentech said its patient foundation provides free medicine to more than 50,000 patients each year. Costanzo got his first free dose in July.

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In Face of COVID Threat, More Dialysis Patients Bring Treatment Home

Maria Duenas, 60, has kidney failure and is on the kidney transplant list. But until she finds a match, she will administer her own dialysis treatment at home.(Heidi de Marco/KHN)

NIPOMO, Calif. — After Maria Duenas was diagnosed with Type 2 diabetes about a decade ago, she managed the disease with diet and medication.

But Duenas’ kidneys started to fail just as the novel coronavirus established its lethal foothold in the U.S.

On March 19, three days after Duenas, 60, was rushed to the emergency room with dangerously high blood pressure and blood sugar, Gov. Gavin Newsom implemented the nation’s first statewide stay-at-home order.

Less than one week later, Duenas was hooked up to a dialysis machine in the Century City neighborhood of Los Angeles, 160 miles from her Central Coast home, where tubes, pumps and tiny filters cleansed her blood of waste for 3½ hours, doing the work her kidneys could no longer do.

In the beginning, Duenas said she didn’t understand the severity of COVID-19, or her increased vulnerability to it. “It’s not going to happen to me,” she thought. “We’re in a small little town.”

But she was unable to find a spot in a dialysis clinic in, or near, Nipomo. So, with her husband, Jose, at her side, Duenas made long road trips to Century City for more than two months.

In May, Duenas’ doctor told her she was a good candidate for home dialysis, which would save her drive time and stress — and reduce her exposure to the virus.

The closet in Duenas’ grandchildren’s playroom is crammed with peritoneal dialysis solution, a mixture of dextrose, calcium and magnesium. She uses two bags for every treatment. Cabinets and drawers in her bedroom are filled with disinfectant wipes, gauze, masks and gloves.(Heidi de Marco/KHN)

Now, Duenas assiduously sterilizes herself and her surroundings five nights a week so she can administer dialysis to herself at home while she sleeps.

“There’s always a chance going in that somebody’s going to have COVID and still need dialysis” in a clinic, Duenas said. “I’m very grateful to have this option.”

The increase in home dialysis has accelerated recently, spurred by social-distancing requirements, increased use of telehealth and remote monitoring technologies — and fear of the virus.

Duenas starts her home dialysis routine around 8 p.m. She must maintain a sterile environment and uses masks and gloves. Her husband, Jose, installed an automatic paper towel dispenser in their bathroom to help ensure proper hygiene.(Heidi de Marco/KHN)

While recent, comprehensive data is hard to come by, experts confirm the trend based on what they’re seeing in their own practices. Fresenius Medical Care North America, one of the country’s two dominant dialysis providers, said it conducted 25% more home dialysis training sessions in the first quarter of 2020 than in the same period last year, according to Renal & Urology News.

“People recognized it would be better if they did it at home,” said Dr. Susan Quaggin, president-elect of the American Society of Nephrology. “And certainly from a health provider’s perspective, we feel it’s a great option.”

Duenas vigorously washes her hands before she cleans the area around the catheter in her abdomen. She also sterilizes the dialysis equipment before hooking herself up for the night.(Heidi de Marco/KHN)

Nearly half a million people in the United States are on dialysis, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Roughly 85% of them travel to a clinic for their treatments.

Dialysis patients are at higher risk of contracting COVID-19 and getting seriously ill with it, said Dr. Anjay Rastogi, director of the UCLA CORE Kidney Program, where Duenas is a patient.

In an analysis of more than 10,000 deaths in 15 states and New York City, the Centers for Disease Control and Prevention found about 40% of people killed by COVID-19 had diabetes. That percentage rose to half among people under 65.

But people on dialysis are also vulnerable to COVID-19 because they usually visit dialysis clinics two to three times a week for an average of four hours at a time, exposing themselves to other patients and, potentially, the virus, Rastogi said.

“Now even more so, we are strongly urging our patients to consider home dialysis,” he said.

Although patients on home dialysis reduce their exposure to COVID-19 by avoiding clinics, they face other challenges. Home dialysis requires supplies such as dialysis fluid, drain bags, tubing, disinfectant and personal protective equipment. According to a recent study, patients may have problems obtaining dialysis supplies because supply chains are strained.(Heidi de Marco/KHN)

Duenas uses her bedroom mirror to make sure her catheter is properly covered with gauze before she goes to bed. She will be tethered to the machine overnight.(Heidi de Marco/KHN)

There are two kinds of dialysis: hemodialysis and peritoneal dialysis. In hemodialysis, which is administered in a hospital or clinic, or sometimes at home, a dialysis machine pumps blood out of the body and through a special filter called a dialyzer, which clears waste and extra fluid from the blood before it is returned to the body.

Dialysis treatment centers that offer hemodialysis have intensified their infection-control procedures in response to COVID-19, said Dr. Kevin Stiles, a nephrologist at Kaiser Permanente in Bakersfield. Visitors are no longer allowed to accompany patients, and patients get temperature checks and must wear masks during treatment, he said. (KHN, which produces California Healthline, is not affiliated with Kaiser Permanente.)

In peritoneal dialysis, which is the more popular home option because it is less cumbersome and restrictive, the inside lining of the stomach acts as a natural filter. Dialysis solution cleanses waste from the body as it is washed into and out of the stomach through a catheter in the abdomen.

It takes Duenas about 45 minutes to prepare her overnight treatment. Her tubing allows her to get as far as her bathroom, but she sometimes gets tangled in it at night.(Heidi de Marco/KHN)

Not everyone is eligible for home dialysis, which comes with its own challenges.

Home dialysis requires patients or their caregivers to lift bags of dialysis solution that weigh 5 to 10 pounds, Stiles said. Good eyesight and hand dexterity are also critical because patients must be able to maintain sterile environments.

Home patients need dialysis equipment and regular deliveries of supplies such as dialysis fluid, drain bags, tubing, disinfectant and personal protective equipment. In response to COVID-19, some clinics have arranged courier services and contracted with labs to deliver supplies to patients.

The Trump administration has encouraged greater use of home dialysis and in July proposed increasing Medicare reimbursement rates for home dialysis machines, citing “the importance that this population stay at home during the public health emergency to reduce risk of exposure to the virus.”

The morning after her treatment, Duenas disinfects the dialysis machine and then disconnects her catheter tube from the machine so that she can move around freely.(Heidi de Marco/KHN)

Medicare covers almost all patients who receive dialysis treatment, including home dialysis, and patients typically pay 20% as coinsurance.

Medicare, which spends an average of $90,000 per hemodialysis patient annually, spent more than $35 billion on patients with end-stage renal disease in 2016.

Duenas is awaiting a kidney transplant. Until she finds a match, she’ll be administering her own peritoneal dialysis at home.

Duenas inspects her drain bag in the morning for fibrin, a protein that can clog her catheter. She must alert her doctor if she finds any floating in the fluid.(Heidi de Marco/KHN)

“To be honest, I didn’t want to do it,” she said of home dialysis. “It was scary having to think about taking care of my own treatment.”

Now, three months later, guided by training and the prompts on the dialysis machine, Duenas feels comfortable, capable and safe.

Looking back, she said, “it was a blessing in disguise.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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Weight Has Greater Impact on Diabetes Than Heart Disease

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Carrying excess weight may have a greater impact on the risk for diabetes than it does on the risk for heart disease or early death, a new study has found.

To look at the effect of obesity independent of genetics, Swedish researchers followed 4,046 pairs of identical twins whose average age was 58. One of the twins was overweight, and the other was not. Since identical twins have the same genes, their weight difference could not be attributed to genetics. The study is in JAMA Internal Medicine.

After accounting for physical activity, smoking and educational level, the researchers found that having a higher body mass index, or B.M.I. — even among those in the obese range of 30 or higher — was not associated with an increased risk for heart attack or death. But a high B.M.I. was associated with an increased risk for diabetes.

“Based on these results, the association between obesity and cardiovascular disease is explained by genetic, not environmental, factors,” said the lead author, Peter Nordstrom, a professor of geriatric medicine at Umea University. “Unfortunately, this also means that environmental factors that reduce obesity do not reduce the risk of cardiovascular disease or death. But they most certainly decrease the risk for diabetes.”

Flu Vaccine Has Added Benefits for People With Diabetes

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People with Type 2 diabetes may get an added benefit from the flu vaccine: a reduced risk of cardiovascular disease.

British researchers studied 124,503 people with Type 2 diabetes over a seven-year period. About two-thirds of them had been vaccinated against flu.

After controlling for sex, age, smoking, body mass index, hypertension, medications and other health and behavioral factors, they found that people with Type 2 diabetes who had gotten the flu vaccine had a 30 percent lower risk of stroke, a 22 percent lower risk of heart failure and a 24 percent lower risk of dying from all causes. They also had a slightly lower, but statistically insignificant, risk for heart attack.

The lead author, Dr. Eszter P. Vamos, a clinical fellow at Imperial College London, said that people with diabetes are already at high risk for cardiovascular disease, and flu is particularly dangerous for them.

“The flu vaccine is largely underused among people with chronic illnesses,” she said. “It’s really important that people with diabetes receive their annual flu vaccine.”

The study, published in the Canadian Medical Association Journal, had a large sample and a long follow-up time, which give it considerable strength. Still, the authors acknowledge they were unable to account for all of the factors that could make people who get a flu shot different from people who do not.

Can Statins Cause Diabetes?

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Sleep Problems Tied to Diabetes in Men

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Men who do not get enough sleep — or get too much — may have an increased risk for Type 2 diabetes, a new study suggests.

Researchers studied 788 healthy men and women participating in a larger health study, measuring their sleep duration using electronic monitors and testing them for markers of diabetes — how well pancreatic cells take up glucose and how sensitive the body’s tissues are to insulin. The study is in the Journal of Clinical Endocrinology & Metabolism.

The average sleep time for both men and women was about seven hours. As the men diverged from the average, in either direction, their glucose tolerance and insulin sensitivity decreased, gradually increasing the deleterious health effects. There was no such association in women.

The researchers weren’t sure why men but not women showed this association but caution that this was a cross-sectional study, a snapshot of one moment in time, and that they draw no conclusions about cause and effect.

The lead author, Femke Rutters, an assistant professor at the VU Medical Center in Amsterdam, said that it is easy to advise men to get regular and sufficient sleep, but because so many lifestyle and health factors may contribute to poor sleep, acting on that advice is much harder.

“There has been a lot of observational work on sleep, but trying to change it is difficult,” she said. “Ideally, men should try for regular sleep.”

How Many Calories We Burn When We Sit, Stand or Walk

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There are many compelling reasons to get up out of your desk chair and stand more at work. But weight control is probably not one of them, according to a new study that precisely measured how many calories people burn during everyday office activities.

The new study’s results suggest that engaging frequently in one type of activity while at work may help many of us avoid weight gain. But that activity is not standing up.

Most of us sit more than we should, and a majority of our sitting time occurs at work, since many modern professions are sedentary. Many of us spend six or seven hours tied to our desks each day.

These long, uninterrupted periods of physical lethargy have been linked with increased risks for diabetes, heart disease, premature mortality and, not least, weight gain.

In response, many people, including me, have begun to look for ways to break up our sitting time. We download smartphone apps that chirp and tell us to stand up several times every hour. Health-minded supervisors organize walking meetings, in which employees discuss business while hoofing along hallways. And standing desks have become so popular that the satirical website The Onion has poked fun at users, declaring “Standing at Work Can Increase Coworkers’ Disdain Up to 70 Percent.”

Recent studies indicate that measures that get us off our seats can help us better regulate blood sugar and lessen the risks for diabetes and chronic disease. But more to the point, many of us are rising from our chairs in the hopes that sitting less will help keep our waistlines and nether quarters from spreading.

Surprisingly few studies, however, have closely tracked how many additional calories we burn if we stand up or walk around our offices.

So for the new experiment, which was published this month in the Journal of Physical Activity and Health, researchers affiliated with the Physical Activity and Weight Management Research Center at the University of Pittsburgh rounded up 74 healthy volunteers. Most were in their mid-20s, of normal weight, and with some acquaintance with office life.

These volunteers were randomly assigned to four different groups. One group was asked to sit and type at a computer for 15 minutes and then stand up for 15 minutes, moving around and fidgeting as little as possible.

Another group also sat for 15 minutes, but watched a television screen and didn’t type. Afterward, they immediately moved to a treadmill and walked for 15 minutes at a gentle, strolling pace.

The third group stood up for 15 minutes and then sat down for 15 minutes.

And the final group walked on the treadmills for 15 minutes and then sat.

Throughout, the volunteers wore masks that precisely measured their energy expenditure, which means how many calories they were using.

Unsurprisingly, sitting was not very taxing. The volunteers generally burned about 20 calories during their 15 minutes of sitting, whether they were typing or staring at a television screen.

More unexpected, standing up was barely more demanding. While standing for 15 minutes, the volunteers burned about 2 additional calories compared to when they sat down. It didn’t matter whether they stood up and then sat down or sat down and then stood up. The total caloric expenditure was about the same and was not sizable.

Over all, in fact, the researchers concluded, someone who stood up while working instead of sitting would burn about 8 or 9 extra calories per hour. (Just for comparison, a single cup of coffee with cream and sugar contains around 50 calories.)

But walking was a different matter. When the volunteers walked for 15 minutes, even at a fairly easy pace, they burned about three times as many calories as when they sat or stood. If they walked for an hour, the researchers calculated, they would incinerate about 130 more calories than if they stayed in their chairs or stood up at their desks, an added energy expenditure that might be sufficient, they write, to help people avoid creeping, yearly weight gain.

The upshot of this experiment is that if your goal is to control your weight at work, then “standing up may not be enough,” said Seth Creasy, a graduate student at the University of Pittsburgh and the lead author of the new study.

You probably need to also incorporate walking into your office routine, he said. Maybe “put the printer at the other end of the hallway, or get up to walk to the water fountain every hour or so” instead of keeping a water bottle at your desk.

“Brief periods of walking can add up to make a big difference” in energy expenditure, he said, while standing barely budges your caloric burn.

Of course, standing up almost certainly has other health benefits apart from weight management, Mr. Creasy said, including better blood sugar control and less back and shoulder pain associated with hunching in a chair all day. So don’t dismantle or abandon your stand-up desk just yet. But don’t expect it to counteract that extra cookie with lunch.

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A Few More Vegetables and a Little Less Meat May Reduce Diabetes Risk

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Credit Justin Mott for The New York Times

You don’t have to be a vegetarian to reap the benefits of a plant-based diet.

New research shows that eating a few extra servings of healthy plant-based foods each day and slightly reducing animal-based foods like meat and dairy products can significantly lower your risk of Type 2 diabetes.

The findings are based on an analysis of the eating patterns of 200,000 men and women from three long-term studies who reported on their diets repeatedly over the course of two decades, and were published this week in PLOS Medicine.

The studies — the Nurses’ Health Study, the Nurses’ Health Study 2 and the Health Professionals Follow-Up Study — asked participants to fill out more than 100 detailed questions about their eating habits. They provided information not just about the foods they ate but about how the food was prepared and even what cooking oils were used.

While self-reported dietary information can be flawed, extra steps were taken to confirm the data. Participants completed questionnaires every two to four years, and the nutrient intake information was compared to tests of blood biomarkers to make sure they matched up. The results were also adjusted, or modified, to account for other characteristics that contribute to Type 2 diabetes, like being overweight.

The research was also unusual in that it distinguished between healthful and unhealthful plant-based foods. Healthful plant-based foods include whole grains, fruits, vegetables nuts, seed and legumes, while an unhealthful plant-based diet could include refined carbohydrates like bagels and muffins, starchy vegetables like potatoes and French fries and sugary foods like cake and cola. Animal-based foods include meat of all kinds, fish and seafood as well as eggs, dairy products and animal fats like butter.

On average, adults who ate a plant-based diet with few animal products cut their risk of Type 2 diabetes by 20 percent. But when researchers distinguished between healthful and unhealthful plant-based foods, they found that diabetes risk dropped by 34 percent among the healthful plant-based eaters. Notably, there wasn’t a benefit to plant-based eating when a person consumed a lot of refined carbohydrates and starchy vegetables. In that case, a person’s risk of developing Type 2 diabetes increased slightly.

While most American adults are omnivores, eating from many different food sources, and few are vegetarian, the research suggests that simply reducing the amount of animal-based food you eat from five or six servings a day to about four servings a day can lower the incidence of Type 2 diabetes. When people make these changes in diet, they usually cut back on red meat and processed meats and substitute healthier plant-based foods, including protein-rich ones like nuts, seeds and legumes, said Frank Hu, the study’s senior author and a professor at Harvard’s T.H. Chan School of Public Health.

“What we’re talking about is a moderate shift – replacing one or two servings of animal food a day with one or two plant-based foods,” said Dr. Hu. “We’re not talking about a dramatic change from being a carnivore to being vegan or even vegetarian – we’re talking about a small shift, that’s doable for most people. You can still include some meat, but not have it in the center of the plate.”

Good plant-based foods are known to be rich in fiber, antioxidants, good fats and a wide array of micronutrients, and have been shown to improve glucose metabolism and lower inflammatory markers. But scientists say they also help promote the good-for-you bacteria that live in your gut.

“When we ingest food, we’re feeding ourselves, but we’re also feeding the bacteria in our gut,” said Dr. Hu. “If you switch from an animal-based dietary pattern to a plant-based pattern, after a while – I don’t know how long it would take, a few weeks or months – the type of bacteria will also change.”

The bacteria in the gut use components of plant-based foods like fiber for their own survival and growth. These components are metabolized by the intestinal bacteria, and the end products are short-chain fatty acids, which have been shown to have beneficial effects on inflammation, insulin resistance and overall metabolism. They also may send a satiety signal to the brain, so people feel fuller.

When you eat refined carbohydrates and have less fiber in the diet, the healthy bacteria that metabolize fiber will be reduced, “so you won’t have the short-chain fatty acids that would have beneficial effects in your body,” Dr. Hu said.

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Walkable Neighborhoods Cut Obesity and Diabetes Rates

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Credit Bryan Anselm for The New York Times

Neighborhoods designed for walking may decrease the rates of being overweight or obese and having diabetes by more than 10 percent, a new study concludes.

Canadian researchers studied more than three million people in 8,777 neighborhoods in urbanized areas of Ontario, ranking them for “walkability” on a 100-point scale that measures population density, numbers of facilities within walking distance of residences and how well connected their webs of streets are.

The study, published in JAMA, adjusted for age, sex, income and other factors, and found that the prevalence of being overweight and obese was more than 10 percent lower in the one-fifth of neighborhoods rated highest for walkability than in the one-fifth rated lowest. Over the 12-year study period, being obese and overweight increased by as much as 9.2 percent in the three-fifths of neighborhoods rated lowest, with no change in the two-fifths rated highest.

The incidence of diabetes was also lowest in the most walkable neighborhoods, a difference that persisted throughout the study.

The authors acknowledge that this was not a randomized trial and does not prove causation. Still, the senior author, Dr. Gillian L. Booth, a physician at St. Michael’s Hospital in Toronto, said that the healthiest neighborhoods seem to be those where cars are not a necessity.

“Walking, cycling and public transit rates were much higher in walkable neighborhoods,” she said, “and that leads to better health outcomes.”

American Girl Has a Hit With Diabetes Doll Kit

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Anja Busse, 13, plays with her American Girl doll, Alice, and her diabetes care kit at her home in Antigo, Wis.

Anja Busse, 13, plays with her American Girl doll, Alice, and her diabetes care kit at her home in Antigo, Wis.Credit Corey J. Schjoth for The New York Times

Children with Type 1 diabetes can’t make their own insulin, so they have to count carbs, prick their fingers to check their blood sugar and get regular insulin infusions.

Now they can also give that care to their dolls.

American Girl, the doll company, has introduced a diabetes care kit for dolls, and it has been available only intermittently because it’s so popular.

The kit, which sells for $24, has 10 doll-size make-believe items, including a blood sugar monitor, a lancing device, an insulin pump that can be clipped to a doll’s waistband with an adhesive to attach the infusion set, as well as an insulin injection pen needle (for dolls not using the pump). There are also a vial of pretend glucose tablets, a medical bracelet, an ID card, logbook and stickers, and everything fits in a bright fuchsia carrying case the size of a small change purse.

Anja Busse, a 13-year-old from Antigo, Wis., who has Type 1 diabetes, has wanted a kit like this for her doll since she learned she had diabetes just over two years ago. She started an online petition urging American Girl to make diabetes accessories for the dolls, rallying the Type 1 diabetes community and garnering 7,000 signatures.

Anja learned that she had the disease in October, 2013, when she was 11. That Christmas, she got her first American Girl doll – which had hazel eyes, blond hair and freckles, just like her — but was disappointed when she scoured the catalog and couldn’t find any diabetes supplies (though she quickly accumulated accessories for girls with disabilities, like a service dog and a wheelchair).

Since then, Anja has become an advocate who educates her peers and adults in her life about Type 1 diabetes. Many people confuse Type 1 diabetes, which develops when the immune system destroys the cells that make insulin, and Type 2 diabetes, which develops when the body can’t use insulin properly. While Type 1 is genetic and cannot be prevented, being overweight and inactive increases the risk of Type 2 diabetes, which is a far more common disease.

“There are a lot of things people just don’t understand,” Anja said. “They would try to give me advice and say I should be on a diet, or that they had a cure for this. One person yelled at me not to eat a cupcake. They confuse it with Type 2 diabetes, and all kinds of rumors that aren’t even true.”

One of the things she always tells her friends, she said, is “You can’t catch it.”

She recently took the doll diabetes kit to help explain Type 1 diabetes to a group of kindergartners.

Buyers have posted rave reviews of the kit on American Girl’s website.

“I ordered this the day it came out,” a teenager wrote. “When my dad showed me, I almost cried. I was diagnosed with Type 1 diabetes when I was seven years old and I bought my first AG doll when I was eight.” She said she bought the diabetes kit the day before her 14th birthday.

A mother wrote, “Finally there’s something for girls with Type 1 diabetes to play with that makes them feel like they fit it, and can get some awareness out there.”

“It makes dealing with this disease a little more tolerable,” wrote another mother.

Type 1 diabetes, which is usually diagnosed in children and adolescents, is on the rise for unknown reasons. The symptoms include intense thirst and dehydration, frequent urination, extreme hunger, fatigue and weakness, abdominal pain, irritability and rapid mood changes, nausea or vomiting, wounds that don’t heal and blurred vision. Signs include low body temperature, rapid heart rate, reduced blood pressure and weight loss.

“American Girl has a long-standing history of creating dolls that speak to diversity and inclusion, so it’s not really new for us to come out with dolls that are a reflection of girls today,” said Stephanie Spanos, a company spokeswoman.

The company has a historical line that includes Hispanic, African-American, Jewish and Native American characters, as well as the Truly Me line of dolls that can be ordered to have the same skin tone, eye and hair color as the little girls who own them.

Girls can order outfits, miniature musical instruments, art supplies and athletic gear for their dolls, and small pretend wheelchairs, eye glasses, hearing aids and service dogs are also available. Customers can custom order a doll without hair for a girl who has alopecia or is going through chemotherapy, and arm crutches were introduced in January.

The idea for a diabetes care kit “came to fruition just like any other product – our design team is constantly bringing forth new ideas for accessories and clothes,” Ms. Spanos said.

Matt Wahmhoff, the designer who developed the kit for American Girl, said he was thrilled to be part of the effort because he has Type 1 diabetes himself. “I was diagnosed at age 11, and it really made me feel different,” Mr. Wahmhoff, who is now 42, said. “My friends were clueless, and I didn’t have a way to share it so I kept it inside me.”

Now little girls will be able to incorporate diabetes in their play, “not only when they play with their dolls, but when they interact and play with their friends, and raise awareness,” he said.

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Hope for Reversing Type 2 Diabetes

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Allan Tutty, who reversed his own type 2 diabetes, photographed on Seaburn Beach in his home town of Sunderland, Great Britain.

Allan Tutty, who reversed his own type 2 diabetes, photographed on Seaburn Beach in his home town of Sunderland, Great Britain.Credit Robert Ormerod for The New York Times

Many experts believe Type 2 diabetes is an incurable disease that gets worse with time. But new research raises the tantalizing possibility that drastic changes in diet may reverse the disease in some people.

Recently, a small clinical trial in England studied the effects of a strict liquid diet on 30 people who had lived with Type 2 diabetes for up to 23 years. Nearly half of those studied had a remission that lasted six months after the diet was over. While the study was small, the finding offers hope to millions who have been told they must live with the intractable disease.

“This is a radical change in our understanding of Type 2 diabetes,” said Dr. Roy Taylor, a professor at Newcastle University in England and the study’s senior author. “If we can get across the message that ‘yes, this is a reversible disease — that you will have no more diabetes medications, no more sitting in doctors’ rooms, no more excess health charges’ — that is enormously motivating.”

It is not the first time that people have reversed type 2 diabetes by losing a lot of weight shortly after a diagnosis. Studies have also shown that obese individuals who have bariatric surgery frequently see the condition vanish even before they lose very much weight.

But the new study, published in Diabetes Care, proved the reversal after diet can persist for at least half a year as long as patients keep weight off, and can occur in people who have had the disease for many years.

The researchers followed the participants after they had completed an eight-week low-calorie-milkshake diet and returned to normal eating. Six months later, those who had gone into remission immediately after the diet were still diabetes-free. Though most of those who reversed the disease had had it for less than four years, some had been diabetic for more than eight years.

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Credit Robert Ormerod for The New York Times

When Allan Tutty, 57, learned five years ago that he had Type 2 diabetes, he asked health care providers if there was a cure. “It was a case of, look, you’ve got it, deal with it, there’s no cure,” said Mr. Tutty, who manages a home for people with brain injuries in Newcastle.

Later, Mr. Tutty spotted a notice recruiting volunteers for a diabetes study that asked, “Would you like the opportunity to reverse your condition?”

Mr. Tutty said he jumped at the chance, becoming one of 30 men and women ages 25 to 80 to sign up. Mr. Tutty was one of 13 participants whose fasting plasma glucose dropped, and during the six-month follow-up remained below the seven millimole per liter (or 126 milligrams per deciliter) that defines diabetes. Although Mr. Tutty completed the study nearly three years ago, his fasting blood sugars continue to range from 5.2 to 5.6 mmol/L, he said.

Type 2 diabetes develops when the body cannot use insulin properly or make enough insulin, so the body cannot properly use or store glucose (a form of sugar) and sugar backs up into the bloodstream, raising blood sugar levels. In the United States, some 8.9 percent of adults 20 and older have been found to have diabetes, and health officials estimate that another 3.5 percent have undiagnosed diabetes.

Although no one knows exactly why the diet appeared to reverse diabetes, Dr. Taylor said the explanation may be related to how the body stores fat. Excess fat in the liver can spill into the pancreas, inhibiting insulin secretion and the liver’s response to insulin, resulting in insulin resistance and diabetes.

Going on a very-low-calorie diet may allow the body to use up fat from the liver, causing fat levels to drop in the pancreas as well. That “wakes up” the insulin-producing cells in the pancreas, normalizing blood glucose levels.

While some previous studies have shown that blood sugars can normalize after significant weight loss, endocrinologists said they were impressed by the persistence of the lower blood sugar levels for months after the diet.

“Decreasing caloric intake for any reason brings with it a rapid improvement in glucose control,” said Dr. Robert Lash, the chairman of the Endocrine Society’s clinical affairs committee and a professor of internal medicine at the University of Michigan. “What’s exciting here is that the improvements in glucose control persisted when the participants went back to eating a diet with a normal number of calories.”

While the research suggests the potential for a cure, questions remain about how long the effect will last and whether it can work for the typical patient with diabetes.

“It’s definitely doable,” said Dr. George King, the chief scientific officer at Joslin Diabetes Center and a professor at Harvard Medical School. The question, he said, is: Can people maintain the weight loss and “continue to have this reversal for many, many years?”

“That is the difficult part,” he added.

Dr. King said that even short-term remission would reduce or put off some of the serious complications associated with diabetes, like nerve damage, kidney damage, loss of vision, heart attacks and strokes. Yet structured weight loss programs are expensive and often not covered by insurance, and physicians — who are often not well-versed in nutrition — may not take the time to counsel patients about diet, Dr. King said.

The participants in the Newcastle trial, who ranged from overweight to extremely obese, were told to stop their diabetes medications and start a 600- to 700-calorie-a-day diet, consisting of three diet milkshakes a day at mealtimes and half a pound of nonstarchy vegetables a day.

Mr. Tutty, who weighed about 213 pounds before the trial, lost a little more than 30 pounds, the average weight loss in the trial. The people in the study most likely to respond to the treatment were in their early 50s on average and younger than the nonresponders, and they had had diabetes for fewer years. The responders were also healthier before the trial: They had been taking fewer medications than nonresponders, had lower fasting glucose and hemoglobin A1c before the trial, and had higher baseline serum insulin levels. Three of those who went into remission had lived with diabetes for more than eight years.

Many of the responders are still in the prediabetes zone and at risk for developing diabetes, Dr. Taylor said. “It’s not fair to say they were completely normalized, but they’re at a level of blood sugar where we don’t expect to see the serious complications associated with diabetes,” he said. “That’s why it’s such good news.”

The big challenge for dieters was returning to normal eating, and trial participants received intensive counseling from a researcher on the team about how to eat after ending the liquid diet, Dr. Taylor said.

“They would describe going back to the kitchen and almost having a panic attack,” he said. “We used that as an opportunity to instill new habits, and were very directive about how much to cook and how much to eat.”

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Out of Shape at 18, at Risk for Future Diabetes

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Being out of shape at age 18 may increase your risk for eventually developing Type 2 diabetes, regardless of your weight and family history, a new study says.

The study looked at data from more than 1.5 million Swedish men, using tests of muscle strength and aerobic capacity when they were conscripted for military service at age 18, between 1969 and 1997. Their muscle strength had been measured with hand grip and other tests, and their aerobic capacity calculated as they exercised on a stationary bicycle.

With this data in hand, researchers checked the men’s medical records from 1987 to 2012. They found 34,008 cases of Type 2 diabetes over an average 26 years of follow-up. The study is in the Annals of Internal Medicine.

Both low aerobic capacity and low muscle strength at 18 were associated with a higher risk for Type 2 diabetes; poor aerobic capacity was a slightly stronger risk factor. Having both weak muscles and low aerobic capacity more than tripled the risk for future diabetes. The effect was independent of other risk factors — body mass index, family history of diabetes, education and socioeconomic status.

“Early life interventions are really important,” said the lead author, Dr. Casey Crump, a professor of family medicine at the Icahn School of Medicine at Mount Sinai in New York. “Prevention of Type 2 diabetes should begin early in life, and should include both aerobic fitness and muscular strength. This is important regardless of people’s weight.”

Making a Case for Eating Fat

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Credit

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Credit Mark Hyman

For years Dr. Mark Hyman was a vegetarian who kept his intake of dietary fat to a minimum. Whole-wheat bread, grains, beans, pasta and fruits and vegetables made up the bulk of his diet, just as the federal government’s dietary guidelines had long recommended. But as he got older, Dr. Hyman noticed something that bothered him: Despite plenty of exercise and a seemingly healthy diet, he was gaining weight and getting flabby.

At first he wrote it off as a normal part of aging. But then he made a shift in his diet, deciding to eat more fat, not less – and the changes he saw surprised him.

He lost weight, his love handles disappeared, and he had more energy. He encouraged his patients to consume more fat as well, and many of them lost weight and improved their cholesterol. Some even reversed their Type 2 diabetes.

Today, as the director of the Cleveland Clinic’s Center for Functional Medicine, Dr. Hyman has become an outspoken advocate about the health benefits of eating fat. He promotes it on talk shows, educates other doctors, and has even managed to wean his close friend Bill Clinton off of his previously prescribed low-fat vegan diet.

Now in a new book called “Eat Fat, Get Thin,” Dr. Hyman takes a deep dive into the science behind dietary fat, making sense of decades of confusing health recommendations and building a case for why even saturated fats, which have long been vilified, belong in a healthy diet. Dr. Hyman argues that Americans have been misled about the benefits of fat because of a disconnect between nutrition science and food policy. In the book he challenges the nutrition orthodoxy while also exploring the food industry’s outsize influence on official health recommendations.

Recently, we sat down with Dr. Hyman to discuss his thoughts on the gap between nutrition science and health recommendations, the reason you should always plan your meals, and why he never leaves home without a stash of “emergency foods” in his backpack. Here are edited excerpts from our conversation:

Q.

Why did you write “Eat Fat, Get Thin”?

A.

I wrote it because we’ve been suffering from 40 years of bad advice about fat that’s led to the biggest obesity and diabetes epidemic in history. The myth that fat makes you fat and causes heart disease has led to a total breakdown in our nutritional framework. I felt it was important to tell the story of how fat makes you thin and how it prevents heart disease and can reverse diabetes. I think people are still very confused about fat.

Q.

In the book you argue that nutrition recommendations are often contradictory. How so?

A.

This year, for example, the U.S. Dietary Guidelines for the first time removed their longstanding restrictions on dietary fat. But they still have recommendations to eat low-fat foods. They say total fat is not an issue, but you should drink low-fat milk and eat low-fat dairy and other low-fat foods. It’s a schizophrenic recommendation from the government, and it’s the same with other professional organizations such as the American College of Cardiology and the American Heart Association. There’s a mismatch between the science and the government and professional recommendations.

Q.

What’s driving this disconnect?

A.

I think the government based its recommendations on some very flawed science, which took hold. It became policy that was turned into the dietary guidelines and the food pyramid that told us to eat six to 11 servings of bread, rice, cereal and pasta a day and to eat fats and oils sparingly. It’s very hard to overturn dogma like that. It’s embedded in our culture now. It’s embedded in food products. The food industry jumped on the low-fat bandwagon, and the professional associations kept driving the message. Unfortunately the science takes decades to catch up into policy and into practice. And I’m trying to close that gap by bringing awareness to the latest science on how fats and carbs work in your body.

Q.

You reviewed hundreds of studies while writing this book. What is your conclusion on saturated fat?

A.

It’s a huge area of controversy. But large reviews of randomized trials, observational research and blood-level data have all found no link between saturated fat or total fat and heart disease. Yet there are still recommendations to limit saturated fat because it raises total cholesterol and LDL cholesterol. But it also raises HDL, and it increases cholesterol particle size, so you actually get a net benefit.

Q.

What do you say to scientists who argue that saturated fat does in fact cause heart disease?

A.

I think the challenge with the research is that a lot of the data combines saturated fat in the context of a high-carbohydrate diet. The real danger is sweet fat. If you eat fat with sweets – so sugar and fat, or refined carbohydrates and fat – then insulin will rise and it’ll make you fat. But if you eliminate the refined carbs and sugar, that doesn’t happen. I think saturated fats can be bad in the context of a high-carbohydrate diet. But in the absence of that, they’re not.

Q.

What foods do you eat and recommend to your patients?

A.

What I eat is a cross between paleo and vegan diets. It combines elements of the two, so I call it a “pegan” diet. It’s low in sugars and refined carbs, and it’s very high in plant foods. About 70 to 80 percent of your diet should be plant foods. It should also include good-quality fats like nuts and seeds, olive oil, avocado, coconut oil and fatty fish. It should basically include whole, fresh food that’s unprocessed and high in fiber and phytonutrients. I always say that vegetables should make up 50 to 75 percent of your plate.

Q.

In a world where fast food is everywhere, wouldn’t that be fairly difficult for most people?

A.

It’s actually very easy to eat well if you just know what to do. The reason most people don’t succeed is they don’t plan their food. They plan their vacations, they plan their kitchen redesign, but they don’t plan out what they’re eating, and that’s a recipe for failure. I always think through how and where I’m going to get my food every day of every week. I also carry with me a set of emergency food so that I’m never in a food emergency.

Q.

What are the “emergency foods” that you carry?

A.

I have to protect myself from myself because I’ll eat whatever if I’m hungry in an airport. So I always carry packets of almond butter, cashew butter, an Evolution bar, a Bulletproof bar, a Tanka bar and a KIND bar. I basically have fat and protein as my snacks, and I have enough food in my bag to last an entire day so I don’t make bad choices.

Q.

We talked a lot about fat. But what is one overarching message you would most like people to understand?

A.

I think we have to get rid of the prevailing dogma that all calories are the same, and that we just need to exercise more and eat less, which is what the food industry and the government promote. The truth is that you can’t exercise your way out of a bad diet. Metabolism is not a math problem. It’s a hormonal problem. Food is not just energy. It’s information. It’s instructions that turn on or off different switches in your body that regulate hunger and metabolism. Obesity is not about how much you eat. It’s about what you eat. If you just focus on quality, not calories, then the quantity takes care of itself.

Big Health Benefits to Small Weight Loss

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Credit iStock

Obese individuals who lose as little as 5 percent of their body weight can improve their metabolic function and reduce the risk of developing Type 2 diabetes and heart disease, a new study has found.

Many current treatment guidelines urge patients to lose between 5 percent and 10 percent of their body weight in order to experience health benefits, but the recommendations were based on earlier studies that didn’t distinguish between participants who lost only 5 percent of their weight and those who lost more.

The study, a clinical trial, randomized 40 obese individuals with signs of insulin resistance to either maintain their body weight or go on a low-calorie diet and lose 5 percent, 10 percent or 15 percent of their body weight.

It found that insulin sensitivity improved significantly after participants lost just 5 percent of their body weight, as did triglyceride concentrations, blood pressure and heart rate. There were no improvements in markers of inflammation at that level of weight loss, however.

“Losing 5 percent is much easier than losing 10 percent, so it was important to understand what the differences might be,” said Dr. Samuel Klein, a professor at Washington University School of Medicine and senior author of the study, published in the journal Cell Metabolism. “You get a big bang for your buck with 5 percent.”

Ask Well: The Sugar in Fruit

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Credit Andrew Scrivani for The New York Times

Do you have a health question? Submit your question to Ask Well.

Sophie Egan is the director of programs and culinary nutrition for strategic initiatives at the Culinary Institute of America. She is the author of the forthcoming book “Devoured: From Chicken Wings to Kale Smoothies — How What We Eat Defines Who We Are” (William Morrow, May 2016).

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Sleep Problems Tied to Type 2 Diabetes

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Women with sleeping difficulties are at increased risk for Type 2 diabetes, researchers report.

Scientists used data from 133,353 women who were generally healthy at the start of the study. During 10 years of follow-up, they found 6,407 cases of Type 2 diabetes.

The researchers looked at four sleep problems: self-reported difficulty falling or staying asleep, frequent snoring, sleep duration of less than six hours, and either sleep apnea or rotating shift work. The study is in Diabetologia.

Self-reported difficulty sleeping was associated with higher B.M.I., less physical activity, and more hypertension and depression. But even after adjusting for these and other health and behavioral characteristics, sleeping difficulty was still associated with a 22 percent increased risk for Type 2 diabetes.

Compared to women with no sleep problems, those with two of the sleep conditions studied had double the risk, and those with all four had almost four times the risk of developing the illness.

The senior author, Dr. Frank B. Hu, a professor of nutrition and epidemiology at Harvard, said that sleep problems are associated with excess secretion of two hormones: ghrelin, which increases appetite, and cortisol, which increases stress and insulin resistance. Both are linked to metabolic problems that increase the risk for diabetes.

“And,” he added, “it’s not just quantity of sleep, but quality as well” that is associated with these health risks.

An Eating Disorder in People With Diabetes

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Credit Luba Lukova

The first time she skipped an insulin dose, the 22-year-old said, it wasn’t planned. She was visiting her grandparents over a summer break from college and indulged in bags of potato chips and fistfuls of candy, but forgot to take the extra insulin that people with Type 1 diabetes, like her, require to keep their blood sugar levels in a normal range.

She was already underweight after months of extreme dieting, but when she stepped on the scale the next day, she saw she had dropped several pounds overnight. “I put two and two together,” said the young woman, who lives in Boston and wished to remain anonymous.

She soon developed a dangerous habit that she used to drive her weight down: She would binge, often consuming an entire pint of Ben & Jerry’s peanut butter cup ice cream, and then would deliberately skip the insulin supplements she needed.

People with Type 1 diabetes, who don’t produce their own insulin, require continuous treatments with the hormone in order to get glucose from the bloodstream into the cells. When they skip or restrict their insulin, either by failing to take shots or manipulating an insulin pump, it causes sugars — and calories — to spill into the urine, causing rapid weight loss.

But the consequences can be fatal. “I knew I was playing with fire, but I wasn’t thinking about my life, just my weight,” said the young woman, who was treated at The Renfrew Center of Boston, which specializes in treating eating disorders, and is in recovery. “I got used to my blood sugars running high all the time. I would get so nauseous I would throw up, which I knew was a serious sign that I should go to the hospital. It was very scary.”

The eating disorder the young woman developed is unique to people with Type 1 diabetes and has been called diabulimia, though it is not a recognized medical condition. (People with Type 2 diabetes who take insulin do not have the same rapid response to insulin restriction.) It occurs when patients manipulate their insulin in order to purge calories, much as someone with bulimia might induce vomiting to lose weight.

Insulin restriction can lead to diabetic ketoacidosis, a potentially fatal condition that develops when the body lacks insulin and starts to break down fat, producing ketones that can poison the body. It also increases the risk of serious long-term complications of diabetes, including kidney disease, blindness, nerve damage, amputations and heart disease.

“It’s a Faustian bargain,” said Dr. Henry Cheng, the Northeast regional medical director for The Renfrew Center.

Young women with Type 1 diabetes, which is often diagnosed in the pre-teenage years, when girls may be preoccupied with weight and body image, are at 2.4 times the risk of developing an eating disorder than other young women without diabetes, research suggests. Weight loss is often the first symptom of Type 1 diabetes, but once the condition is diagnosed and patients start insulin treatment, they tend to gain weight.

The combination of Type 1 diabetes and an eating disorder is “very dangerous,” said Ann Goebel-Fabbri, a psychologist in Brookline, Mass., who specializes in treating people with diabetes who have eating disorders. “Anorexia is the most lethal psychiatric diagnosis that exists, and the risk of mortality is so much more heightened when Type 1 diabetes is added.”

Research suggests insulin manipulation is not uncommon. A recent study in Germany found that among patients ages 11 to 21 who were being treated with insulin for Type 1 diabetes, one in three girls and one in six boys had reported either disordered eating, insulin restriction or both.

Another study from the Joslin Diabetes Center in Boston that followed 234 adult women with Type 1 diabetes for 11 years found that 30 percent reported engaging in insulin restriction behaviors. Those who restricted insulin died at an average age of 45, compared with 58 for those who didn’t restrict insulin.

Treatment for diabulimia is especially challenging because approaches to managing eating disorders and diabetes are at odds with one another, said Trish Lieberman, the director of nutrition at Renfrew. “The treatment for diabetes includes very intense focus on reading labels, counting calories and carbohydrates, and limiting sodium and fat,” she said. “All these things that are very effective for treating diabetes are actually contraindicated for eating disorders, where we try to take a more intuitive approach, saying there aren’t good or bad foods.”

Indeed, Dr. Goebel-Fabbri said, the meticulous focus on food in diabetes “can mimic an eating disorders mind-set.”

An added danger occurs when diabetic patients disengage from their medical care, she said. That’s what happened to the Boston college student, who put off going to the doctor for months at a time, hoping the delays would give her time to change her behavior and improve her blood glucose test results. She was alarmingly underweight, and her friends and family were concerned.

Last spring, with severe pain racking her body and fearful she had damaged her kidneys (she had not), she finally enrolled in an intensive five-week day treatment program at Renfrew, followed by a slightly less intensive six-week program.

“At that point, it wasn’t so much for me,” she said. “I almost felt like if I were to die, I would deserve it. I was thinking more of my mom. I couldn’t do that to my mother.”

Though she still suffers from obsessive thoughts about food, she said, “I’m in a much better place. My weight is at a healthy range. I’m more comfortable about reaching out when I need help.”

Experts say both physicians and family members should be on the lookout for eating disorders in Type 1 diabetes patients who have repeated episodes of ketoacidosis, or consistently poor blood sugar control that doesn’t improve. While eating disorders usually develop during the preteen and teenage years, they may emerge later, during college or early adulthood, in those with Type 1 diabetes, experts say.

Once patients get help and start recovering, they can regain their health and stave off long-term complications, Dr. Goebel-Fabbri said. “What’s so positive, and what people need to hear, is that healing can occur, once blood sugar gets to a healthier range.”

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