Relationship between diabetic knowledge, attitudes and practices among patients with diabetes in China: a structural equation model

OBJECTIVES

Whether the routine delivery of diabetes-related knowledge can change patients' attitudes and hence influence their self-management activities remains unknown in primary healthcare settings in China. Thus, this study aims to explore the complex transformation process between knowledge, attitude and practice (KAP) among patients with diabetes in a city in China.

DESIGN

A cross-sectional study.

SETTING

Yuhuan City, Zhejiang Province, China.

PARTICIPANTS

A total of 803 patients with diabetes were invited to attend a questionnaire survey and 782 patients with type 2 diabetes completed the survey. The average age of participants was 58.47 years old, 48.21% of whom only attended primary school or below.

PRIMARY AND SECONDARY OUTCOME MEASURES

A questionnaire based on existing scales and expert consultation was applied to assess patients' socio-demographic information (SI), disease progression risk and diabetes-related KAP. A structural equation model was built to analyse the relationships between patients' characteristics and KAP.

RESULTS

No significant association was found between patients' knowledge and attitude (β=0.01, p=0.43). Better knowledge and attitude were both found to be associated with better diet and physical activities (β=0.58, p<0.001; β=0.46, p=0.01). However, patients with a more positive attitude toward diabetic care showed worse foot care practice (β=-0.13, p=0.02), while better knowledge was associated with better foot care practice (β=0.29, p<0.001). In addition, patients with higher SI (β=0.88, p<0.001) and/or disease progression risk (β=0.42, p<0.001) tended to present higher levels of disease knowledge.

CONCLUSIONS

While successful KAP transformation has been achieved in practice for diet and physical activities, there is a need to improve foot care practice. Health education should also prioritise the prevention, detection and care of diabetic foot. Also, appropriate methods should be adopted to deliver health education to vulnerable patients, such as the elderly, those living in rural areas, those with minimal education, the unemployed and low-income patients.

Unveiling the effects of living standards on diabetes and hypertension with the mediating role of overweight and obesity: a cross-sectional study in Bangladesh

OBJECTIVE

The purpose of the study was to ascertain how the standard of living is associated with the likelihood of developing diabetes and hypertension directly as well as indirectly through overweight and obesity.

STUDY DESIGN

The study used 2017-2018 Bangladesh Demographic and Health Survey data. It examined the household living standard (LSD) as the main factor, and body mass index (BMI) as a mediator. Outcomes included diabetes status, hypertension status and their co-occurrence. Structural equation modelling with logistic regression and bootstrapping were used for mediation analysis and computing bias-corrected SEs.

SETTING

The research was carried out in Bangladesh and included both male and female adults.

PARTICIPANTS

The study encompassed a total of 11 961 adults (5124 males and 6837 females) aged 18 years or older.

RESULTS

Among the participants, 10.3% had diabetes, 28.6% had hypertension and 4.9% had both conditions. The prevalence of diabetes, hypertension or both conditions was 18.5%, 33.5% and 9.7%, respectively, among those with a high LSD. Regression analysis demonstrated that individuals with high LSD had significantly elevated risks of these conditions compared with those with low LSD: 133% higher odds for diabetes (OR 2.22; 95% CI 1.97 to 2.76), 25% higher odds for hypertension (OR 1.25; 95% CI 1.10 to 1.42) and 148% higher odds for both conditions (OR 2.48; 95% CI 1.96 to 3.14). Moreover, the indirect effects of high LSD through obesity surpassed its direct effects for developing diabetes, hypertension or both conditions.

CONCLUSION

This study emphasises that with the enhancement of LSD, individuals often experience weight gain, resulting in elevated BMI levels. This cascade effect significantly amplifies the risks of diabetes, hypertension or both conditions. To counteract this concerning trajectory, policy interventions and targeted awareness campaigns are imperative. These efforts must prioritise the promotion of heightened physical activity and the mitigation of the overweight/obesity surge associated with rising LSD.

Investigating the ability to adhere to cardiometabolic medications with different properties: a retrospective cohort study of >500 000 patients in the USA

OBJECTIVE

Poor medication adherence remains highly prevalent and adversely affects health outcomes. Patients frequently describe properties of the pills themselves, like size and shape, as barriers, but this has not been evaluated objectively. We sought to determine the extent to which oral medication properties thought to be influential translate into lower objectively-measured adherence.

DESIGN

Retrospective cohort study.

SETTING

US nationwide commercial claims database, 2016-2019.

PARTICIPANTS

Among patients initiating first-line hypertension, diabetes or hyperlipidaemia treatment based on clinical guidelines, we measured pill size, shape, colour and flavouring, number of pills/day and fixed-dose combination status as properties.

OUTCOME MEASURES

Outcomes included discontinuation after the first fill (ie, never filling again over a minimum of 1-year follow-up) and long-term non-adherence (1-year proportion of days covered <0.80). We estimated associations between each property and outcomes, by therapeutic class (eg, statins), with multivariable logistic regression.

RESULTS

Across 604 323 patients, 14.6% discontinued after filling once (ie, were non-persistent), and 54.0% were non-adherent over 1-year follow-up. Large pill size was associated with non-adherence, except for thiazides (eg, metformin adjusted OR (aOR): 1.12, 95% CI: 1.06 to 1.18). Greater pill burden was associated with a higher risk of non-adherence across all classes (eg, metformin aOR: 1.58, 95% CI: 1.53 to 1.64 for two pills/day). Taking less than one pill/day was also associated with higher risk of non-adherence and non-persistence (eg, non-persistence statin aOR: 1.29, 95% CI: 1.20 to 1.38). Pill shape, colour, flavouring and combination status were associated with mixed effects across classes.

CONCLUSIONS

Pill burden and pill size are key properties affecting adherence for almost all classes; others, like size and combination, could modestly affect medication adherence. Clinical interventions could screen patients for potential intolerance to medication and potentially implement more convenient dosing schedules.

Protocol of the Berlin Long-term Observation of Vascular Events (BeLOVE): a prospective cohort study with deep phenotyping and long-term follow up of cardiovascular high-risk patients

INTRODUCTION

The Berlin Long-term Observation of Vascular Events is a prospective cohort study that aims to improve prediction and disease-overarching mechanistic understanding of cardiovascular (CV) disease progression by comprehensively investigating a high-risk patient population with different organ manifestations.

METHODS AND ANALYSIS

A total of 8000 adult patients will be recruited who have either suffered an acute CV event (CVE) requiring hospitalisation or who have not experienced a recent acute CVE but are at high CV risk. An initial study examination is performed during the acute treatment phase of the index CVE or after inclusion into the chronic high risk arm. Deep phenotyping is then performed after ~90 days and includes assessments of the patient's medical history, health status and behaviour, cardiovascular, nutritional, metabolic, and anthropometric parameters, and patient-related outcome measures. Biospecimens are collected for analyses including 'OMICs' technologies (e.g., genomics, metabolomics, proteomics). Subcohorts undergo MRI of the brain, heart, lung and kidney, as well as more comprehensive metabolic, neurological and CV examinations. All participants are followed up for up to 10 years to assess clinical outcomes, primarily major adverse CVEs and patient-reported (value-based) outcomes. State-of-the-art clinical research methods, as well as emerging techniques from systems medicine and artificial intelligence, will be used to identify associations between patient characteristics, longitudinal changes and outcomes.

ETHICS AND DISSEMINATION

The study was approved by the Charité-Universitätsmedizin Berlin ethics committee (EA1/066/17). The results of the study will be disseminated through international peer-reviewed publications and congress presentations.

STUDY REGISTRATION

First study phase: Approved WHO primary register: German Clinical Trials Register: https://drks.de/search/de/trial/DRKS00016852; WHO International Clinical Registry Platform: http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00016852. Recruitment started on July 18, 2017.Second study phase: Approved WHO primary register: German Clinical Trials Register DRKS00023323, date of registration: November 4, 2020, URL: http://www.drks.de/ DRKS00023323. Recruitment started on January 1, 2021.

Effects of pharmacist-led interventions on glycaemic control, adherence, disease management and health-related quality of life in patients with type 2 diabetes: a protocol for a network meta-analysis

INTRODUCTION

The increase in the number of patients with uncontrolled type 2 diabetes mellitus (T2DM) is in need of effective management interventions. However, research to date has been limited to the evaluation of the outcomes of community pharmacists alone. Therefore, the aim of the study protocol is to compare the effects of clinical pharmacist-led intervention strategies for the management of T2DM in the outpatient settings.

METHOD AND ANALYSIS

The study will collect and analyse data applying standard Cochrane methodological procedures. A search for eligible studies and ongoing trials will be conducted using PubMed, Embase, Medline (via Ovid), EBSCO (via Ovid), Lippincott Williams & Wilkins (LWW) Journals (via Ovid), ProQuest Health and Medical Complete, and ClinicalTrials.gov (clinicaltrials.gov) from database inception to December 2023. Clinical and health outcomes will be measured using both glycaemic control related indicators (eg, glycated haemoglobin, fasting blood glucose, postprandial glucose) and general indicators (eg, adherence, disease management and health-related quality of life). The meta-analysis will conduct pairwise meta-analysis using random effects models and network meta-analysis (NMA) employing the Bayesian hierarchical model. The visualisation and statistical analysis will be carried out using RevMan, R Studio and ADDIS. Additionally, we will evaluate the certainty of the evidence by using Grading of Recommendations Assessment, Development and Evaluation system.

ETHICS AND DISSEMINATION

There will be no primary data collection from NMA participants, and there is no requirement for formal ethical review. Our aim is to present the results of this NMA in a peer-reviewed scientific journal, at conferences, and in the mainstream media.

PROSPERO REGISTRATION NUMBER

CRD42022355368.

Mental health status of individuals with diabetes in Korea before and during the COVID-19 pandemic: a comparison of data from the Korean national health and nutrition examination surveys of 2018-2019 and 2020-2021

OBJECTIVES

This study aimed to compare the mental health status of patients with diabetes before and after the COVID-19 pandemic and to determine the effect of COVID-19 on their mental health status. This study was the first to investigate the relationship between diabetes and mental health in the Korean population during the COVID-19 pandemic.

DESIGN

This retrospective cross-sectional study investigated the prevalence of mental health problems before (2018-2019) and during (2020-2021) the COVID-19 pandemic in individuals with diabetes aged 40 years or older who participated in the Korea National Health and Nutrition Examination Survey. Mental health problems were assessed using self-reported experiences of depression diagnosis, stress perception and suicide ideation. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9). Clinically significant depression requiring treatment was determined using an optimal cut-off score of 10 out of a total of 27 points.

PARTICIPANTS

There were 824 men and 763 women in the 2018-2019 survey and 882 men and 887 women in 2020-2021.

RESULTS

In the unadjusted analysis, women had a statistically significantly higher prevalence of suicide ideation in 2020-2021 (2.9, 95% CI: 1.5 to 4.2) than in 2018-2019 (1.0, 95% CI: 0.4 to 1.7, but p<0.0067). There was no statistically significant difference in both men and women in 2018-2019 after adjusting for age, education, economic activity, hypoglycaemic drug intake or insulin injection, current alcohol consumption, hypertension and hypercholesterolaemia. A comparison of the results of the PHQ-9 survey conducted in 2018-2019 and 2020-2021 found no statistically significant difference in the prevalence of depressive disorder among both men and women.

CONCLUSIONS

Long-term, retrospective observations and studies on the effects of COVID-19 on the mental health of patients with diabetes should be conducted in the future.

Efficacy of automated insulin delivery (AID) systems in type 1 diabetes: protocol of a systematic review and network meta-analysis of outpatient randomised controlled trials

INTRODUCTION

Automated insulin delivery (AID), also known as artificial pancreas system or 'closed-loop system', represents a novel option for current treatments for type 1 diabetes (T1D). The objective of this systematic review and meta-analysis is to assess the efficacy of AID systems in comparison with current intensified insulin therapy for glycaemic control and patient-reported outcomes in individuals with T1D.

METHODS AND ANALYSIS

Studies will be eligible if they are randomised controlled trials (RCTs) in people with T1D of all ages, and if they compare an AID system for self-administration during the day and night period with any other type of insulin therapy for at least 3 weeks. The primary outcome will be time in the glucose target range of 70-180 mg/dL. A systematic review will be conducted in the MEDLINE, Embase, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov registries from their inception dates. Two authors will independently screen all references based on titles and abstracts against the eligibility criteria. For data extraction, standard forms will be developed and tested before extraction. All information will be assessed independently by at least two reviewers. The risk of bias of the included studies will be assessed using the Cochrane Risk of Bias 2 tool. The data synthesis will include a random-effects pairwise and network meta-analysis (NMA) in a frequentist framework. Where applicable and if sufficient RCTs are available, sensitivity analyses will be performed, and heterogeneity and publication bias will be assessed. The certainty of evidence from the NMA will be evaluated following the Grading of Recommendations Assessment, Development, and Evaluation working group guidance.

ETHICS AND DISSEMINATION

No ethical approval is needed. The results will be reported to the funder, presented in a peer-reviewed scientific journal and at conferences, and disseminated via press release, social media and public events.

PROSPERO REGISTRATION NUMBER

CRD42023395492.

Vitamin D deficiency and its associated factors among patients with type 2 diabetes mellitus: a systematic review and meta-analysis

OBJECTIVE

The study intended to assess the pooled prevalence of vitamin D deficiency (VDD) and its associated factors among patients with type 2 diabetes mellitus (T2DM).

DESIGN

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were employed to plan and conduct this systematic review and meta-analysis.

DATA SOURCES

PubMed, Medline, Google Scholar, Web of Science, Science Direct and the Worldwide Science database were searched from their inception to 31 January 2023.

METHODS

Data were extracted using a standardised data extraction format prepared in Microsoft Excel. The inverse variance (I2) test was used to evaluate the presence of heterogeneity across the included studies. To identify the possible source of heterogeneity, subgroup analysis was carried out. Funnel plot symmetry, Begg's and Egger's tests were used to evaluate the existence of publication bias. In addition, factors associated with VDD among patients with T2DM were examined. All statistical analyses were carried out with STATA V.14 software.

RESULTS

A total of 54 studies with 38 016 study participants were included in the study. The pooled prevalence of VDD among patients with T2DM was found to be 64.2% (95% CI 60.6% to 67.8%) with a substantial level of heterogeneity (I2=98.2%; p<0.001). Results of the subgroup analysis indicated that the pooled prevalence of VDD among patients with T2DM was highest (70.9%) in African nations and lowest (57.1%) in Middle East countries. Being female (pooled OR (POR) 1.60, 95% CI 1.29 to 1.97), having poor glycaemic control (POR 2.50; 95% CI 1.74 to 3.59), hypertension (POR 1.21; 95% CI 1.08 to 1.36), obesity (body mass index ≥25) (POR 1.68; 95% CI 1.16 to 2.44), dyslipidaemia (POR 2.54, 95% CI 1.37 to 4.73), albuminuria (POR 2.22, 95% CI 1.71 to 2.95), nephropathy (POR 1.58; 95% CI 1.08 to 2.31) and retinopathy (POR 1.48: 95% CI 1.17 to 1.89) were predictors of VDD among patients with T2DM.

CONCLUSIONS

More than half of patients with T2DM were suffering from VDD. Being female, having poor glycaemic control, hypertension, obesity, dyslipidaemia, albuminuria, nephropathy and retinopathy were the predictors of VDD among patients with T2DM.

Study protocol for development and validation of a single tool to assess risks of stroke, diabetes mellitus, myocardial infarction and dementia: DemNCD-Risk

INTRODUCTION

Current efforts to reduce dementia focus on prevention and risk reduction by targeting modifiable risk factors. As dementia and cardiometabolic non-communicable diseases (NCDs) share risk factors, a single risk-estimating tool for dementia and multiple NCDs could be cost-effective and facilitate concurrent assessments as compared with a conventional single approach. The aim of this study is to develop and validate a new risk tool that estimates an individual's risk of developing dementia and other NCDs including diabetes mellitus, stroke and myocardial infarction. Once validated, it could be used by the public and general practitioners.

METHODS AND ANALYSIS

Ten high-quality cohort studies from multiple countries were identified, which met eligibility criteria, including large representative samples, long-term follow-up, data on clinical diagnoses of dementia and NCDs, recognised modifiable risk factors for the four NCDs and mortality data. Pooled harmonised data from the cohorts will be used, with 65% randomly allocated for development of the predictive model and 35% for testing. Predictors include sociodemographic characteristics, general health risk factors and lifestyle/behavioural risk factors. A subdistribution hazard model will assess the risk factors' contribution to the outcome, adjusting for competing mortality risks. Point-based scoring algorithms will be built using predictor weights, internally validated and the discriminative ability and calibration of the model will be assessed for the outcomes. Sensitivity analyses will include recalculating risk scores using logistic regression.

ETHICS AND DISSEMINATION

Ethics approval is provided by the University of New South Wales Human Research Ethics Committee (UNSW HREC; protocol numbers HC200515, HC3413). All data are deidentified and securely stored on servers at Neuroscience Research Australia. Study findings will be presented at conferences and published in peer-reviewed journals. The tool will be accessible as a public health resource. Knowledge translation and implementation work will explore strategies to apply the tool in clinical practice.

What are the perspectives of adults aged 18-40 living with type 2 diabetes in urban settings towards barriers and opportunities for better health and well-being: a mixed-methods study

OBJECTIVES

Delivered as part of the global assessment of diabetes in urban settings, this study explores different aspects of living with type 2 diabetes, for adults aged 18-40. Primary questions were as follows: (1) can we identify subgroups of adults under 40 years old sharing specific perspectives towards health, well-being and living with type 2 diabetes and (2) do these perspectives reveal specific barriers to and opportunities for better type 2 diabetes prevention and management and improved well-being?

DESIGN

The study employed a mixed-method design with data collected through demographic questionnaires, Q-sort statement sorting exercises, focus groups discussions and individual interviews.

SETTING

Primary care across Greater Manchester, UK.

PARTICIPANTS

Those aged between 18 and 40, with a confirmed type 2 diabetes diagnosis, and living in Greater Manchester were eligible to participate. A total of 46 people completed the Q-sort exercise and 43 were included in the final analysis. Of those, 29 (67%) identified as female and 32 (75%) as white. Most common time since diagnosis was between 5 and 10 years.

RESULTS

The Q-sort analysis categorised 35 of the 43 participants (81%) into five subgroups. Based on average statement sorts for each subgroup, perspectives were characterised as: (1) stressed and calamity coping (n=13), (2) financially disadvantaged and poorly supported (n=12), (3) well-intentioned but not succeeding (n=5), (4) withdrawn and worried (n=2) and (5) young and stigmatised (n=3). Holistic analysis of our qualitative data also identified some common issues across these subgroups.

CONCLUSIONS

Adults under 40 with type 2 diabetes are not a homogeneous group, but fall into five identifiable subgroups. They also experience issues specific to this age group that make it particularly difficult for them to focus on their own health. More tailored support could help them to make the necessary lifestyle changes and manage their type 2 diabetes better.

Protocol for a double-blinded randomised controlled trial to assess the effect of faecal microbiota transplantations on thyroid reserve in patients with subclinical autoimmune hypothyroidism in the Netherlands: the IMITHOT trial

BACKGROUND

Hashimoto's thyroiditis (HT) is a common endocrine autoimmune disease affecting roughly 5% of the general population and involves life-long treatment with levothyroxine, as no curative treatment yet exists. Over the past decade, the crosstalk between gut microbiota and the host immune system has been well-recognised, identifying the gut microbiome as an important factor in host health and disease, including susceptibility to autoimmune diseases. Previous observational studies yielded a link between disruption of the gut microbiome composition and HT. This is the first study that investigates the potential of restoring a disrupted gut microbiome with faecal microbiota transplantations (FMTs) to halt disease progression and dampen autoimmunity.

METHODS AND ANALYSIS

The IMITHOT trial is a randomised, double-blinded, placebo-controlled study evaluating either autologous or allogenic FMTs in medication-naïve patients with subclinical autoimmune hypothyroidism. In total, 34 patients will be enrolled to receive either three allogenic or autologous FMTs. FMT will be made of fresh stool and directly administered into the duodenum. Patients will be evaluated at baseline before the first FMT is administered and at 6, 12 and 24 months post-intervention to assess efficacy and adverse events. The primary outcome measure will be the net incremental increase (incremental area under the curve) on thyrotropin-stimulated free thyroxine and free triiodothyronine release at 6 and 12 months compared with baseline. Results will be disseminated via peer-reviewed journals and international conferences. The recruitment of the first patient and donor occurred on 18 December 2019.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the hospital Ethics Committee (Medical Ethics Committee) at Amsterdam University Medical Center. The trial's outcomes offer high-quality evidence that aids in unveiling distinct patterns within the gut microbiota potentially associated with improved thyroid function. Consequently, this may open avenues for the future clinical applications of microbial-targeted therapy in individuals at risk of developing overt HT.

TRIAL REGISTRATION NUMBER

NL7931.

Association between serum triglyceride to high-density lipoprotein cholesterol ratio and sarcopenia among elderly patients with diabetes: a secondary data analysis of the China Health and Retirement Longitudinal Study

OBJECTIVE

Previous studies investigating the association between the serum triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio and the occurrence of sarcopenia in different populations have yielded inconsistent results. This study aimed to investigate the potential association between TG/HDL-C ratio and sarcopenia among elderly Chinese patients with diabetes.

DESIGN

A secondary data analysis.

SETTING

This was a secondary analysis of data from the China Health and Retirement Longitudinal Study.

PARTICIPANTS

In this study, 752 elderly individuals with diabetes were included after excluding individuals aged <60 years old, those with missing data for the assessment of sarcopenia and missing measurements for plasma glucose or glycated haemoglobin.

OUTCOME MEASURES

The primary information included TG/HDL-C ratio, muscle strength, physical performance, muscle mass and covariables. The association between TG/HDL-C ratio and sarcopenia was assessed using ordinal logistic regression and linear regression analysis.

RESULTS

On multivariate ordinal logistic regression, among male patients, compared with those with the lowest quartile of TG/HDL-C ratio (≤1.41), those with the highest quartile (>4.71) had a significantly lower risk of more severe sarcopenia (OR 0.24, 95% CI 0.10 to 0.54). Similarly, among female patients, compared with those with the lowest quartile of TG/HDL-C ratio (≤2.07), those with the highest quartile (>5.61) had a significantly lower risk of more severe sarcopenia (OR 0.17, 95% CI 0.07 to 0.44). In multivariate linear regression, male patients with the highest quartile of TG/HDL-C ratio (β=0.36, 95% CI 0.20 to 0.51) had higher muscle mass than those with the lowest quartile. Similarly, female patients with the highest quartile of TG/HDL-C ratio (β=0.31, 95% CI 0.10 to 0.51) had higher muscle mass than those with the lowest quartile.

CONCLUSIONS

There was a negative association between TG/HDL-C ratio categorised by quartile and sarcopenia, which indicates that a higher TG/HDL-C ratio may be related to better muscle status.

Metabolic control and incidence of hypoglycaemia, hospitalisation and complications among Saudi patients with type 2 diabetes initiating second-line therapy: an analysis of the Saudi Arabia data from the DISCOVER Observational Study programme

OBJECTIVES

The aim of the global DISCOVERing Treatment Reality of Type 2 Diabetes in Real World Settings (DISCOVER) Study was to provide a comprehensive real world assessment of the treatment pattern changes for patients with type 2 diabetes. The aim of this analysis was to assess the metabolic control and the annual incidence of hypoglycaemia, hospitalisation and complications among Saudi patients with type 2 diabetes initiating second-line therapy.

DESIGN

This study is part of the observational, longitudinal, prospective multinational DISCOVER Study.

SETTING

Governmental and private health sectors from different regions within Saudi Arabia.

PARTICIPANTS

The study recruited 519 patients with type 2 diabetes aged ≥18 years who were switching to second-line therapy. Patients who were already using insulin/injectable agents, patients with type 1 diabetes, pregnant women, and patients undergoing dialysis or with a history of renal transplantation were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Metabolic control among patients with type 2 diabetes mellitus; fear of hypoglycaemia; quality of life; and the incidence of complications, hypoglycaemic events and/or hospitalisations. Data were analysed using descriptive statistics.

RESULTS

A total of 519 patients were recruited with a mean age of 52.4±11 years. Of these participants, 54.7% were male and 45.3% were female. The incidence of hypoglycaemia was 56.72/1000 patient-years. The Hypoglycemia Fear Survey II showed a significant increase in patient worry related to hypoglycaemia from 6.4±11.9 at baseline to (p=0.0446) at the 36-month follow-up. The incidence of hospitalisation was 30.81/1000 patient-years. There was a moderate improvement in glycaemic control, represented as an HbA1c reduction from 8.8% at baseline to 8.2% at the 36-month follow-up. The incidence of macroangiopathy was 24.51/1000 patient-years and the incidence of microvascular complications such as retinopathy and albuminuria was 47.00/1000 patient-years and 221.71/1000 patient-years, respectively. The mean score of fear of hypoglycaemia showed an increase with 13.0±21.5 at baseline to 16.1±22.2 at the 36-month follow-up. When assessing the patients' quality of life, there was an improvement in the mental component score from 47.4±9.1 at baseline to 53.0±6.7 at the 36-month follow-up.

CONCLUSIONS

Treatment intensification decisions should be made individually, weighing the benefit of good glycaemic control against the risk of hypoglycaemia.

TRIAL REGISTRATION NUMBER

NCT02322762 and NCT02226822.

Prevalence of type 2 diabetes and pre-diabetes in Sri Lanka: a systematic review and meta-analysis

OBJECTIVE

The purpose of this research was to determine the prevalence of diabetes and pre-diabetes in Sri Lanka.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (via PubMed), Web of Science, Sri Lankan Journals online and Google Scholar were searched for relevant articles published between January 1990 and June 2022 investigating the prevalence of pre-diabetes and diabetes in Sri Lanka.

METHODS

Random effect meta-analyses were conducted to derive the pooled prevalence of pre-diabetes and diabetes and their 95% CIs. Heterogeneity was explored by subgroup and meta-regression analyses. Sensitivity analyses were used to evaluate the impact of any single study on the pooled estimates. Two authors screened articles, extracted data and evaluated the quality of selected studies.

RESULTS

A total of 479 articles were reviewed, and 15 studies (n=30 137 participants) were selected in the final analysis. The overall pooled prevalence of diabetes was 12.07% (95% CI, 8.71% to 15.89%; prediction interval: 1.28-31.35). The pooled pre-diabetes prevalence was 15.57% (95% CI, 9.45% to 22.88%; prediction interval: 0.02-49.87). The pooled type 2 diabetes prevalence was the highest in the latest period of 2011-2021 (17.25%) than in the period of 2000s (11.84%) and 1990s (5.62%).

CONCLUSIONS

The growing trend of diabetes and pre-diabetes over the last 30 years is alarming in Sri Lanka. The government of Sri Lanka needs to take steps to improve diabetes education, screening, diagnosis and treatment.

PROSPERO REGISTRATION NUMBER

CRD42021288591.

Associations between human cytomegalovirus infection and type 2 diabetes mellitus: a systematic review and meta-analysis

OBJECTIVE

Multiple studies have reported a potential contribution of human cytomegalovirus (HCMV) to the pathogenesis of type 1 diabetes and post-transplantation diabetes. However, the association between HCMV and type 2 diabetes mellitus (T2DM) remains unclear. In this paper, we employ the meta-analysis approach to investigate the potential correlation between HCMV infection and T2DM.

METHOD

The data of our study were collected from PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure and WAN FANG databases from inception to November 2022. Using the Review Manager V.5.4 software, the meta-analysis was performed.

RESULTS

A total of 18 139 patients from 22 studies were included in our analysis. In the Asian subgroup, the patients with T2DM group had a significantly higher frequency of HCMV infection and older age compared with the healthy group. In the European, the frequency of HCMV infection in the T2DM was lower than the healthy group, although this difference was not statistically significant. After adjusting for demographic factors, the adjusted OR of T2DM for risk of by HCMV status was not found to be significant (adjusted OR=1.19, 95% CI=0.88 to 1.62, p>0.05). Additionally, T2DM with vasculopathy had a significantly higher rate of HCMV infection compared with those without vasculopathy (OR=1.87, 95% CI=1.24 to 2.83, p<0.05). Among T2DM with HCMV infection, there were significant increases in fasting blood glucose levels and the proportion of CD8+ T lymphocytes. Conversely, fasting blood insulin levels, the proportion of CD4+ T lymphocyte and the CD4+/CD8+ ratio were significantly decreased compared with the healthy group.

CONCLUSION

At present, the available evidence does not provide a clear understanding of whether there is a significant association between T2DM and HCMV infection. Additionally, T2DM with HCMV infection exhibited significantly worse blood glucose regulation and immune markers, as well as a higher frequency of vasculopathy.

PROSPERO REGISTRATION NUMBER

CRD42022342066.

Dual hormone fully closed loop in type 1 diabetes: a randomised trial in the Netherlands - study protocol

INTRODUCTION

The management of type 1 diabetes (T1DM) has undergone significant advancements with the availability of novel technologies, notably continuous and flash glucose monitoring (CGM and FGM, respectively) and hybrid closed loop (HCL) therapy. The dual hormone fully closed loop (DHFCL) approach with insulin and glucagon infusion has shown promising effects in small studies on glycaemic regulation and quality of life in T1DM.

METHODS AND ANALYSIS

The Dual Hormone Fully Closed Loop for Type 1 Diabetes (DARE) study is a non-commercial 12-month open-label, two-arm randomised parallel-group trial. The primary aim of this study is to determine the long-term effects on glycaemic control, patient-reported outcome measurements and cost-effectiveness of the DHFCL compared with usual care, that is, HCL or treatment with multiple daily insulin injections+FGM/CGM. We will include 240 adult patients with T1DM in 14 hospitals in the Netherlands. Individuals will be randomised 1:1 to the DHFCL or continuation of their current care.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Medical Research Ethics Committee NedMec, Utrecht, the Netherlands. Findings will be disseminated through peer-reviewed publications and presentations at local, national and international conferences.

TRIAL REGISTRATION NUMBER

NCT05669547.

Perceived health system facilitators and barriers to integrated management of hypertension and type 2 diabetes in Kenya: a qualitative study

OBJECTIVE

Understanding the facilitators and barriers to managing hypertension and type 2 diabetes (T2D) will inform the design of a contextually appropriate integrated chronic care model in Kenya. We explored the perceived facilitators and barriers to the integrated management of hypertension and T2D in Kenya using the Rainbow Model of Integrated Care.

DESIGN

This was a qualitative study using data from a larger mixed-methods study on the health system response to chronic disease management in Kenya, conducted between July 2019 and February 2020. Data were collected through 44 key informant interviews (KIIs) and eight focus group discussions (FGDs).

SETTING

Multistage sampling procedures were used to select a random sample of 12 study counties in Kenya.

PARTICIPANTS

The participants for the KIIs comprised purposively selected healthcare providers, county health managers, policy experts and representatives from non-state organisations. The participants for the FGDs included patients with hypertension and T2D.

OUTCOME MEASURES

Patients' and providers' perspectives of the health system facilitators and barriers to the integrated management of hypertension and T2D in Kenya.

RESULTS

The clinical integration facilitators included patient peer support groups for hypertension and T2D. The major professional integration facilitators included task shifting, continuous medical education and integration of community resource persons. The national referral system, hospital insurance fund and health management information system emerged as the major facilitators for organisational and functional integration. The system integration facilitators included decentralisation of services and multisectoral partnerships. The major barriers comprised vertical healthcare services characterised by service unavailability, unresponsiveness and unaffordability. Others included a shortage of skilled personnel, a lack of interoperable e-health platforms and care integration policy implementation gaps.

CONCLUSIONS

Our study identified barriers and facilitators that may be harnessed to improve the integrated management of hypertension and T2D. The facilitators should be strengthened, and barriers to care integration redressed.

US Army basic combat training alters the relationship between body mass index and per cent body fat

INTRODUCTION/BACKGROUND

As a proxy for adiposity, body mass index (BMI) provides a practical public health metric to counter obesity-related disease trends. On an individual basis, BMI cannot distinguish fat and lean components of body composition. Further, the relationship between BMI and body composition may be altered in response to physical training. We investigated this dynamic relationship by examining the effect of US Army basic combat training (BCT) on the association between BMI and per cent body fat (%BF).

METHODS

BMI and %BF were measured at the beginning (week 1) and end (week 9) of BCT in female (n=504) and male (n=965) trainees. Height and weight were obtained for BMI, and body composition was obtained by dual X-ray absorptiometry. Sensitivity and specificity of BMI-based classification were determined at two BMI thresholds (25 kg/m2 and 27.5 kg/m2).

RESULTS

A progressive age-related increase in fat-free mass index (FFMI) was observed, with an inflection point at age 21 years. In soldiers aged 21+, BMI of 25.0 kg/m2 predicted 33% and 29% BF in women and 23% and 20% BF in men and BMI of 27.5 kg/m2 predicted 35% and 31% BF in women and 26% and 22% BF in men, at the start and end of BCT, respectively. Sensitivity and specificity of BMI-based classification of %BF were poor. Soldiers below BMI of 20 kg/m2 had normal instead of markedly reduced %BF, reflecting especially low FFMI.

CONCLUSIONS

BCT alters the BMI-%BF relationship, with lower %BF at a given BMI by the end of BCT compared with the beginning, highlighting the unreliability of BMI to try to estimate body composition. The specific BMI threshold of 25.0 kg/m2, defined as 'overweight', is an out-of-date metric for health and performance outcomes. To the extent that %BF reflects physical readiness, these data provide evidence of a fit and capable military force at BMI greater than 25.0 kg/m2.

Manchester Intermittent and Daily diet Type 1 Diabetes App Study (MIDDAS-Type 1): protocol for a randomised feasibility trial of an intermittent and continuous low-energy diet in patients with type 1 diabetes and overweight and obesity

INTRODUCTION

Rising levels of overweight and obesity among people with type 1 diabetes (T1D) contribute to insulin resistance, dyslipidaemia, retinopathy, cardiometabolic complications and psychological morbidity. Continuous low-energy diets (CLED) providing approximately 800 kcal (3347 kJ)/day can produce significant weight loss in type 2 diabetes, and intermittent low-energy diets (ILED) may be an alternative. The Manchester Intermittent and Daily diet Type 1 Diabetes App Study (MIDDAS-Type 1) aims to assess the safety, acceptability and feasibility of remotely delivered ILED and CLED programmes for people with T1D and overweight and obesity.

METHODS AND ANALYSIS

Twelve participants with T1D and body mass index ≥27.5 kg/m² (≥25 kg/m² in high-risk ethnic minorities) recruited from an National Health Service (NHS) trust and research register in England will be randomised to a remotely delivered CLED (n=6) or ILED (n=6) for 12 weeks. The CLED includes a daily Optifast 850 kcal (3556 kJ) 75 g carbohydrate formula diet. The ILED includes 2 days/week of Optifast and 5 days of a portion-controlled Mediterranean diet (170-250 g carbohydrate/day). Both groups will receive matched high-frequency remote support from a dietitian, nurse and psychologist via telephone and/or the Oviva app. The primary outcome will assess safety (occurrence of severe hypoglycaemia, ketonaemia, ketoacidosis and time above and below target blood glucose). Secondary outcomes include study uptake, retention, dietary adherence, acceptability, intervention delivery fidelity and potential efficacy in relation to change in weight, insulin requirements, glycated haemoglobin, lipids, insulin resistance (estimated glucose disposal rate) and quality of life. Participants will be invited for optional repeat measurements at 52 weeks.

ETHICS AND DISSEMINATION

The trial protocol (V4.0/08.06.2022) was granted ethical approval by Cambridge East Research Ethics Committee (Ref: 21/EE/0014). The study will inform progression to a full-scale randomised controlled trial to test the efficacy of these programmes for patients with T1D and overweight and obesity.

TRIAL REGISTRATION NUMBER

NCT04674384; Pre-results.

Associations of serum aminotransferase and the risk of all-cause and cause-specific mortality in Chinese type 2 diabetes: a community-based cohort study

OBJECTIVE

Investigating the associations of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) with all-cause, cardiovascular disease (CVD) and cancer mortality in a large cohort of community-dwelling patients with type 2 diabetes mellitus (T2DM).

DESIGN

Community-based prospective cohort study conducted between 2013 and 2014.

SETTING

44 selected townships in Changshu and Huai'an City, Jiangsu province, China.

PARTICIPANTS

20340 participants with T2DM were recruited in Jiangsu province, China.

METHODS

We use Cox proportional hazard models to estimate the HR and 95% CIs of associations of serum ALT and AST levels with all-cause and cause-specific mortality. Restricted cubic splines were used to explore the dose-response relationships between ALT and AST levels with mortality.

RESULTS

ALT and AST levels were inversely associated with CVD mortality, compared with the lowest quintile (Q1), the multivariable HRs of the highest quintile (Q5) was 0.82 (95% CI: 0.66 to 1.01, p for trend=0.022) and 0.78 (95% CI: 0.63 to 0.96, p for trend=0.022), respectively. Furthermore, the HRs for ALT levels in all-cause mortality were 0.90 (95% CI: 0.79 to 1.01, p for trend=0.018), and the HRs for AST levels in cancer mortality were 1.29 (95% CI: 1.02 to 1.63, p for trend=0.023). Stronger inverse effects of ALT and AST levels on all-cause mortality were observed in the older subgroup and in those with dyslipidaemia (all p for interaction <0.05). Further analysis based on gender showed that the associations between serum aminotransferases and the mortality risk were more significant in women and substantially attenuated in men.

CONCLUSION

Our findings suggested patients with T2DM with lower levels of ALT and AST had an increased risk of CVD mortality, which needs confirmation in future clinical trials.

Effects of metformin on bone mineral density and bone turnover markers: a systematic review and meta-analysis

OBJECTIVES

Metformin is associated with osteoblastogenesis and osteoclastogenesis. This study aims to investigate the impacts of metformin therapy on bone mineral density (BMD) and bone turnover markers.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

METHODS

Searches were carried out in PubMed, EMBASE, Web of science, Cochrane library, ClinicalTrials.gov from database inception to 26 September 2022. Two review authors assessed trial eligibility in accordance with established inclusion criteria. The risk of bias was assessed using the Cochrane Risk of Bias tool (RoB V.2.0). Data analysis was conducted with Stata Statistical Software V.16.0 and Review Manager Software V.5.3.

RESULTS

A total of 15 studies with 3394 participants were identified for the present meta-analysis. Our pooled results indicated that metformin had no statistically significant effects on BMD at lumbar spine (SMD=-0.05, 95% CI=-0.19 to 0.09, p=0.47, participants=810; studies=7), at femoral (MD=-0.01 g/cm2, 95% CI=-0.04 to 0.01 g/cm2, p=0.25, participants=601; studies=3) and at hip (MD=0.01 g/cm2, 95% CI=-0.02 to 0.03 g/cm2, p=0.56, participants=634; studies=4). Metformin did not lead to significant change in osteocalcin, osteoprotegerin and bone alkaline phosphatase. Metformin induced decreases in N-terminal propeptide of type I procollagen (MD=-6.09 µg/L, 95% CI=-9.38 to -2.81 µg/L, p=0.0003, participants=2316; studies=7) and C-terminal telopeptide of type I collagen (MD=-55.80 ng/L, 95% CI=-97.33 to -14.26 ng/L, p=0.008, participants=2325; studies=7).

CONCLUSION

This meta-analysis indicated that metformin had no significant effect on BMD. Metformin decreased some bone turnover markers as N-terminal propeptide of type I procollagen and C-terminal telopeptide of type I collagen. But the outcomes should be interpreted with caution due to several limitations.

Association between serum uric acid and measures of adiposity in Chinese adults: a cross-sectional study

OBJECTIVE

The purposes of the study were to investigate the detailed association of serum uric acid (SUA) with visceral fat area (VFA) and body fat percentage (BFP) as calculated by bioelectrical impedance analysis (BIA) and build non-invasive diagnosis models of hyperuricaemia by combining obesity-related indicators, age and sex.

METHOD

A total of 19 343 adults were included. Multivariable regression analysis models were employed to analyse the association of SUA with VFA and BFP. Receiver operating characteristic curves were generated to diagnose hyperuricaemia in adults.

RESULTS

After fully adjusting for covariates, SUA was positively associated with VFA, BFP and body mass index (BMI) with βs of 0.447, 2.522 and 4.630 (95% CI= (0.412 to 0.482), (2.321 to 2.723) and (4.266 to 4.994)). After stratification by gender, this association persists (p<0.001). Fitted smoothing curves identified non-linear relationships between SUA and both VFA and BMI after full adjustment in males (inflection points: 93.9 cm² and 30.9 kg/m²). A non-linear relationship also exists between SUA and BFP in females (inflection point: 34.5%). A combined model incorporating BFP, BMI, age and sex exhibited the best ability to diagnose hyperuricaemia (AUC (area under the curve) =0.805, specificity=0.602, sensitivity=0.878). For normal-weight and lean populations, individuals with hyperuricaemia tended to have higher levels of VFA and BFP in females and males, respectively (p<0.001). The combination of VFA, BFP, BMI, age and sex exhibited the best ability to diagnose hyperuricaemia in normal-weight and lean populations (AUC=0.803, specificity=0.671, sensitivity=0.836).

CONCLUSION

VFA and BFP are independent factors associated with SUA. In males, SUA shows a non-linear relationship with VFA and BMI. In females, SUA and BFP exhibit a non-linear relationship. In normal-weight and lean individuals, the accumulation of VFA and BFP may be involved in hyperuricaemia. VFA and BFP were helpful in diagnosing hyperuricaemia in adults, especially for normal-weight and lean populations.

Text message-based intervention, Keeping in Touch (KiT), to support youth as they transition to adult type 1 diabetes care: a protocol for a multisite randomised controlled superiority trial

INTRODUCTION

Transition from paediatric to adult care can be challenging for youth living with type 1 diabetes (T1D), as many youth feel unprepared to transfer to adult care and are at high risk for deterioration of glycaemic management and acute complications. Existing strategies to improve transition experience and outcomes are limited by cost, scalability, generalisability and youth engagement. Text messaging is an acceptable, accessible and cost-effective way of engaging youth. Together with adolescents and emerging adults and paediatric and adult T1D providers, we co-designed a text message-based intervention, Keeping in Touch (KiT), to deliver tailored transition support. Our primary objective is to test the effectiveness of KiT on diabetes self-efficacy in a randomised controlled trial.

METHODS AND ANALYSIS

We will randomise 183 adolescents with T1D aged 17-18 years within 4 months of their final paediatric diabetes visit to the intervention or usual care. KiT will deliver tailored T1D transition support via text messages over 12 months based on a transition readiness assessment. The primary outcome, self-efficacy for diabetes self-management, will be measured 12 months after enrolment. Secondary outcomes, measured at 6 and 12 months, include transition readiness, perceived T1D-related stigma, time between final paediatric and first adult diabetes visits, haemoglobin A1c, and other glycaemia measures (for continuous glucose monitor users), diabetes-related hospitalisations and emergency department visits and the cost of implementing the intervention. The analysis will be intention-to-treat comparing diabetes self-efficacy at 12 months between groups. A process evaluation will be conducted to identify elements of the intervention and individual-level factors influencing implementation and outcomes.

ETHICS AND DISSEMINATION

The study protocol version 7 July 2022 and accompanying documents were approved by Clinical Trials Ontario (Project ID: 3986) and the McGill University Health Centre (MP-37-2023-8823). Study findings will be presented at scientific conferences and in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT05434754.

Association of uric acid with the decline in estimated glomerular filtration rate in middle-aged and elderly populations: evidence based on the China Health and Retirement Longitudinal Study

OBJECTIVE

Whether uric acid (UA) has an effect on renal function remains controversial. We aimed to investigate the association between serum UA with the decline in estimated glomerular filtration rate (eGFR) in middle-aged and elderly populations in the China Health and Retirement Longitudinal Study (CHARLS).

DESIGN

Longitudinal cohort study.

SETTING

This was a second analysis of a public dataset (CHARLS).

PARTICIPANTS

In this study, 4538 middle-aged and elderly individuals were screened after removing individuals younger than 45 years old, with kidney disease, malignant tumour and missing values.

OUTCOME MEASURES

Blood tests were performed both in 2011 and 2015. Decline in eGFR was defined as an eGFR decrease of more than 25% or deterioration of the eGFR stage during the 4-year follow-up period. Logistic models corrected for multiple covariables were used to analyse the association of UA with the decline in eGFR.

RESULTS

The median (IQR) concentrations of serum UA grouped by quartiles were 3.1 (0.6), 3.9 (0.3), 4.6 (0.4) and 5.7 (1.0) mg/dL, respectively. After multivariable adjustment, the OR of the decline in eGFR was higher for quartile 2 (3.5-<4.2 mg/dL: OR 1.44; 95% CI 1.07 to 1.64; p<0.01), quartile 3 (4.2-<5.0 mg/dL: OR 1.72; 95% CI 1.36 to 2.18; p<0.001) and quartile 4 (≥5.0 mg/dL: OR 2.04; 95% CI 1.58 to 2.63; p<0.001) when compared with quartile 1 (<3.5 mg/dL), and the p value for the trend was <0.001.

CONCLUSIONS

Over a 4-year follow-up period, we found that elevated UA was associated with a decline in eGFR in the middle-aged and elderly individuals with normal renal function.

Diabetes mellitus monitoring and control among adults in Australian general practice: a national retrospective cohort study

OBJECTIVES

This study investigated whether the monitoring and control of clinical parameters are better among patients with newly compared with past recorded diabetes diagnosis.

DESIGN

Retrospective cohort study.

SETTING

MedicineInsight, a national general practice database in Australia.

PARTICIPANTS

101 875 'regular' adults aged 18+ years with past recorded (2015-2016) and 9236 with newly recorded (2017) diabetes diagnosis.

MAIN OUTCOME MEASURES

Two different groups of outcomes were assessed in 2018. The first group of outcomes was the proportion of patients with clinical parameters (ie, glycated haemoglobin A1c (HbA1c), blood pressure (BP), total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol, triglycerides, estimated glomerular filtration rate and albumin-to-creatinine ratio) monitored at least once in 2018. The second group of outcomes were those related to diabetes control in 2018 (HbA1c ≤7.0%, (BP) ≤140/90 mm Hg, total cholesterol <4.0 mmol/L and LDL-C <2.0 mmol/L). Adjusted ORs (OR_adj) and adjusted probabilities (%) were obtained based on logistic regression models adjusted for practice variables and patients' socio-demographic and clinical characteristics.

RESULTS

The study included 111 111 patients (51.7% men; mean age 65.3±15.0 years) with recorded diabetes diagnosis (11.0% of all 1 007 714 adults in the database). HbA1c was monitored in 39.2% (95% CI 36.9% to 41.6%) of patients with newly recorded and 45.2% (95% CI 42.6% to 47.8%) with past recorded diabetes (OR_adj 0.78, 95% CI 0.73 to 0.82). HbA1c control was achieved by 78.4% (95% CI 76.7% to 80.0%) and 54.4% (95% CI 53.4% to 55.4%) of monitored patients with newly or past recorded diabetes, respectively (OR_adj 3.11, 95% CI 2.82 to 3.39). Less than 20% of patients with newly or past recorded diabetes had their HbA1c, BP and total cholesterol levels controlled (OR_adj 1.08, 95% CI 0.97 to 1.21).

CONCLUSIONS

The monitoring of clinical parameters was lower among patients with newly than past recorded diabetes. However, diabetes control was similarly low in both groups, with only one in five monitored patients achieving control of all clinical parameters.