A1C level and future risk of diabetes: a systematic review

Development of a novel clinical decision support tool for diabetes prevention and feasibility of its implementation in primary care

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Clinical decision support may represent a strategy for promoting diabetes prevention in primary care.

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We developed a novel clinical decision support tool with input from primary care providers.

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This clinician-facing tool was associated with improvements in processes of prediabetes care.

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Exploratory analyses found small, but nonsignificant weight loss associated with its use.

Prediabetes impacts 88 million U.S. adults, yet uptake of evidence-based treatment with intensive lifestyle interventions and metformin remains exceedingly low. After incorporating feedback from 15 primary care providers collected during semi-structured interviews, we developed a novel Prediabetes Clinical Decision Support (PreDM CDS) from August 2019 to February 2020. This tool included order options enabling prediabetes management in a single location within the electronic health record. We conducted a retrospective observational study examining the feasibility of implementing this tool at Erie Family Health Centers, a large community health center, examining its use and related outcomes among patients for whom it was used vs not. Overall, 7,424 eligible patients were seen during the implementation period (February 2020 to August 2021), and the PreDM CDS was used for 108 (1.5 %). Using the PreDM CDS was associated with higher rates of hemoglobin A1c orders (70.4 % vs 22.2 %; p < 0.001), lifestyle counseling (38.0 % vs 7.8 %; p < 0.001), and metformin prescription orders (5.6 % vs 2.6 %; p = 0.06). Exploratory analyses revealed small, nonsignificant weight loss among patients for whom the PreDM CDS was used. This study demonstrates the feasibility of developing and implementing the PreDM CDS in primary care. Its low use was likely related to not imposing an interruptive ‘pop-up’ alert, as well as major changes in workflows and clinical priorities during the Covid-19 pandemic. Use of the tool was associated with improved process outcomes. Future efforts with the PreDM CDS should follow standard CDS implementation processes that were not possible due to the Covid-19 pandemic.

Risk of Macrovascular and Microvascular Disease in Diabetes Diagnosed Using Oral Glucose Tolerance Test With and Without Confirmation by Hemoglobin A1c: The Whitehall II Cohort Study

BACKGROUND

It is unclear whether replacing oral glucose tolerance test (OGTT) with hemoglobin A1c (HbA1c) measurement for diagnosing diabetes is justified. We aimed to assess the proportion of OGTT-diagnosed diabetes cases that can be confirmed by HbA1c and to examine whether individuals with OGTT diagnosis but nondiagnostic HbA1c are at higher risk of macrovascular and microvascular disease.

METHODS

Participants were 5773 men and women from the population-based Whitehall II prospective cohort study in the United Kingdom. New OGTT diabetes cases diagnosed in clinical examinations in 2002 to 2004 and 2007 to 2009 were assessed for HbA1c confirmation (≥6.5%) in these and subsequent clinical examinations in 2012 to 2013 and 2015 to 2016. All participants were followed up for major cardiovascular events through linkage to electronic health records until 2017 and for incident chronic kidney disease (estimated glomerular filtration rate <60 mL·min^-1·1.73 m^-2) until the last clinical examination. In analysis of vascular disease risk, new OGTT-diagnosed diabetes cases with and without diagnostic HbA1c and preexisting diabetes cases were compared with diabetes-free participants.

RESULTS

Of the 378 (59.3%) participants with OGTT-diagnosed diabetes, 224 were confirmed by HbA1c during 4.1 years (SD, 4.1 years) of follow-up. We recorded 942 cardiovascular events over 12.1 years. After adjustment for nonmodifiable risk factors and compared with the 4997 diabetes-free participants, 371 participants with new HbA1c-confirmed diabetes and 405 participants with preexisting diabetes had increased risk of cardiovascular disease (hazard ratio, 1.53 [95% CI, 1.12-2.10] and 1.85 [95% CI, 1.50-2.28], respectively). The corresponding hazard ratios in the analysis of incident chronic kidney disease (487 cases; follow-up, 6.6 years) were 1.69 (95% CI, 1.09-2.62) for 282 participants with new HbA1c-confirmed diabetes and 1.67 (95% CI, 1.22-2.28) for 276 participants with preexisting diabetes. In both analyses, OGTT cases with nondiagnostic HbA1c (n=149 and 107) had a risk (hazard ratio, 0.99-1.07) similar to that of the diabetes-free population.

CONCLUSIONS

More than 40% of OGTT-diagnosed diabetes cases were not confirmed by HbA1c during an extended follow-up. However, because these individuals have a risk of cardiovascular disease and chronic kidney disease similar to that of the diabetes-free population, replacement of OGTT with HbA1c-based diagnosis appears justified.

Effect of aqueous extract of Scorodophloeus zenkeri bark on chronic hyperglycemia and its complications in a diabetic Wistar rat model induced by streptozotocin

Diabetes and its complications represent a real major public health problem in the world because of its high rates of morbidity and mortality. Chronic hyperglycemia, oxidative stress, dyslipidemia and inflammation play a major role in the pathophysiology of diabetes and its vascular complications. The objective of this study was to evaluate the effect of aqueous extract of S. zenkeri on chronic hyperglycemia and its complications in a streptozotocin-induced diabetic Wistar rat model. The barks of S. zenkeri were washed, dried and crushed; the powder was dissolved in distilled water (1:10 weight/volume) then macerated and the filtrate obtained was dried in an oven. Subsequently, after quantification of the bioactive compounds (total polyphenols, flavonoids and alkaloids) present in the extract, an in vivo study was conducted in an animal model of streptozotocin-induced hyperglycemia. For this fact, the rats were divided into four groups of five rats as folow: a normoglycaemia group (NC), an untreated hyperglycaemia group (PC), two hyperglycaemia groups including a test group receiving by esophageal gavage, the aqueous extract of the bark of S zenkerii (AESZ) at a dose of 300 mg/kg body weight and a control group receiving metformin at a dose of 20 mg/kg body weight. During the treatment which lasted 21 days, the weights have been taken every two days and the blood sugar levels every week. At the end of the treatment, the rats were killed under light chloroform anesthesia; the plasma, hemolysate, serum and liver homogenate prepared were used to assay the biochemical parameters of oxidative stress (catalase, MDA), lipid profile (Triglycerides, total cholesterol and HDL-cholesterol) and immunological (CRP and NFS). It emerged that the extract limited weight loss and caused a reduction in blood sugar of -26.59% after 21 days of treatment; the extract caused an increase in the activity of erythrocyte catalase and a reduction in the concentration of hepatic MDA, as well as a very marked reduction in inflammatory cells and CRP. The extract also caused a reduction in dyslipidemiawhich was materialized by a reduction in CRR, AC, AIP and an increase in CPI. These results suggest that this extract contains bioactive compounds capable of reducing chronic hyperglycemia while preventing its complications, thus justifying its traditional use in the management of diabetes.

Salivary Metabolomics of Well and Poorly Controlled Type 1 and Type 2 Diabetes

Objective

The concentrations of endogenous metabolites in saliva can be altered based on the systemic condition of the hosts and may, in theory, serve as a reflection of systemic disease progression. Hemoglobin A1C is used clinically to measure long-term average glycemic control. The aim of the study was to demonstrate if there were differences in the salivary metabolic profiles between well and poorly controlled type 1 and type 2 subjects with diabetes. Subjects and Methods. Subjects with type 1 and type 2 diabetes were enrolled (n = 40). The subjects were assigned to phenotypic groups based on their current level of A1C: <7 = well-controlled and >7 = poorly controlled. Demographic data, age, gender, and ethnicity, were used to match the two phenotypic groups. Whole saliva samples were collected and immediately stored at -80°C. Samples were spiked using an isotopically labeled internal standard and analyzed by UPLC-TOF-MS using a Waters SYNAPT G2-Si mass spectrometer.

Results

Unsupervised principal components analysis (PCA) and orthogonal partial least squares regression discrimination analysis (OPLS-DA) were used to define unique metabolomic profiles associated with well and poorly controlled diabetes based on A1C levels.

Conclusion

OPLS-DA demonstrates good separation of well and poorly controlled in both type 1 and type 2 diabetes. This provides evidence for developing saliva-based monitoring tools for diabetes.

Smoking causes the disorder of glucose metabolism under different levels of blood pressure in male occupational population

Smoking is an important modifiable factor in the risk of type 2 diabetes. Type 2 diabetes and hypertension overlap in the population. The present study investigated effects of smoking on glucose metabolism under different blood pressure (BP) levels in occupational population. A smoking survey among occupational groups was conducted in 2018. The general linear model was used to analyze the differences of glucose metabolism indexes and BP indexes influenced by different smoking intensity (never 0, mild <10, moderate <20, heavy ≥20 pack‐years). Odds ratios of developing diabetes and β‐cell deficiency were analyzed by using logistic regression model. BP was further taken into account in the relationship between smoking and glucose metabolism. As a result, 1730 male workers aged 21 to 60 years were included in the analysis finally. Compared to never smokers, heavy smokers had significantly increased fasting plasma glucose. Moderate and above smokers had significantly increased glycosylated hemoglobin, decreased fasting plasma insulin and β‐cell function, after adjustment for covariates. Further, smoking intensity was found to have a dose‐dependent relationship with impaired β‐cell function and diabetes. In conclusion, smoking has a positive dose‐dependent relationship with β‐cell deficiency and diabetes. Male smoking workers, especially the moderate or higher smoking, with high‐normal and high BP levels are at high risk of abnormal glucose metabolism.

Hepatitis B Virus Infection and Increased Risk of Gestational Diabetes Regardless of Liver Function Status: A Xiamen Area Population-Based Study

Background &amp; Aims: Hepatitis B virus (HBV) infection is a significant cause of liver function damage. However, previous studies on HBV mainly aimed at ordinary people, and there is a lack of consensus on the relationship between HBV infection and gestational diabetes mellitus (GDM) and whether HBV-infected pregnant women should undergo antiviral treatment. In addition, systematic studies on the impact of HBV infection on GDM have rarely been studied directly. Therefore, the overall goal of this study was to pursue the association between HBV infection, liver function, and GDM using Xiamen area gestational big data.

Methods: Using the Xiamen Primary Health Information System-maternal and child health information system, the data on participants (138,867 in total) expected confinement between 2008 and 2018 were included. Using univariate and multivariate logistic regressions, we constructed models to determine the role of HBV infection and liver function status in GDM. In addition, an analysis of variance tests was performed to study whether the relationship between HBsAg and GDM differed in the normal liver function and the abnormal liver function subgroups.

Results: HBsAg's positive status showed a substantial correlation with GDM onset in univariate and multivariate logistic regressions (p &lt; 0.001). Subgroup analysis among HBsAg, liver function, and GDM suggests that both HBsAg and liver function affect the onset of GDM and have the highest prevalence of both abnormalities. Furthermore, ANOVA was used to investigate the association of HBsAg positive (p &lt; 0.001), abnormal liver function (p &lt; 0.001), and their interaction (p = 0.302) on the onset of GDM. This result showed that HBsAg is an independent factor of GDM pathogenesis, regardless of liver function status.

Conclusion: HBsAg and liver function are independent factors in GDM. Therefore, regarding these results, while clinicians consider the traditional risk factors of GDM, it is necessary to consider the HBV infection status. Conducting a dietary intervention for HBsAg-positive pregnant women at the early stage of pregnancy is conducive to reducing the adverse effects.

Domains from the health belief model predict enrollment in the National Diabetes Prevention Program among insured adults with prediabetes

AIMS

To examine enrollment in the National Diabetes Prevention Program (DPP) by insured adults with prediabetes according to domains of the Health Belief Model (HBM).

METHODS

Between 2015 and 2019, University of Michigan employees, retirees, and dependents with prediabetes were offered the National DPP at no out-of-pocket cost. Individuals with prediabetes were identified and mailed letters encouraging them to enroll. We surveyed those who enrolled and a random sample of those who did not using the HBM as a framework to examine factors associated with enrollment. Analyses were performed using multivariable logistic regression models.

RESULTS

Of 64,131 employees, retirees, and dependents, 8131 were identified with prediabetes and 776 (9.5%) enrolled in the National DPP. Of those surveyed, 532 of 776 National DPP enrollees and 945 of 2673 non-enrollees responded to the survey (adjusted response rates 74% and 43%, respectively). Among survey respondents, factors associated with National DPP enrollment included older age, female sex, higher BMI, prediabetes awareness, greater perceived benefits of health-protective action, and one or more cues to action.

CONCLUSIONS

Optimizing National DPP enrollment among adults with prediabetes will require identifying individuals with prediabetes, increasing personal awareness of the diagnosis, increasing perceived benefits of enrollment, and providing strong cues to action.

Bidirectional Longitudinal Relationships Between Arterial Stiffness and Hypertension Are Independent of Those Between Arterial Stiffness and Diabetes: A Large-Scale Prospective Observational Study in Employees of a Japanese Company

Background

Hypertension and diabetes frequently coexist; however, it has not yet been clarified if the bidirectional longitudinal relationships between arterial stiffness and hypertension are independent of those between arterial stiffness and diabetes.

Methods and Results

In this 16‐year prospective observational study, 3960 middle‐aged employees of a Japanese company without hypertension/diabetes at the study baseline underwent annual repeated measurements of blood pressure, serum glycosylated hemoglobin A_1c levels, and brachial‐ankle pulse wave velocity. By the end of the study period, 664, 779, 154, and 406 subjects developed hypertension, prehypertension, diabetes, and prediabetes, respectively. Increased brachial‐ankle pulse wave velocity at the baseline was associated with a significant odds ratio (per 1 SD increase) for new onset of prehypertension/hypertension with (2.45/3.28; P<0.001) or without (2.49/2.76; P<0.001) coexisting prediabetes/diabetes, but not for new onset of prediabetes/diabetes without coexisting hypertension. Analyses using the latent growth curve model confirmed the bidirectional relationships between brachial‐ankle pulse wave velocity and hypertension, but no such relationship was observed between brachial‐ankle pulse wave velocity and abnormal glucose metabolism.

Conclusions

In middle‐aged employees of a Japanese company, while bidirectional relationships were found to exist between increased arterial stiffness and hypertension, such a relationship was not found between increased arterial stiffness and diabetes. Therefore, it appears that increased arterial stiffness may be associated with the development of hypertension but not with that of diabetes.

Development and Validation of a Model That Predicts the Risk of Diabetic Nephropathy in Type 2 Diabetes Mellitus Patients: A Cross-Sectional Study

Purpose

To develop a nomogram model that predicts the risk of diabetic nephropathy (DN) incidence in type 2 diabetes mellitus (T2DM) patients.

Methods

We collect information from electronic medical record systems. The data were split into a training set (n=521) containing 73.8% of patients and a validation set (n=185) holding the remaining 26.2% of patients based on the date of data collection. Stepwise and multivariable logistic regression analyses were used to screen out DN risk factors. A predictive model including selected risk factors was developed by logistic regression analysis. The results of binary logistic regression are presented through forest plots and nomogram. Lastly, the c-index, calibration plots, and receiver operating characteristic (ROC) curves were used to assess the accuracy of the nomogram in internal and external validation. The clinical benefit of the model was evaluated by decision curve analysis.

Results

Predictors included serum creatinine (Scr), hypertension, glycosylated hemoglobin A1c (HbA1c), blood urea nitrogen (BUN), body mass index (BMI), triglycerides (TG), and Diabetic peripheral neuropathy (DPN). Harrell's C-indexes were 0.773 (95% CI:0.726-0.821) and 0.758 (95% CI:0.679-0.837) in the training and validation sets, respectively. Decision curve analysis (DCA) demonstrated that the novel nomogram was clinically valuable.

Conclusion

Our simple nomogram with seven factors may help clinicians predict the risk of DN incidence in patients with T2DM.

Associations Between Device-Measured Physical Activity and Glycemic Control and Variability Indices Under Free-Living Conditions

Background: Disturbances of glycemic control and large glycemic variability have been associated with increased risk of type 2 diabetes in the general population as well as complications in people with diabetes. Long-term health benefits of physical activity are well documented but less is known about the timing of potential short-term effects on glycemic control and variability in free-living conditions. Materials and Methods: We analyzed data from 85 participants without diabetes from the Food & You digital cohort. During a 2-week follow-up, device-based daily step count was studied in relationship to glycemic control and variability indices using generalized estimating equations. Glycemic indices, evaluated using flash glucose monitoring devices (FreeStyle Libre), included minimum, maximum, mean, standard deviation, and coefficient of variation of daily glucose values, the glucose management indicator, and the approximate area under the sensor glucose curve. Results: We observed that every 1000 steps/day increase in daily step count was associated with a 0.3588 mg/dL (95% confidence interval [CI]: -0.6931 to -0.0245), a 0.0917 mg/dL (95% CI: -0.1793 to -0.0042), and a 0.0022% (95% CI: -0.0043 to -0.0001) decrease in the maximum glucose values, mean glucose, and in the glucose management indicator of the following day, respectively. We did not find any association between daily step count and glycemic indices from the same day. Conclusions: Increasing physical activity level was linked to blunted glycemic excursions during the next day. Because health-related benefits of physical activity can be long to observe, such short-term physiological benefits could serve as personalized feedback to motivate individuals to engage in healthy behaviors.

Clinical correlates of plasma insulin levels over the life course and association with incident type 2 diabetes: the Framingham Heart Study

INTRODUCTION

Insulin is a glucose-lowering hormone that affects carbohydrate, lipid, and protein metabolism. Limited data exist on the correlates of insulin levels over the life course in healthy community-dwelling individuals.

RESEARCH DESIGN AND METHODS

Using multilevel modeling of multiple serial observations over 21 years, we assessed the longitudinal correlates of fasting insulin and the cross-sectional correlates of fasting and 2-hour (2h, post 75 g glucose challenge) plasma insulin concentrations in 2140 relatively healthy Framingham Heart Study participants without diabetes (61% women; mean age, 42 years). We used multivariable-adjusted Cox regression to relate glycemic markers (fasting and 2h-insulin, fasting glucose, 2h-glucose, and hemoglobin A_1C) to the risk of type 2 diabetes during follow-up.

RESULTS

Over the life course, fasting insulin concentrations were inversely associated with age, male sex, and physical activity, whereas waist circumference, the total/high-density lipoprotein (HDL) cholesterol ratio, and blood triglycerides were positively associated with insulin levels (p<0.005 for all). Male sex (inversely related) and the total/HDL cholesterol ratio (positively related) emerged as the most important cross-sectional correlates of 2h-insulin (p<0.005 for all). All markers were associated with higher risk of type 2 diabetes (352 cases, median follow-up 18 years, p<0.001 for all).

CONCLUSIONS

We observed common and distinct correlates of fasting and 2h-insulin levels. Our findings highlight a potential role of insulin in lipid and lipoprotein metabolism. Furthermore, fasting and 2h-insulin are critical markers of future diabetes risk. Further studies are needed to confirm our findings.

2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Prediabetes and What It Means: The Epidemiological Evidence

Prediabetes is an intermediate stage between normal glycemia and diabetes and is highly prevalent, especially in older age groups and obese individuals. Five different definitions of prediabetes are used in current practice, which are based on different cut points of HbA_1C, fasting glucose, and 2-h glucose. A major challenge for the field is a lack of guidance on when one definition might be preferred over another. Risks of major complications in persons with prediabetes, including diabetes, cardiovascular disease, kidney disease, and death, also vary depending on the prediabetes definition used. Randomized clinical trials have demonstrated that lifestyle and pharmacologic interventions can be cost-effective, prevent diabetes, and improve cardiovascular risk factors in adults with prediabetes. However, the practical implementation of lifestyle modification or the use of metformin for treating prediabetes is inadequate and complicated by a lack of agreement on how to define the condition. Establishing consensus definitions for prediabetes should be a priority and will help inform expansion of insurance coverage for lifestyle modification and improve current screening and diagnostic practices.

Predicting changes in glycemic control among adults with prediabetes from activity patterns collected by wearable devices

The use of wearables is increasing and data from these devices could improve the prediction of changes in glycemic control. We conducted a randomized trial with adults with prediabetes who were given either a waist-worn or wrist-worn wearable to track activity patterns. We collected baseline information on demographics, medical history, and laboratory testing. We tested three models that predicted changes in hemoglobin A1c that were continuous, improved glycemic control by 5% or worsened glycemic control by 5%. Consistently in all three models, prediction improved when (a) machine learning was used vs. traditional regression, with ensemble methods performing the best; (b) baseline information with wearable data was used vs. baseline information alone; and (c) wrist-worn wearables were used vs. waist-worn wearables. These findings indicate that models can accurately identify changes in glycemic control among prediabetic adults, and this could be used to better allocate resources and target interventions to prevent progression to diabetes.

Prediabetes Defined by First Measured HbA1c Predicts Higher Cardiovascular Risk Compared With HbA1c in the Diabetes Range: A Cohort Study of Nationwide Registries

OBJECTIVE

To assess the risk of major adverse cardiovascular events (MACE), all-cause mortality, and initiation of medical treatment in subjects with prediabetes according to first-time measured HbA_1c.

RESEARCH DESIGN AND METHODS

Through registry databases, we identified 326,305 Danish patients with a first HbA_1c between 40 and 51 mmol/mol (5.8-6.8%) from 2011 to 2017. After exclusion of patients with prior disease, 84,678 patients were followed 12 months after first HbA_1c measurement. Cox regression models were used to estimate hazard ratios (HRs) of MACE and standardized absolute risks. Cumulative incidences were used to analyze initiation of glucose-lowering, antihypertensive, cholesterol-lowering, and antithrombotic medication.

RESULTS

The 12-month risk of MACE and all-cause mortality increased gradually with increasing HbA_1c until 47 mmol/mol (6.5%). In comparisons of subjects with HbA_1c 40-41 mmol/mol (5.8-5.9%), subjects with HbA_1c 46-47 mmol/mol (6.4-6.5%) had a 0.79% (95% CI 0.33-1.24) higher standardized absolute risk and an HR of 2.21 (95% CI 1.67-2.92) of MACE. Patients with HbA_1c 48-49 mmol/mol (6.5-6.6%) had a 0.09% (95% CI -0.35 to 0.52) lower absolute risk and an HR of 1.33 (95% CI 0.87-2.05) of MACE. Initiation of medication was significantly lower among patients with HbA_1c of 46-47 mmol/mol (6.4-6.5%) than among patients with HbA_1c of 48-49 mmol/mol (6.5-6.6%).

CONCLUSIONS

In the Danish population screened for diabetes with HbA_1c, the highest risk of MACE and all-cause mortality was found in subjects with HbA_1c just below the diagnostic threshold for diabetes. Our results highlight the need for increased focus on the treatment of cardiovascular risk factors for subjects with prediabetes.

Association of glycated hemoglobin A1c levels with cardiovascular outcomes in the general population: results from the BiomarCaRE (Biomarker for Cardiovascular Risk Assessment in Europe) consortium

BACKGROUND

Biomarkers may contribute to improved cardiovascular risk estimation. Glycated hemoglobin A1c (HbA1c) is used to monitor the quality of diabetes treatment. Its strength of association with cardiovascular outcomes in the general population remains uncertain. This study aims to assess the association of HbA1c with cardiovascular outcomes in the general population.

METHODS

Data from six prospective population-based cohort studies across Europe comprising 36,180 participants were analyzed. HbA1c was evaluated in conjunction with classical cardiovascular risk factors (CVRFs) for association with cardiovascular mortality, cardiovascular disease (CVD) incidence, and overall mortality in subjects without diabetes (N = 32,496) and with diabetes (N = 3684).

RESULTS

Kaplan-Meier curves showed higher event rates with increasing HbA1c levels (log-rank-test: p < 0.001). Cox regression analysis revealed significant associations between HbA1c (in mmol/mol) in the total study population and the examined outcomes. Thus, a hazard ratio (HR) of 1.16 (95% confidence interval (CI) 1.02-1.31, p = 0.02) for cardiovascular mortality, 1.13 (95% CI 1.03-1.24, p = 0.01) for CVD incidence, and 1.09 (95% CI 1.02-1.17, p = 0.01) for overall mortality was observed per 10 mmol/mol increase in HbA1c. The association with CVD incidence and overall mortality was also observed in study participants without diabetes with increased HbA1c levels (HR 1.12; 95% CI 1.01-1.25, p = 0.04) and HR 1.10; 95% CI 1.01-1.20, p = 0.02) respectively. HbA1c cut-off values of 39.9 mmol/mol (5.8%), 36.6 mmol/mol (5.5%), and 38.8 mmol/mol (5.7%) for cardiovascular mortality, CVD incidence, and overall mortality, showed also an increased risk.

CONCLUSIONS

HbA1c is independently associated with cardiovascular mortality, overall mortality and cardiovascular disease in the general European population. A mostly monotonically increasing relationship was observed between HbA1c levels and outcomes. Elevated HbA1c levels were associated with cardiovascular disease incidence and overall mortality in participants without diabetes underlining the importance of HbA1c levels in the overall population.

One-hour post-load hyperglycemia combined with HbA1c identifies individuals with augmented duodenal levels of sodium/glucose co-transporter 1

AIMS

Individuals with HbA1c-defined prediabetes (HbA1c 5.7-6.4%) and 1-hour post-load plasma glucose (1hPG) ≥ 155 mg/dl have an increased risk to develop type 2 diabetes (T2DM). T2DM is associated with a higher intestinal expression of sodium/glucose co-transporter 1 (SGLT-1) and glucose transporter 2 (GLUT-2). It is currently unsettled whether HbA1c-defined dysglycemic conditions combined to 1hPG ≥ 155 mg/dl are associated with changes in SGLT-1 and GLUT-2 duodenal abundance.

METHODS

SGLT-1 and GLUT-2 protein levels were assessed by western blot on duodenal mucosa biopsies of 57 individuals underwent an upper gastrointestinal endoscopy.

RESULTS

Compared with the normal group (HbA1c < 5.7%), individuals with HbA1c-defined pre-diabetes and diabetes exhibit no significant change in duodenal SGLT-1 abundance. Conversely, duodenal GLUT-2 levels were progressively increased in subjects with prediabetes and diabetes. Stratifying participants according to HbA1c and 1hPG we found that amongst subjects with HbA1c-defined normal or prediabetes condition those having 1hPG ≥ 155 mg/dl displayed higher duodenal levels of SGLT-1 as compared to their counterparts with 1hPG < 155 mg/dl; in contrast to GLUT-2 levels, which were similar between normal and with prediabetes subjects, regardless of 1hPG value.

CONCLUSION

A value of 1hPG ≥ 155 mg/dl may identify a subset of individuals within HbA1c-defined glycemic categories having a higher duodenal abundance of SGLT-1.

Beyond "Watching the Sweets": An interpretive description of adolescent's understandings and insights into preventing prediabetes and type 2 diabetes

PURPOSE

The purpose of this study was to explore adolescents' experiences and knowledge of type 2 diabetes (T2D) and identify appropriate T2D education and prevention interventions for this population.

DESIGN AND METHODS

This interpretive description study was conducted at two urban high schools in midwestern Canada. Participants had been previously screened and considered at high risk for T2D, prediabetes, or as having T2D. Individual, semistructured interviews were conducted with twelve adolescents between the age of 14-19 years meeting these criteria. Thematic analysis was completed using interview transcripts.

RESULTS

Themes and subthemes identified included (1) Type 2 Diabetes: More Than Too Many Sweets (Mostly Diet but Insulin Does Play a Role, and A Serious but Common Disease); (2) Who Holds the Power? (Personal Responsibility for Health, Family as Role Models, and Community Connections); and (3) Bringing Home the Message (Our Considerations for Schools, I need the Expert's Support, and Using Technology to Get the Points Across).

PRACTICE IMPLICATIONS

Findings from this study provide target areas for education and prevention interventions and approaches for working with adolescents surrounding prediabetes and T2D that may be effective.

An increase in inflammation and islet dysfunction is a feature of prediabetes

AIMS

Type 2 diabetes (T2D) is a global health problem that will be diagnosed in almost 300 million people by 2025 according to the World Health Organization. Before being diagnosed with T2D, individuals may have glucose levels above normal but below the diabetic range. This condition is known as prediabetes. Studies showed that people with prediabetes had an increase in several pro-inflammatory cytokines in their serum and in their fasting glucose levels. The answer remains unclear when inflammation begins in the pancreas and islets, and what is the extent of this inflammation.

METHODS

Subjects with haemoglobin A1c levels from 5.7% to 6.4% were classified as pre-diabetic. Sections of pancreas and isolated islets from normal donors and donors with prediabetes were tested for markers of inflammation and glucose-stimulated insulin secretion (GSIS).

RESULTS

Gene and protein expression of the inflammatory markers resistin, interleukin-1 beta, tumour necrosis factor-alpha, interleukin-6, and monocyte chemoattractant protein-1 increased in donors with prediabetes compared to normal donors. GSIS response was significantly decreased in pre-diabetic islets compared to normal islets. Donors with prediabetes also had decreased expression of CD163+ cells but not CD68+ cells.

CONCLUSIONS

Based on our findings, inflammation and islet dysfunction may be more significant than originally thought in people with prediabetes. Rather than being in a normal state before diabetes occurs, it appears that subjects are already in an early diabetic condition resembling more closely T2D.

Classifying and communicating risks in prediabetes according to fasting glucose and/or glycated hemoglobin: PREDAPS cohort study

OBJECTIVE

Information about prognostic outcomes can be of great help for people with prediabetes and for physicians in the face of scientific controversy about the cutoff point for defining prediabetes. We aimed to estimate different prognostic outcomes in people with prediabetes.

DESIGN

Prospective cohort of subjects with prediabetes according to American Diabetes Association guidelines.

MAIN OUTCOME MEASURES

The probabilities of diabetes onset versus non-onset, the odds against diabetes onset, and the probability of reverting to normoglycemia according to different prediabetes categories were calculated.

RESULTS

The odds against diabetes onset ranged from 29:1 in individuals with isolated FPG of 100-109 mg/dL to 1:1 in individuals with FPG 110-125 mg/dL plus HbA1c 6.0-6.4%. The probability of reversion to normoglycemia was 31.2% (95% CI 24.0-39.6) in those with isolated FPG 100-109 mg/dL and 6.2% (95% CI 1.4-10.0) in those with FPG 110-125 mg/dL plus HbA1c 6.0-6.4%. Of every 100 participants in the first group, 97 did not develop diabetes and 31 reverted to normoglycemia, while in the second group those figures were 52 and 6.

CONCLUSIONS

Using odds of probabilities and absolute numbers might be useful for people with prediabetes and physicians to share decisions on potential interventions.Key pointsCommunicating knowledge on the course of the disease to make clinical decisions is not always done appropriately.Prediabetes is an example where risk communication is important because the prognosis of subjects with prediabetes is very heterogeneous.Depending on fasting plasma glucose and HbA1c levels, the odds of probabilities against diabetes onset ranged from 29: 1 to 1: 1.Depending on fasting plasma glucose and HbA1c levels, the number of subjects in 100 who revert to normoglycemia ranged from 31 to 6.Using probabilities and number absolutes on the prognosis of prediabetes may be useful for people with prediabetes and physicians to share decisions on potential interventions.

The retinopathy-derived HbA1c threshold of 6.5% for type 2 diabetes also captures the risk of diabetic nephropathy in NHANES

AIM

To determine if an HbA1c diagnostic threshold of less than 6.5% (<48 mmol/mol) could be identified based on a urinary albumin-creatinine ratio (UACR) of 30 mg/g or higher in subjects not known to have diabetes.

METHODS

A UACR was measured for 20 158 participants in the 2011-2018 nationally representative cross-sectional National Health and Nutrition Examination Surveys (NHANES; cycles 7-10 inclusive).

RESULTS

There was a significant trend for an increasing risk with a UACR of 30 mg/g or higher across increasing HbA1c categories (P < .0001). This trend was mainly attributable to the high prevalence of raised UACR in the 7.0% or higher HbA1c subgroup of subjects not previously diagnosed with diabetes. None of the odds ratios in the lower HbA1c subgroups versus the HbA1c subgroup of less than 5.0% reached significance. There were racial/ethnic differences in UACR risk (P < .0001), with White and Black subjects exhibiting little increased risk (vs. HbA1c <5.0%) until they reached an HbA1c of 7.0%, while Asian and Hispanic subjects showed some increased, but non-significant, risks at lower HbA1c levels. Maximizing the area under receiver operating characteristic curves from logistic regressions predicted an ideal HbA1c threshold of 5.8%, but there was little variation in area from 5.5% to 7.0%.

CONCLUSION

A clinically useful diagnostic threshold below 6.5% for HbA1c for elevated UACR risk was not identified, with an increased risk only obvious at an HbA1c of 7.0% or higher. Thus, the retinopathy-derived HbA1c threshold of 6.5% also captures the risk of diabetic nephropathy in NHANES.

Type 2 diabetes in pediatrics

Type 2 diabetes (T2D) in adolescents has become an increasing health concern throughout the world and its prevention and screening should be implemented in pediatric care. As clinical features at presentation, in some cases can be similar to type 1 diabetes and family history can be in favour of a monogenic form of diabetes, it is pivotal for physicians to be aware of youth-onset T2D specificities to ensure an accurate diagnosis. The global increase of overweight and obesity can complicate the diagnostic process and makes it essential to apply a systematic approach to each new diagnosis. Microvascular complications may be present at the time of diagnosis and chronic complications are frequent and need to be screened regularly. Regular screening of comorbidities should also be performed. Childhood T2D should be followed up by pediatric diabetes units to avoid diagnostic errors and delay in care. A multidisciplinary approach, by an experienced team, is pivotal to provide treatment options targeting the unique needs of pediatric patients. Treatment programs must include the whole family and address all the aspects of the care (lifestyle, pharmacological therapy, psychological aspects, complications and comorbidities). An organized process of transition to adult care is essential.

Pancreatic and gut hormones as predictors of new-onset prediabetes after non-necrotising acute pancreatitis: a prospective longitudinal cohort study

OBJECTIVE

Early identification of individuals at high risk for metabolic derangements after an attack of acute pancreatitis (AP) is critical with a view to tertiary preventing of this disease. The aim was to investigate whether fasting pancreatic and gut hormones at baseline were predictive of future risk of new-onset prediabetes after acute pancreatitis (NOPAP) in individuals with non-necrotising AP.

METHODS

This was a prospective longitudinal cohort study that included 69 consecutive non-diabetic participants with AP, of whom 55% (n = 38) had normoglycaemia both at baseline and during follow-up, 25% (n = 17) had prediabetes both at baseline and during follow-up, and 20% (n = 14) were normoglycaemic at baseline but developed NOPAP during follow-up. The associations between the study groups and circulating fasting levels of pancreatic and gut hormones (insulin, glucagon, C-peptide, amylin, glucose-dependent insulinotropic peptide, glucagon-like peptide-1, pancreatic polypeptide, and peptide YY) were studied using multinomial regression in both unadjusted and adjusted analyses.

RESULTS

Elevated plasma insulin and glucagon at baseline were significantly associated with NOPAP (adjusted odds ratio 1.99, 95% CI 1.01 to 3.92 and adjusted odds ratio 3.44, 95% CI 1.06 to 11.19, respectively). The same hormones had no significant association with antecedent prediabetes in AP. The other studied hormones were not significantly associated with the study groups.

CONCLUSIONS

Normoglycaemic AP individuals with elevated fasting levels of insulin and glucagon at baseline constitute a high-risk group for future NOPAP.

Phenotyping the Prediabetic Population-A Closer Look at Intermediate Glucose Status and Cardiovascular Disease

Even though the new thresholds for defining prediabetes have been around for more than ten years, there is still controversy surrounding the precise characterization of this intermediate glucose metabolism status. The risk of developing diabetes and macro and microvascular disease linked to prediabetes is well known. Still, the prediabetic population is far from being homogenous, and phenotyping it into less heterogeneous groups might prove useful for long-term risk assessment, follow-up, and primary prevention. Unfortunately, the current definition of prediabetes is quite rigid and disregards the underlying pathophysiologic mechanisms and their potential metabolic progression towards overt disease. In addition, prediabetes is commonly associated with a cluster of risk factors that worsen the prognosis. These risk factors all revolve around a common denominator: inflammation. This review focuses on identifying the population that needs to be screened for prediabetes and the already declared prediabetic patients who are at a higher risk of cardiovascular disease and require closer monitoring.

Development of a preoperative prediction model for new-onset diabetes mellitus after partial pancreatectomy: A retrospective cohort study

Pancreatectomy is an invasive surgery that is sometimes associated with complications. New-onset diabetes mellitus sometimes develops after partial pancreatectomy and severely affects the patient's quality of life. This study aimed to develop a preoperative prediction model of new-onset diabetes mellitus after partial pancreatectomy, which will help patients and surgeons to achieve more easily better common decisions on regarding whether to perform partial pancreatectomy. This retrospective cohort study analyzed medical records of patients who underwent partial pancreatectomy (total pancreatectomy excluded) from April 1, 2008, to February 28, 2016, which were available in the database provided by Medical Data Vision Co., Ltd. (Tokyo, Japan). The predictors were preoperative age, body mass index, hemoglobin A1c level, blood glucose level, and indication for partial pancreatectomy. The outcome was the development of new-onset diabetes mellitus at 1 to 12 months after partial pancreatectomy. We used a logistic regression model and calculated the scores of each predictor. To determine test performance, we assessed discrimination ability using the receiver operating characteristic curve and calibration with a calibration plot and the Hosmer-Lemeshow test. We also performed internal validation using the bootstrap method. Of 681 patients, 125 (18.4%) had new-onset diabetes mellitus after partial pancreatectomy. The developed prediction model had a possible range of 0 to 46 points. The median score was 13, and the interquartile range was 9 to 22. The C-statistics of the receiver operating characteristic curve on the score to predict the outcome was .70 (95% confidence interval [CI], .65-.75). Regarding the test performance, the Hosmer-Lemeshow test was not significant (P = .17), and calibration was good. In the bootstrapped cohorts, the C-statistics was .69 (95% CI, .62-.76). We developed a preoperative prediction model for new-onset diabetes mellitus after partial pancreatectomy. This would provide important information for surgeons and patients when deciding whether to perform partial pancreatectomy.

Prevalence and co-existence of cardiometabolic risk factors and associations with nutrition-related and socioeconomic indicators in a national sample of Gambian women

Cardiovascular diseases (CVD) are on the rise in Sub-Saharan Africa, and a large proportion of the adult population is thought to suffer from at least one cardiometabolic risk factor. This study assessed cardiometabolic risk factors and the contribution of nutrition-related indicators in Gambian women. The prevalence and co-existence of diabetes (elevated glycated hemoglobin (HbA1c ≥ 6.5%) or prediabetes (HbA1c ≥ 5.7% to < 6.5%), hypertension (systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg), obesity (body mass index (BMI) ≥ 30.0) and inflammation (C-reactive protein (CRP) > 3 mg/L or alpha-1-acid glycoprotein (AGP) > 1 g/L) and the contribution of nutrition related and socioeconomic indicators were measured in non-pregnant women 15-49 years of age in the Gambia using data from a nationally representative cross-sectional stratified survey. Nationally, 54.5% (95% CI: 47.4, 61.4) of 1407 women had elevated HbA1c. Of these, 14.9% were diabetic and 85.1% were prediabetic. Moreover, 20.8% (95% CI 17.8, 20.0) of 1685 women had hypertension, 11.1% (95% CI 9.0, 13.7) of 1651 were obese and 17.2% (95% CI 5.1, 19.6) of 1401 had inflammation. At least one of the aforementioned cardiometabolic risk factor was present in 68.3% (95% CI 63.0, 73.1) of women. Obesity increased the risk of hypertension (aRR 1.84; 95% CI 1.40, 2.41), diabetes (aRR 1.91; 95% CI 1.29, 2.84), elevated HbA1c (aRR 1.31; 95% CI 1.14, 1.51) and inflammation (aRR 3.47; 95% CI 2.61, 4.61). Inflammation increased the risk of hypertension (aRR 1.42; 95% CI 1.14, 1.78). Aging increased the risk of hypertension, obesity and inflammation. Further, inadequate sanitation increased the risk for diabetes (aRR 1.65; 95% CI 1.17, 2.34) and iron deficiency increased the risk of elevated HbA1c (aRR 1.21; 95% CI 1.09, 1.33). The high prevalence of cardiometabolic risk factors and their co-existence in Gambian women is concerning. Although controlling obesity seems to be key, multifaceted strategies to tackle the risk factors separately are warranted to reduce the prevalence or minimize the risk of CVD.

Quality of Diabetes Care in the USA

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of the current quality of diabetes care in the USA, discuss barriers to guideline-recommended treatment adherence, and outline strategies for the improvement in care.

RECENT FINDINGS

Current treatment guidelines highlight the importance of glycemic control, use of novel medications with proven cardiovascular efficacy, and multifactorial cardiovascular risk factor intervention for the treatment of diabetes and associated complications. Albeit proven evidence for these guidelines, the vast majority of patients with diabetes remain insufficiently treated. Interventions to improve outcomes require focus on care delivery systems, physician behavior, and patient-centered approaches. De-fragmenting care systems to form collaborative, multi-specialty teams, use of standardized and comprehensive treatment algorithms, development of quality assessment tools, avoiding physician therapeutic inertia, and addressing patient barriers, including lack of perceived benefit, insufficient diabetes education and access to care, and medication costs, represent key objectives to improve diabetes care and outcomes. Clinical research in standardized trials has proven the feasibility to reduce morbidity and mortality associated with diabetes. Implementing models of care to disseminate these encouraging research findings to the wider population and to overcome barriers to achieving guideline-recommended treatment goals should be the objective to improve our current quality of diabetes care in the USA.

Diabetes prevention in the Caribbean using Lifestyle Intervention and Metformin Escalation (LIME): Protocol for a hybrid Type-1 effectiveness-implementation trial using a quasi-experimental study design

BACKGROUND

Globally, several diabetes prevention interventions have been shown to be cost-effective, yet they have had limited adaptation, implementation, and evaluation in the Caribbean and among Caribbean-descent individuals, where the burden of type 2 diabetes is high. We report on the protocol for the Lifestyle Intervention with Metformin Escalation (LIME) study - an evidence-based diabetes prevention intervention to reduce the incidence of diabetes among Caribbean-descent individuals with prediabetes.

METHODS

LIME is a hybrid type-I effectiveness-implementation quasi-experimental study taking place in 4 clinical sites in Barbados, Trinidad, the U.S. Virgin Islands, and Puerto Rico. LIME targets individuals who self-identify as Caribbean or Caribbean-descent and have high-risk prediabetes with a hemoglobin A1c (HbA1c) between 6 and 6.4%. Eligible participants in the intervention arm are enrolled in a six-week lifestyle modification workshop. Six months later, individuals who have not lost at least 5% of their bodyweight or continue to have an HbA1c of 6% or higher are prescribed metformin medication. In total, participants are followed for one year. The primary effectiveness outcome is proportion of individuals who lower their HbA1c below 6%.

DISCUSSION

LIME is a unique diabetes prevention intervention for Caribbean and Caribbean-descent individuals. LIME utilizes a tailored lifestyle change curriculum, incorporates appropriate metformin prescribing when lifestyle change alone is insufficient, targets the highest-risk individuals with prediabetes, and is based in a clinical setting to ensure sustainability.

Challenge of diabetes mellitus and researchers’ contributions to its control

The aim of this review study was to assess the past significant events on diabetes mellitus, transformations that took place over the years in the medical records of treatment, countries involved, and the researchers who brought about the revolutions. This study used the content analysis to report the existence of diabetes mellitus and the treatments provided by researchers to control it. The focus was mainly on three main types of diabetes (type 1, type 2, and type 3 diabetes). Ethical consideration has also helped to boost diabetic studies globally. The research has a history path from pharmaceuticals of organic-based drugs to metal-based drugs with their nanoparticles in addition to the impacts of nanomedicine, biosensors, and telemedicine. Ongoing and future studies in alternative medicine such as vanadium nanoparticles (metal nanoparticles) are promising.

Gender-Specific Prevalence of Risk Factors for Non-Communicable Diseases by Health Service Use among Schoolteachers in Afghanistan

Objectives of this study were: (1) to examine gender differences in biomedical indicators, lifestyle behaviors, self-health check practices, receipt of professional non-communicable disease (NCD)-related lifestyle advice, and the use of health services among teachers in Afghanistan; and (2) to seek the patterns of these indicators among users and non-users of health services among both male and female teachers. This cross-sectional study was carried out among 600 schoolteachers in Kabul city in February 2017. Gender differences in percentage distributions of abnormal biomedical indicators, lifestyle behaviors, self-health check practices, and receipt of professional lifestyle advice were examined. These patterns were further analyzed according to the use of health services in the previous 12 months by both genders. The results showed that male teachers had a higher prevalence of hypertension, increased serum triglycerides, physically active lifestyle, and tobacco use than female teachers (28.2/20.4, p = 0.038; 47.0/37.9, p = 0.040; 54.3/40.9, p = 0.002; 15.8/0.7, p < 0.001, respectively); female teachers had a higher prevalence of increased serum LDL cholesterol, overweight/obesity, and frequent consumption of fruits/vegetables than male teachers (61.3/50.8, p = 0.018; 64.7/43.5, p < 0.001; 71.4/53.8, p < 0.001, respectively). Female teachers were more likely to receive professional lifestyle advice related to NCDs than male teachers. Although users of health services practiced self-health checks and received professional lifestyle advice more frequently than non-users, abnormal biomedical indicators were similarly shown among users and non-users of health services in both genders. In conclusion, high prevalence of abnormal biomedical indicators was indicated in both male and female teachers, although the specific abnormal biomedical indicators differed by gender. Users and non-users of health services presented a similar prevalence of these abnormal indicators. Understanding the differences in patterns of NCD risk factors is essential when developing gender-informed policies.

Diagnosis, risk factors and management of diabetes mellitus in HIV-infected persons in France: A real-life setting study

BACKGROUND

Diabetes mellitus (DM) is a major and increasing public health problem that may be underdiagnosed and undertreated among persons living with HIV (PLWH).

OBJECTIVE

To describe the diagnosis, treatment and follow-up of DM among PLWH.

METHODS

This study was performed inside a monocentric cohort of 1494 PLWH. DM was defined as having a FG ≥126 mg/dL twice or a HbA1c ≥6.5%, or a history of diabetes, or receiving antidiabetic treatment. The first visit mentioning a diagnosis of DM was considered as the baseline visit. Chi-Square or Fisher exact test were used to examine the association between categorical variables and DM, Wilcoxon or Student t-test were used for continuous variables.

RESULTS

156 PLWH with DM were included. Compared to non-diabetic participants, they were more likely to be native of Sub Saharan Africa (31.6% vs. 22.4%, p = 0.027) and older (54.6 vs. 49.9 years, p<0.001), to have a higher BMI (> 25 for 46.1% vs. 35.3%, p = 0.020) and a poorer control of HIV (HIV RNA<50 copies/mL: 80.1% vs. 89.5%, p<0.001). The diagnosis of DM was missed in 37.8% of PLWH, and 47.2% of PLWH treated for DM did not reach a HbA1c<7%. PLWH with DM were more frequently on antihypertensive and/or lipid-lowering medications: 94.2% had a LDL-cholesterol <70 mg/dL and 60.9% had a blood pressure <140/90 mmHg.

CONCLUSION

In a setting of HIV-control, HIV care providers should focus on metabolic issues. The management of DM and associated risk factors is mandatory to prevent cardiovascular disease in PLWH.

Dissonance in the discourse of the duration of diabetes: A mixed methods study of patient perceptions and clinical practice

Background

Remission of diabetes can be rewarding for patients and physicians, but there is limited study of how patients perceive the timeline of a disease along the continuum of glycaemic control.

Objective

To explore how patients perceive the timeline of diabetes along the continuum of glycaemic control and their goals of care and to identify whether family physicians communicate the principles of regression and remission of diabetes.

Design

Mixed methods approach of qualitative semi‐structured interviews with purposive sampling followed by cross‐sectional survey of physicians.

Participants

Thirty‐three patients living with prediabetes (preDM) or type 2 diabetes mellitus (T2DM) at medical centres in Georgia and Nevada; and 387 family physicians providing primary care within the same health system.

Results

Patients described two timelines of diabetes: as a lifelong condition or as a condition that can be cured. Patients who perceived a lifelong condition described five treatment goals: reducing glucose‐related laboratory values, losing weight, reducing medication, preventing treatment intensification and avoiding complications. For patients who perceived diabetes as a disease with an end, the goal of care was to achieve normoglycaemia. In response to patient vignettes that described potential cases of remission and regression, 38.2% of physician respondents would still communicate that a patient has preDM and 94.6% would tell the patient that he still had diabetes.

Conclusions

Most physicians here exhibited reluctance to communicate remission or regression in patient care. Yet, patients describe two different potential timelines, including a subset who expect their diabetes can be ‘cured’. Physicians should incorporate shared decision making to create a shared mental model of diabetes and its potential outcomes with patients.

Patient or Public Contribution

In this mixed methods study, as patients participated in the qualitative phase of this study, we asked patients to tell us what additional questions we should ask in subsequent interviews. Data from this qualitative phase informed the design and interpretation of the quantitative phase with physician participants.

Diagnosing type 2 diabetes using Hemoglobin A1c: a systematic review and meta-analysis of the diagnostic cutpoint based on microvascular complications

AIMS

Diabetic microvascular complications of retinopathy, nephropathy and neuropathy may occur at hemoglobin A1c levels (HbA1c) below the 6.5% (48 mmol/mol) diagnostic threshold. Our objective was to assess the validity of the HbA1c diagnostic cutpoint of 6.5% based upon published evidence of the prevalence of retinopathy, nephropathy and neuropathy as markers of diabetes.

METHODS

Data Sources PubMed, Embase, Cochrane, Scopus and CINAHL from 1990-March 2019, grey literature sources. Study Selection All studies reported after 1990 (to ensure standardized HbA1c values) where HbA1c levels were presented in relation to prevalence of retinopathy, nephropathy or neuropathy in subjects not known to have diabetes. Data Extraction Studies were screened independently, data abstracted, and risk of bias appraised. Data Synthesis Data were synthesized using HbA1c categories of < 6.0% (< 42 mmol/mol), 6.0-6.4% (42-47 mmol/mol) and ≥ 6.5% (≥ 48 mmol/mol). Random-effects meta-analyses were conducted for retinopathy, nephropathy and neuropathy prevalence stratified by HbA1c categories. Random-effects multivariable meta-regression was conducted to identify predictors of retinopathy prevalence and sources of between-study heterogeneity.

RESULTS

Pooled mean prevalence was: 4.0%(95% CI: 3.2-5.0%) for retinopathy, 10.5% (95% CI: 4.0-19.5%) for nephropathy, 2.5% (95% CI: 1.1-4.3%) for neuropathy. Mean prevalence when stratified for HbA1c < 6.0%, 6.0-6.4% and ≥ 6.5% was: retinopathy: 3.4% (95% CI: 1.8-5.4%), 2.3% (95% CI: 1.6-3.2%) and 7.8%(95% CI: 5.7-10.3%); nephropathy: 7.1% (95% CI: 1.7-15.9%), 9.6% (95% CI: 0.8-26.4%) and 17.1% (95% CI: 1.0-46.9%); neuropathy: 2.1% (95% CI: 0.0-6.8%), 3.4% (95% CI: 0.0-11.6%) and 2.8% (95% CI: 0.0-12.8%). Multivariable meta-regression showed HbA1c ≥ 6.5% (OR: 4.05; 95% CI: 1.92-8.57%), age > 55 (OR: 3.23; 95% CI 1.81-5.77), and African-American race (OR: 10.73; 95% CI: 4.34-26.55), to be associated with higher retinopathy prevalence. Marked heterogeneity in prevalence estimates was found across all meta-analyses (Cochran's Q-statistic p < 0.0001).

CONCLUSIONS

The prevalence of nephropathy and moderate retinopathy was increased in subjects with HbA1c values ≥ 6.5% confirming the high specificity of this value for diagnosing T2DM; however, at HbA1c < 6.5% retinopathy increased at age > 55 years and, most strikingly, in African-Americans, suggesting there may be excess microvascular complication prevalence (particularly nephropathy) in individuals below the diabetes diagnostic threshold.

Prediabetes and intermediate hyperglycemia prevalence in adults and associated factors, Health National Survey

This study aimed to evaluate the prevalence of prediabetes and intermediate hyperglycemia in Brazilian adults, according to different diagnostic criteria, and establish associated factors to its occurrence. We analyzed the National Health Survey laboratory data collected from 2014 to 2015. The prevalence of the conditions was calculated according to the American Diabetes Association (ADA) diagnostic criteria based on glycated hemoglobin (HbA1c) 5.7%-6.4%, and the World Health Organization (WHO) 6-6.4%, among those without criteria for diabetes. Crude and adjusted prevalence rates (PR) and 95% CI were calculated using Poisson regression with robust variance. The prevalence of prediabetes by ADA and WHO criteria was 18.5 and 7.5%, respectively. We observed a gradient of increased prevalence by the age of the population and risk factors, like arterial hypertension, obesity, elevated waist circumference, and low HDL cholesterol levels. Less educated people and the self-declared black had a higher prevalence. This study pointed out a range from 7.5 to 18.5% of Brazilian adults with prediabetes and intermediate hyperglycemia and identified a risk score to this condition's occurrence.

Utility of Screening Fasting Plasma Glucose and Glycated Hemoglobin to Circumvent the Need for Oral Glucose Tolerance Test in Women with Prior Gestational Diabetes

INTRODUCTION

Our aim is to propose an evidence-based strategy for screening postpartum dysglycemia.

METHODS

This study included adult non-pregnant women who were diagnosed with gestational diabetes (GDM) using International Association of Diabetes in Pregnancy Study Group (IADPSG) criteria during their index pregnancy (2012-2019). Eligible participants underwent a concurrent oral glucose tolerance test (OGTT) and glycated hemoglobin (HbA1c) test. A detailed questionnaire documenting relevant personal and medical history was filled, and the relevant anthropometric parameters were recorded.

RESULTS

We evaluated data from 377 women at a mean (± SD) age of 32.1 ± 4.6 years and at a median duration of 15 (10-33) months following childbirth. Diabetes was diagnosed in 42 (11.1%) women. Use of a combination cutoff [fasting plasma glucose (FPG) ≥ 6.1 mmol/L or glycated hemoglobin (HbA1c) ≥ 6.0% (42 mmol/mol)] avoided OGTT in 80.9% of the study cohort, without missing the diagnosis of diabetes in any study subject. The diagnosis was missed in 2.4% of women with diabetes (and 0.3% of whole cohort) using only the FPG criterion (≥ 5.6 mmol/L) or HbA1c criterion [HbA1c ≥ 5.7% (39 mmol/mol)] alone. These tests avoided the need for an OGTT in 75.3% and 65.5% of women, respectively.

CONCLUSIONS

The proposed strategies are likely to be both patient- and physician-friendly and have the potential to address several barriers for postpartum screening among women with prior GDM.

Increased particle size of triacylglycerol-enriched remnant lipoproteins, but not their plasma concentration or lipid content, augments risk prediction of incident type 2 diabetes

AIMS/HYPOTHESIS

Type 2 diabetes prevention requires the accurate identification of those at high risk. Beyond the association of fasting serum triacylglycerols with diabetes, triacylglycerol-enriched remnant lipoproteins (TRLs) more accurately reflect pathophysiological changes that underlie progression to diabetes, such as hepatic insulin resistance, pancreatic steatosis and systemic inflammation. We hypothesised that TRL-related factors could improve risk prediction for incident diabetes.

METHODS

We included individuals from the Brazilian Longitudinal Study of Adult Health cohort. We trained a logistic regression model for the risk of incident diabetes in 80% of the cohort using tenfold cross-validation, and tested the model in the remaining 20% of the cohort (test set). Variables included medical history and traits of the metabolic syndrome, followed by TRL-related measurements (plasma concentration, TRL particle diameter, cholesterol and triacylglycerol content). TRL features were measured using NMR spectroscopy. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC).

RESULTS

Among 4463 at-risk individuals, there were 366 new cases of diabetes after a mean (±SD) of 3.7 (±0.63) years of follow-up. We derived an 18-variable model with a global AUROC of 0.846 (95% CI: 0.829, 0.869). Overall TRL-related markers were not associated with diabetes. However, TRL particle diameter increased the AUROC, particularly in individuals with HbA_1c <39 mmol/mol (5.7%) (hold-out test set [n = 659]; training-validation set [n = 2638]), but not in individuals with baseline HbA_1c 39-46 mmol/mol (5.7-6.4%) (hold-out test set [n = 233]; training-validation set [n = 933]). In the subgroup with baseline HbA_1c <39 mmol/mol (5.7%), AUROC in the test set increased from 0.717 (95% CI 0.603, 0.818) to 0.794 (95% CI 0.731, 0.862), and AUPRC in the test set rose from 0.582 to 0.701 when using the baseline model and the baseline model plus TRL particle diameter, respectively. TRL particle diameter was highly correlated with obesity, insulin resistance and inflammation in those with impaired fasting glucose at baseline, but less so in those with HbA_1c <39 mmol/mol (5.7%).

CONCLUSIONS/INTERPRETATION

TRL particle diameter improves the prediction of diabetes, but only in individuals with HbA_1c <39 mmol/mol (5.7%) at baseline. These data support TRL particle diameter as a risk factor that is changed early in the course of the pathophysiological processes that lead to the development of type 2 diabetes, even before glucose abnormalities are established. Graphical abstract.

The Risk Threshold for Hemoglobin A1c Associated With Albuminuria: A Population-Based Study in China

BACKGROUND

Diabetic kidney disease (DKD) is a kind of common microvascular complication of diabetes. This study aims to explore the possible links between blood sugar level and albuminuria, providing the exact cut point of the "risk threshold" for blood glucose with DKD.

METHODS

The relationship between blood glucose and albuminuria was modeled using linear and logistic regression in the REACTION study cohorts (N= 8932). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by logistic regression model. Two-slope linear regression was used to simulate associations between blood glucose and ACR.

RESULTS

We found that the increase in ACR was accompanied by increased HbA1c, with a turning point at 5.5%. The positive correlation remained highly significant (P<0.001) when adjusted for age, sex, marital status, education, smoking status, drinking status, BMI, waistline, SBP and DBP. In subgroup analyses including gender, obesity, hypertension, and smoking habits, the relationship was significant and stable.

CONCLUSIONS

We determined a risk threshold for HbA1c associated with albuminuria in a Chinese population over the age of 40. HbA1c ≥ 5.5% was positively and independently associated with ACR. These results suggest the necessity of early blood glucose control and renal function screening for DKD in at-risk populations.

2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Perioperative hyperglycaemia in elective arthroplasties. Should we do better?

BACKGROUND

Perioperative dysglycaemia is associated with deleterious outcomes but guidelines to improve glucose management are poorly or inconsistently adhered to. We evaluated glucose management among diabetic and non-diabetic patients undergoing elective hip or knee arthroplasty.

METHODS

Capillary plasma glucose (CPG) was measured prospectively four times daily of 209 patients undergoing elective hip or knee surgery. Actions of the attending teams to CPG values and detection of patients at risk were analysed.

RESULTS

A total of 209 patients were enrolled. All diabetic patients on insulin (6/6) had hyperglycaemia (≥7.8 mmol/l) more than twice and severe hyperglycaemia (>10 mmol/l) at least once. Of the 27 diabetic patients not on insulin 26 (96.3%) had CPG ≥ 7.8 mmol/l ≥ 2 times and 17 (63%) >10 mmol/l. The corresponding figures of the 176 non-diabetic patients were 137 (77.8%) and 61 (34.7%). Severe hyperglycaemia occurred in 54/176 (30.1%) of the non-diabetic patients with pre-operative HbA1c < 42 mmol/mol and random plasma glucose < 7.8 mmol/l. Of the 84 hyperglycaemic episodes > 10 mmol/l, none was treated. Patients with a FINDRISC score ≥ 12 (corresponding to moderate to high risk of diabetes) and hyperglycaemia went unnoticed.

CONCLUSIONS

Hyperglycaemia is common among elective orthopaedic surgery patients with or without diabetes. More than 80% of the 209 patients had hyperglycaemia and 40% had severe hyperglycaemia. None of the patients was treated according to guidelines and none of the patients at risk of hyperglycaemia or diabetes was noticed. There is an obvious need for further education and support by diabetes specialists.

CLINICAL TRIAL REGISTRATION

Clinical trials, gov. NCT03306810.

Is pasireotide-induced diabetes mellitus predictable? A pilot study on the effect of a single dose of pasireotide on glucose homeostasis

INTRODUCTION

Pasireotide (PAS) is an effective treatment for Cushing's disease (CD) but its use is burdened by an associated high incidence of diabetes mellitus (DM). The aim of this study was to examine the effect of a single subcutaneous injection of PAS on glucose metabolism in CD, and to identify predictors of DM onset.

METHODS

Fifteen patients with CD (13 females, 2 males; median age 43 years [IQR 34-50]) were submitted to an acute PAS test (600 µg s.c.), measuring glucose, insulin, C-peptide, GIP, glucagon, GLP-1, ACTH, and cortisol at the baseline and every 30 min for 2 h. Then they were treated twice daily with PAS 600 µg, and followed up with clinical and hormone assessments for a median of 6 months [2-13].

RESULTS

PAS prompted a significant decrease in all hormonal parameters considered except for glycemia, which increased (as expected), reaching the highest value at 120' (p < 0.0001). Overall, 9/15 patients developed DM within 2 months of starting PAS therapy. There were no differences in age, weight, visceral adiposity, HOMA index, fasting glucose or severity of CD between patients who developed DM and those who did not. Baseline fasting glucagon levels were higher in the DM patients (17.95 [12.45-20.54] vs. 10.53 [8.11-12.33] pmol/L, p = 0.0256), and so were GIP and HbA1c levels (37 [5.5-39.5] vs. 29 [27-31.8] mmol/mol, p = 0.0008). Glucose at 120' was also significantly higher in the DM patients (9.5 [8.65-11.95] vs. 6.85 [4.48-9] mmol/L, p = 0.012).

CONCLUSIONS

PAS was rapidly able to suppress insulin and incretin secretion, with a subsequent rise in glucose levels into the diabetic range. It also induced a significant inhibition of glucagon production. The patients at higher risk of DM during PAS therapy were those with higher glucagon levels, HbA1c > 34.5 mmol/mol, and a glucose peak after PAS administration > 9 mmol/L. CD patients with these features given PAS therapy should therefore be monitored more carefully.

Detection of diabetes and prediabetes using glycosylated hemoglobin in Chinese adults living in Shanghai: A prospective analysis

BACKGROUND

This study aimed to evaluate the discriminative abilities of glycosylated hemoglobin (HbA1c) and to examine the optimal HbA1c cutoff values for diabetes and prediabetes in Chinese adults.

METHODS

Data of a population-based cohort of Chinese adults aged ≥40 years living in Jiading District in Shanghai were used. At baseline, 9389 and 7241 participants were included to identify the optimal HbA1c cutoff values for diabetes and prediabetes, respectively using the 1999 World Health Organization criteria as reference. In addition, the follow-up data on incident diabetes of 4538 participants were used to determine the HbA1c cutoff value for prediabetes using the development of diabetes as reference. The discriminative abilities of HbA1c were evaluated using receiver operating characteristic (ROC) curves, and the optimal cutoff values were determined by Youden's index.

RESULTS

The areas under the ROC curves were 0.849 for diabetes, 0.614 for prediabetes using baseline data, and 0.648 for prediabetes using follow-up data. An HbA1c cutoff value of 6.0% had the largest Youden's index to diagnose diabetes with a sensitivity of 70.2% and a specificity of 87.4%. An HbA1c cutoff value of 5.6% was indicated for prediabetes using both baseline and follow-up data. However, the sensitivity and specificity were both low (55.4% and 61.1% using an oral glucose tolerance test as reference, 64.6% and 57.1% using incident diabetes as reference).

CONCLUSIONS

An HbA1c value ≥6.0% could be used to detect diabetes in Chinese adults aged ≥40 years. However, although an HbA1c value of 5.6% to 5.9% was indicated in this study, the overall discrimination of HbA1c for prediabetes was poor.

Diet quality and its association with glycemic parameters in different diabetes progression stages. A cross-sectional questionnaire study at a primary care clinic

BACKGROUND

Diabetes mellitus is a leading cause of preventable deaths and becomes a major public health concern in Malaysia. Multiple studies have reported the association between diet quality and glycemic parameters among known diabetic subjects. Its influence in individuals with borderline diabetes (i.e. pre-diabetes) or unknown diabetes is still unclear.

OBJECTIVE

The objective of this study was to assess the association between diet quality evaluated by healthy eating index (HEI) with the glucose outcome in individuals with distinct diabetes progression stages, as well as to identify causal factors in relation to their diabetes status.

METHOD

A cross-sectional study was conducted at clinical care setting in Universiti Sains Malaysia (USM) between October 2018-March 2019. Normoglycemic controls (n = 47), at-risk of pre-diabetes (n = 58), pre-diabetes (n = 24) as well as individuals with undiagnosed diabetes (n = 18) were queried about their habitual diet by using Food Frequency Questionnaire (FFQ). Correlation analyses were performed to examine the relationship between HEI score and 1) Fasting plasma glucose (FPG) 2) postprandial blood glucose (2-HPP) and glycosylated hemoglobin (HbA1c). Multinomial regression was performed to identify predictors associated with diabetes status of study participants.

RESULT

Overall, diet quality of study participants was unsatisfactory with the mean score of 58.05 ± 9.07 that need improvement. Total HEI score was negatively correlated with the 2-HPP levels in pre-diabetic patients (r = - 0.45, p = 0.05). No significant association was revealed between glycemic parameters and total HEI score among other groups. Age, body mass index (BMI), triglycerides and female gender were positively correlated with the risk of pre-diabetes, at-risk of pre-diabetes and undiagnosed diabetes (p < 0.01).

CONCLUSION

Diet quality was not strongly associated with glycemic parameters among study participants. Age, BMI, triglycerides and female gender are crucial factors, that needed to be prioritized by primary care providers when managing pre-diabetes/diabetes to achieve possible reversion. Further in-depth investigations with large sample are warranted to confirm study findings.

Identification of MODY among patients screened for gestational diabetes: a clinician's guide

PURPOSE

Screening of gestational diabetes/GDM (although different in different countries) represents a standard procedure allowing to identify women with pregnancy-associated diabetes. Some of the women with GDM (up to 5%) may, however, suffer from previously undiagnosed MODY (Maturity-Onset Diabetes of the Young). Currently, no international or local guidelines focused on the identification of MODY among GDM exist. Thus, the aim of this manuscript is to propose a clear guide for clinicians on how to detect MODY among pregnant women with gestational diabetes.

METHODS

Based on the available literature about diagnosis (in general population) of MODY and management of MODY (both, in general population and in pregnant women), we propose a clear clinical guide on how to diagnose and manage MODY in pregnancy.

RESULTS

The manuscript suggests a feasible clinical approach how to recognize MODY among patients with GDM and how to manage pregnancy of women with three most common MODY subtypes.

CONCLUSION

A correct classification of diabetes is, nonetheless, essential, particularly in case of MODY, as the management of pregnant women with MODY is different and the correct diagnosis of MODY enables individualized treatment with regard to optimal pregnancy outcomes.

Risk of severe maternal morbidity or death in relation to elevated hemoglobin A1c preconception, and in early pregnancy: A population-based cohort study

BACKGROUND

The relation between prepregnancy average glucose concentration and a woman's risk of severe maternal morbidity (SMM) is unknown. The current study evaluated whether an elevated preconception hemoglobin A1c (A1c) is associated with SMM or maternal death among women with and without known prepregnancy diabetes mellitus (DM).

METHODS AND FINDINGS

A population-based cohort study was completed in Ontario, Canada, where there is universal healthcare. The main cohort included 31,225 women aged 16-50 years with a hospital live birth or stillbirth from 2007 to 2015, and who had an A1c measured within 90 days before conception, including 28,075 women (90%) without known prepregnancy DM. The main outcome was SMM or maternal mortality from 23 weeks' gestation up to 42 days postpartum. Relative risks (RRs) were generated using modified Poisson regression, adjusting for the main covariates of maternal age, multifetal pregnancy, world region of origin, and tobacco/drug dependence. The mean maternal age was 31.1 years. Overall, SMM or death arose among 682 births (2.2%). The RR of SMM or death was 1.16 (95% CI 1.14-1.19; p < 0.001) per 0.5% increase in A1c and 1.16 (95% CI 1.13-1.18; p < 0.001) after adjusting for the main covariates. The adjusted relative risk (aRR) was increased among those with (1.11, 95% CI 1.07-1.14; p < 0.001) and without (1.15, 95% CI 1.02-1.29; p < 0.001) known prepregnancy diabetes, and upon further adjusting for body mass index (BMI) (1.15, 95% CI 1.11-1.20; p < 0.001), or chronic hypertension and prepregnancy serum creatinine (1.11, 95% CI 1.04-1.18; p = 0.002). The aRR of SMM or death was 1.31 (95% CI 1.06-1.62; p = 0.01) in those with a preconception A1c of 5.8%-6.4%, and 2.84 (95% CI 2.31-3.49; p < 0.001) at an A1c > 6.4%, each relative to an A1c < 5.8%. Among those without previously recognized prepregnancy diabetes and whose A1c was >6.4%, the aRR of SMM or death was 3.25 (95% CI 1.76-6.00; p < 0.001). Study limitations include that selection bias may have incorporated less healthy women tested for A1c, and BMI was unknown for many women.

CONCLUSIONS

Our findings indicate that women with an elevated A1c preconception may be at higher risk of SMM or death in pregnancy or postpartum, including those without known prepregnancy DM.

Reproducibility of a prediabetes classification in a contemporary population

Aims

To assess whether meeting both fasting plasma glucose (FPG) and HbA1c criteria for prediabetes in people at high risk indicates with near certainty the presence of dysglycemia on repeat testing.

Methods

Observational study using data from Vitamin D and Type 2 Diabetes (D2d) study. HbA1c, FPG were measured at screening visit 1; FPG, HbA1c and 2 h plasma glucose (2hPG) measured at screening visit 2 (a median of 21 days later); participants classified as having normal glucose regulation (all 3 tests in normal range), prediabetes or diabetes (at least 1 of 3 tests in diabetes range). A predictive model was developed to estimate the probability of confirming dysglycemia and for detecting diabetes at screening visit 2 based on values of FPG and HbA1c at screening visit 1.

Results

Of 1271 participants who met both FPG and HbA1c criteria for prediabetes at screening visit 1, 98.6% exhibited dysglycemia (defined as prediabetes or diabetes) on repeat testing (84.5% were classified as having prediabetes, 14.1% were reclassified as having diabetes). Of those with diabetes, 62.6% were identified by 2hPG alone.

Conclusions

Combined measurement of FPG and HbA1c is a reliable and reproducible measure to identify presence of dysglycemia among people at high risk. A prediction model is provided to help clinicians decide whether an oral glucose tolerance test will provide value in detecting diabetes based on the 2hPG criterion.

Feasibility of procedures for a randomised pilot study of reduced exertion, high-intensity interval training (REHIT) with non-diabetic hyperglycaemia patients

Background

Physical activity and exercise interventions to improve health frequently bring about intended effects under ideal circumstances but often fail to demonstrate benefits in real-world contexts. The aim of this study was to describe the feasibility of an exercise intervention (reduced-exertion, high-intensity interval training) in non-diabetic hyperglycaemia patients delivered in a National Health Service setting to assess whether it would be appropriate to progress to a future large-scale study.

Methods

The intention was to recruit 40 participants from a single centre (specialist diabesity centre). Patients were eligible to take part if they were diagnostically defined as non-diabetic hyperglycaemic based on a glycated haemoglobin (HbA_1c) value of 42–46 mmol mol. Study procedures including recruitment, occurrence of adverse events, intervention acceptability, and intervention adherence were used to assess feasibility.

Results

Key criteria for progression to a larger study were not met. The study revealed several issues including patient eligibility, challenges to recruitment, patient consent, and poor clinician engagement. Furthermore, despite the simplicity and convenience of using HbA_1c to screen for diabetes risk, the process of accurately screening and case finding eligible patients was problematic. The small sample recruited for this trial (n = 6) also limits the interpretation of data, thus it is not possible to estimate the variability of intended outcomes to use in a formal sample size calculation for a full-scale trial. Some aspects of the intervention worked well. The acceptability of the exercise intervention and outcome measures met progression criteria thresholds and adherence was very high, with 97% of exercise sessions completed for participants that finished the study.

Conclusions

Given the issues, the trial is not feasible in its current form. Yet, this preparatory stage of trial design pre-empted problems with the intervention that could be changed to optimise the design and conduct of future studies. Solutions to the issues identified in this study revolve around using a dedicated local recruiter with a strong relationship among the healthcare team and patients, using participant incentives to take part, and allowing for a longer recruitment period.

Trial registration

ClinicalTrials.gov, NCT04011397. Registered 07 July 2019—retrospectively registered.