Global aetiology and epidemiology of type 2 diabetes mellitus and its complications

Ten years of experience with DPP-4 inhibitors for the treatment of type 2 diabetes mellitus

Achieving and maintaining recommended glycemic targets without causing adverse e ffects, including hypoglycemia, is challenging, especially in older patients with type 2 diabetes mellitus (T2DM). The introduction of dipeptidyl peptidase-4 (DPP-4) inhibitors, more than 10 years ago, has provided an alternative to conventional medications for the intensification of glucose-lowering treatment after failure of metformin monotherapy, and therefore, marked an important advance in the management of T2DM. By prolonging the activity of incretin hormones, DPP-4 inhibitors induce insulin release and decrease glucagon secretion in a glucose-dependent manner. This results in a more physiologic glycemic control as compared to that ensured by insulin secretagogues (sulfonylureas and glinides). Overall, DPP-4 inhibitors have a favorable safety profile and can be used without dose adjustments in older adults and in patients with mild renal impairment; they have a neutral effect on body weight and do not cause hypoglycemia by themselves. Safety issues, reported mainly in post-marketing surveillance programs and including cardiovascular outcomes and the risk of acute pancreatitis, are being extensively investigated. The aim of this review is to discuss the impact of DPP-4 inhibitors on the treatment of T2DM, after 10 years of experience, with an emphasis on diabetes care in Italy. We will first describe T2DM treatment in Italy and then provide an overview of the main findings from randomized controlled trials, real-world studies and post-marketing surveillance programs with DPP-4 inhibitors.

Glycaemic control after treatment intensification in patients with type 2 diabetes uncontrolled on two or more non-insulin antidiabetic drugs in a real-world setting

AIM

To assess glycaemic control after treatment intensification in patients with type 2 diabetes uncontrolled on ≥2 non-insulin antidiabetic drugs (NIADS).

METHODS

A retrospective cohort study, using electronic health records from the SIDIAP database (2010-2014), was conducted. Intensification was defined as the prescription of any new antidiabetic drug in patients treated with ≥2 NIADS and HbA1c >7%. The primary outcome was the absolute change in HbA1c 6-12 months after any intensification. Secondary analyses included the percentage of patients reaching HbA1c <7%, HbA1c <8%, and a reduction of HbA1c >1% after the first intensification.

RESULTS

There were 21 241 intensifications in 15 205 patients with a mean (SD) HbA1c of 9.02% (±1.35). Insulin and dipeptidyl peptidase-4 inhibitors (DPP4i) were the most frequently added therapies. The mean baseline-adjusted HbA1c reduction was 0.78% (95% CI, -0.80 to -0.76), varying from -0.69% with DPP4i to -0.85% with glucagon-like peptide-1 receptor agonists while the addition of insulin was associated with a reduction >1%. After the first intensification, 48.9% of patients achieved HbA1c <8%, 16.2% HbA1c <7%, and 43.1% a reduction >1%. High previous HbA1c was positively associated with the reduction of HbA1c >1% [odds ratio (OR) 2.13 (95% CI: 2.05-2.21)], but inversely associated with the attainment of HbA1c <7% [OR 0.64 (0.61-0.67)] or < 8% [OR 0.63 (0.60-0.65)]. Older age, male gender, higher Charlson index, and short diabetes duration were associated with achievement of HbA1c <7%.

CONCLUSIONS

Despite intensification, most patients failed the glycaemic goal of HbA1c <7%. The reduction depended mainly on preintensification HbA1c values, with small differences between drugs.

Social inequality and diabetes mellitus - developments over time among the adult population in Germany

The connection between social disadvantage and the presence of known diabetes and specific risk factors is well documented. This article summarises the results from the Robert Koch Institute examination surveys that were conducted between 1997 and 1999 as well as 2008 and 2011 to address social inequality - operationalised by level of education - with regard to prevalences of known and unknown diabetes, risk of diabetes and care of diabetes as well as their development over time. Both survey periods showed that the low education group has higher prevalences of known and unkown diabetes as well as a higher risk of developing diabetes within the next five years compared to the medium and high education group. Over time, prevalence tended to increase for known diabetes and to decrease for unknown diabetes for all education groups. For the 5-year diabetes risk, only the high education group showed a clear decrease over time. The chosen indicators of diabetes care indicated no clear differences between education groups and an improvement of diabetes care over time. For some indicators of care (foot examination, statins), improvements were only seen in the low education group. In conclusion, social inequalities in the prevalence of known and unknown diabetes as well as in diabetes risk remain in Germany; for the indicators of care, however, no clear education gradient is evident. Over time, inequality regarding the prevalence of diabetes has not increased further. However, with regard to diabetes risk, inequality has become slightly more evident. For individual care indicators, improvements are limited to specific education groups.

SELECTION OF A FILLER FOR TABLETS MANUFACTURED WITH DIRECT COMPRESSION METHOD CONTAINING DRY GINGER EXTRACT

The preliminary studies of physico-chemical and pharmaco-technological properties of the dry extract of ginger have determined the need for introduction of different groups of excipients for developing a solid dosage form for the treatment of type II diabetes mellitus. Aim. To choose the rational filler in the composition of tablets with ginger obtained by direct compression. Materials and methods. The study object was the dry extract of ginger (DEG) (producer “Megaprom”, Dnepr,Ukraine) and modern excipients for the production of tablets by direct compression: GalenIQ 721 (BENEO-Palatinit Gmb), Flowlac 100 (Meggle Co.), Tablettose 80 (Meggle Co.), Farmaxx (Merck), Microcelac 100 (Meggle Co.), Vivapur 112 and 102 (JRS Pharm), Prosolv HD 90, Prosolv SMCC 50 (JRS Pharm) manufactured in Germany. Pharmaco-technological and physico-chemical properties of the samples were studied according to conventional methods of the State Pharmacopoeia of Ukraine. Results and discussion. According to the results of the crystallographic analysis, the ability to the moisture absorption, resistance to crushing, disintegration time, fluidity indicators, angle of repose and bulk volume the effect of modern excipients on physicochemical and pharmaco-technological properties of the dry extract of ginger has been studied. Conclusions. According to the results of microscopic analysis, it has been found, that the rational fillers are GalenIQ 721, Prosolv HD 90, Prosolv SMCC 50, Vivapur 102 and Vivapur 112, as they provide a uniform system and the necessary resistance to destruction. The study of the kinetics of the moisture absorption has shown that addition of the fillers significantly reduces the increase in moisture compared to the dry extract. The mixture with GalenIQ 721 has the lowest parameters of moisture absorption at a relative air humidity of 45 %, 75 % and 100 %. In accordance with the results of the pharmaco-technological studies, it has been found that addition of GalenIQ 721 leads to improved flowability, disintegration, settling qualities; it indicates the feasibility of its inclusion into the composition of the solid dosage form.

Berberine alleviates hyperglycemia by targeting hepatic glucokinase in diabetic db/db mice

Berberine (BBR) is a widely used anti-diabetic agent, and liver glucokinase (GK) has been reported to be involved. However, the mechanisms of BBR in regulating GK are still unknown. Here, we found that BBR upregulated GK immunofluorescence expression in AML12 cells cultured in high glucose and increased glycogen content simultaneously. BBR improved hyperglycemia in db/db mice, and increased liver glucose-6-phosphate/glucose-1-phosphate (G-6-P/G-1-P) was found by analyzing metabolites (serum, liver, and feces) based on gas chromatography-mass spectrometry (GC-MS) metabolomics. Pharmacokinetics-pharmacodynamics (PK-PD) assessment revealed enriched BBR distribution in the liver, and liver G-6-P had the same trend as the concentration-time curve of BBR. G-6-P is solely catalyzed by GK, and GK activity and expression showed a positive correlation with liver BBR levels. In db/db mice, BBR also upregulated GK in liver fractions (cytoplasm and nucleus) and liver glycogen content. GK functionally worked by dissociating from GK regulatory protein (GKRP), and although GKRP expression was not affected, we found a decreased ratio of GK binding with GKRP in BBR treated db/db mice. In conclusion, our study suggests the dissociation of GK from GKRP as the potential mechanism for liver GK increase upon BBR treatment, which contributes to the anti-diabetic effect of BBR.

Clinical significance of high-mobility group box-1 (HMGB1) in subjects with type 2 diabetes mellitus (T2DM) combined with chronic obstructive pulmonary disease (COPD)

Background

Simple method to predict type 2 diabetes mellitus (T2DM) combined with chronic obstructive pulmonary disease (COPD) is in great need clinically. This study aims to assess the clinical significance of high‐mobility group box‐1 (HMGB1) in predicting T2DM combined with COPD in Chinese patients with T2DM or COPD.

Methods

Serum concentrations of glycated hemoglobin (HbA1C), fasting plasma glucose (FPG), fasting insulin (FINS), total cholesterol (TC), triglyceride (TG), low‐density lipoprotein cholesterol (LDL‐c), high‐density lipoprotein cholesterol (HDL‐c), C‐reactive protein (CRP), fibrinogen (FIB), HMGB1, white blood cell count (WBC), neutrophil% (NEU%), and lung function text such as forced expiratory volume 1/forced vital capacity (FEV1/FVC) and forced expiratory volume 1% predicted value (FEV1%pred) were measured in 126 T2DM patients, 118 COPD patients, 112 T2DM combined with COPD patients, and 120 healthy controls. Logistic regression was used to estimate the risk factors for T2DM combined with COPD.

Results

High‐mobility group box‐1 elevated in patients with T2DM combined with COPD, significantly higher than other subjects (P < 0.05), and differences in HMGB1 also existed between patients with T2DM or COPD and healthy individuals (P < 0.01). HMGB1 was positively correlated with HOMA‐IR, FBG, and HbA1c (P < 0.01) and negatively correlated with FEV1/FVC and FEV1%pred (P < 0.01). Logistic regression showed that HMGB1 was identified to be independent risk factor for T2DM combined with COPD.

Conclusion

High‐mobility group box‐1 was independent risk factor for T2DM combined with COPD and can be served to predict the occurrence of T2DM combined with COPD.

Metabolic Syndrome Features: Is There a Modulation Role by Mineral Water Consumption? A Review

Metabolic syndrome (MetSyn) promotes, among others, the development of atherosclerotic cardiovascular disease and diabetes. Its prevalence increases with age, highlighting the relevance of promoting precocious MetSyn primary prevention and treatment with easy-to-implement lifestyle interventions. MetSyn features modulation through mineral water consumption was reviewed on Pubmed, Scopus and Google Scholar databases, using the following keywords: metabolic syndrome, hypertension, blood pressure (BP), cholesterol, triglycerides, apolipoprotein, chylomicron, very low-density lipoprotein, low-density lipoprotein, high-density lipoprotein (HDL), glucose, insulin, body weight, body mass index, waist circumference (WC), obesity and mineral(-rich) water. Twenty studies were selected: 12 evaluated BP, 13 assessed total-triglycerides and/or HDL-cholesterol, 10 analysed glucose and/or 3 measured WC. Mineral waters were tested in diverse protocols regarding type and composition of water, amount consumed, diet and type and duration of the study. Human and animal studies were performed in populations with different sizes and characteristics. Distinct sets of five studies showed beneficial effects upon BP, total-triglycerides, HDL-cholesterol and glucose. WC modulation was not reported. Minerals/elements and active ions/molecules present in mineral waters (and their pH) are crucial to counterbalance their inadequate intake and body status as well as metabolic dysfunction and increased diet-induced acid-load observed in MetSyn. Study characteristics and molecular/physiologic mechanisms that could explain the different effects observed are discussed. Further studies are warranted for determining the mechanisms involved in the putative protective action of mineral water consumption against MetSyn features.

MicroRNA-223 is essential for maintaining functional β-cell mass during diabetes through inhibiting both FOXO1 and SOX6 pathways

The initiation and development of diabetes are mainly ascribed to the loss of functional β-cells. Therapies designed to regenerate β-cells provide great potential for controlling glucose levels and thereby preventing the devastating complications associated with diabetes. This requires detailed knowledge of the molecular events and underlying mechanisms in this disorder. Here, we report that expression of microRNA-223 (miR-223) is up-regulated in islets from diabetic mice and humans, as well as in murine Min6 β-cells exposed to tumor necrosis factor α (TNFα) or high glucose. Interestingly, miR-223 knockout (KO) mice exhibit impaired glucose tolerance and insulin resistance. Further analysis reveals that miR-223 deficiency dramatically suppresses β-cell proliferation and insulin secretion. Mechanistically, using luciferase reporter gene assays, histological analysis, and immunoblotting, we demonstrate that miR-223 inhibits both forkhead box O1 (FOXO1) and SRY-box 6 (SOX6) signaling, a unique bipartite mechanism that modulates expression of several β-cell markers (pancreatic and duodenal homeobox 1 (PDX1), NK6 homeobox 1 (NKX6.1), and urocortin 3 (UCN3)) and cell cycle-related genes (cyclin D1, cyclin E1, and cyclin-dependent kinase inhibitor P27 (P27)). Importantly, miR-223 overexpression in β-cells could promote β-cell proliferation and improve β-cell function. Taken together, our results suggest that miR-223 is a critical factor for maintaining functional β-cell mass and adaptation during metabolic stress.

The promise of zebrafish as a model of metabolic syndrome

Metabolic syndrome is a cluster including hyperglycaemia, obesity, hypertension, and hypertriglyceridaemia as a result of biochemical and physiological alterations and can increase the risk of cardiovascular disease and diabetes. Fundamental research on this disease requires validated animal models. One potential animal model that is rapidly gaining in popularity is zebrafish (Danio rerio). The use of zebrafish as an animal model conveys several advantages, including high human genetic homology, transparent embryos and larvae that allow easier visualization. This review discusses how zebrafish models contribute to the development of metabolic syndrome studies. Different diseases in the cluster of metabolic syndrome, such as hyperglycaemia, obesity, diabetes, and hypertriglyceridaemia, have been successfully studied using zebrafish; and the model is promising for hypertension and cardiovascular metabolic-related diseases due to its genetic similarity to mammals. Genetic mutation, chemical induction, and dietary alteration are among the tools used to improve zebrafish models. This field is expanding, and thus, more effective and efficient techniques are currently developed to fulfil the increasing demand for thorough investigations.

Analysis of Patents Issued in China for Antihyperglycemic Therapies for Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) is prevalent, with a dramatic increase in recent years. Moreover, its microvascular and macrovascular complications cause significant societal issues. The demand for new and effective antidiabetic therapies grows with each passing day and motivates organizations and individuals to pay more attention to such products. In this article, we focused on oral antihyperglycemic drugs patented in China and introduced them according to their antihyperglycemic mechanisms. By searching the website of State Intellectual Property Office of the People's Republic of China (http://www.sipo.gov.cn), 2,500 antihyperglycemic patents for T2DM were identified and analyzed. These consisted of 4 patents for derivatives of herbal extracts (0.2%), 162 patents for herbal extracts (6.5%), 61 compositions for traditional Chinese medicine (TCM) (2.4%), 2,263 patents for synthetic compounds (90.5%), and 10 (0.4%) patents of the combination of synthetic compounds and TCM. As the most common drugs for diabetes mellitus, synthetic compounds can also be classified into several categories according to their working mechanisms, such as insulin secretion promotor agents, insulin sensitizer agents, α-glucosidase inhibitors, and so forth. This article discussed the chemical structure, potential antihyperglycemic mechanism of these antihyperglycemic drugs in patents in China. Expert opinion: Insulin sensitivity and β-cell function could be improved by weight loss to prevent prediabetes into T2DM. However, 40-50% patients with impaired glucose tolerance (IGT) still progress to T2DM, even after successful long-term weight loss. Antihyperglycemic remedies provide a treatment option to improve insulin sensitivity and maintain β-cell function. Combination therapy is the best treatment for diabetes. Combination therapy can reduce the dosage of each single drug option, and avoid the side effects. Drugs with different mechanisms are complementary, and are better adapted to patients with changing conditions. Classical combination therapies include combinations such as sulfonylureas plus biguanides or glucosidase inhibitors, biguanide plus glucosidase inhibitors or insulin sensitizers, insulin treatment plus biguanides or glucosidase inhibitors. The general principle of combination therapy is that two drugs with different mechanisms are selected jointly, and the combination of three types of hypoglycemic drugs is not recommended. After reading a large amount of literature, we have rarely found a case of three oral hypoglycemic agents, which may mean that the combination of three oral hypoglycemic agents is unnecessary and has unpredictable risks. There is no objection to the idea of multi-drug therapy. But multiple drugs can only be used when it shows a significant benefit to the patients. Combined use of multiple antidiabetic drugs poses a risk to patients due to drug interactions and overtreatment.

The sodium-glucose cotransporter 2 inhibitor luseogliflozin can suppress muscle atrophy in Db/Db mice by suppressing the expression of foxo1

We investigated the effect of the sodium glucose cotransporter-2 inhibitor (SGLT-2i) luseogliflozin on skeletal muscle. Eight-week-old mice were fed a standard diet or the standard diet with added luseogliflozin for 8 weeks. The mice were divided into the following four genotype/dietary groups: Db/m mice without SGLT-2i, Db/m mice with SGLT-2i inhibitor, Db/Db without SGLT-2i, and Db/Db with SGLT-2i. Among the mice with and without SGLT-2i, the ratio of soleus and plantaris muscle to body weight in the Db/Db mice was significantly lower than that in the Db/m mice. The cross-sectional area of soleus muscle in the Db/Db mice without SGLT-2i was significantly higher than that in the Db/Db mice with SGLT-2i. The expression of foxo1 in soleus muscle of the Db/Db mice was significantly higher than that of the Db/m mice, and the foxo1 expression of the Db/Db mice with SGLT-2i was significantly lower than that of the mice without SGLT-2i. The fluorescence intensity of foxo1 in the Db/Db mice fed SGLT-2i was significantly lower than that in the Db/Db mice without SGLT-2i. The administration of luseogliflozin resulted in the suppression of both the increased foxo1 expression and the reduced muscle cross-sectional area in the soleus muscle of Db/Db mice.

Determinants of knowledge, attitude and practice in patients with both type 2 diabetes and chronic kidney disease in Fiji

Background: In Fiji, Type 2 diabetes mellitus (T2DM) and Chronic kidney disease (CKD) are amongst the top four causes of premature mortality, disability and death. This study aims to identify the determinants of knowledge, attitude and practice (KAP) in T2DM patients with CKD in Fiji in 2018. Methods: A cross-sectional study was conducted at Sigatoka Sub-divisional Hospital (SSH) in Fiji in July-August, 2018 using a self-structured questionnaire to test KAP of 225 patients. The inclusion criteria were confirmed T2DM patients (Fijian citizens) with CKD, aged 30 years or above and attending Special Out-Patient's Department (SOPD) at SSH. Independent t-test and ANOVA was used to test differences between demographic variable and practice score while non-parametric tests were used for knowledge and attitude. Spearman correlation and multiple linear regressions were conducted. All tests were set at 5% level of significance. Results: From 249 questionnaires distributed, 225 responded thus response rate was 95%. The mean KAP level was high: knowledge, 23.3/30 (SD±3.25); attitude, 23.1/30 (SD±2.73) and practice, 7.1/10 (SD±2.04). A high level of knowledge was seen in those with university-level education (p<0.001), unemployed (p=0.05) and high average monthly income (p=0.03). Those aged 61-70 years had a 0.53-point lower attitude score (p=0.05) than other age categories, while those >70 years had a 1.78-point lower attitude score (p=0.01) than other age categories. Fijians of Indian descent (FID) had lower attitude (p=0.002) and higher practice (p=0.001) scores. Conclusion: Patients with both T2DM and CKD at SSH have high levels of KAP. The determinants of KAP have been shown and thus, this study identified high-risk groups for low KAP, which can become the focus of future public health intervention.

Cause-Specific Mortality in Multiethnic South East Asians With Type 2 Diabetes Mellitus

Data on specific causes of mortality in South East Asians with type 2 diabetes mellitus (T2DM) remain scarce. We followed 2061 outpatients with T2DM (Chinese 63%, Malays 20%, and Asian Indians 17%) for an average of 5.5 (standard deviation = 2.9) years and identified 365 death events by data linkage with national death registry. Cardiovascular disease was the main cause of mortality (44%), followed by renal disease (17%), infection (17%), cancer (14%), and others causes (8%). Survival analyses revealed that risks for all-cause and cause-specific mortality vary greatly among ethnic groups. Presence of diabetic kidney disease was an independent risk factor for death attributable to cardiovascular disease, renal disease, and infection, while HbA1c level predicted all major causes of deaths even after accounting for multiple other risk factors. These data reinforce the importance of glycemic control and prevention of diabetic kidney disease for mitigation of mortality burden in multiethnic Asians with T2DM.

Dietary Supplementation of Vine Tea Ameliorates Glucose and Lipid Metabolic Disorder via Akt Signaling Pathway in Diabetic Rats

A traditional Chinese tea with many pharmacological effects, vine tea (VT) is considered a potential dietary supplement to improve type 2 diabetes (T2D). To investigate the effect and mechanism of VT on glucose and lipid metabolic disorders in T2D rats, Wistar rats fed a normal diet served as the normal control, while rats fed a high-fat diet combined with low-dose streptozotocin (STZ)-induced T2D were divided into three groups: The model group (MOD); the positive control group (MET, metformin at 200 mg/kg/d); and the VT-treated group (VT500, allowed to freely drink 500 mg/L VT). After four weeks of intervention, biochemical metrics indicated that VT significantly ameliorated hyperglycemia, hyperlipidemia and hyperinsulinemia in T2D rats. Metabolomics research indicated that VT regulated the levels of metabolites closely related to glucose and lipid metabolism and promoted glycogen synthesis. Furthermore, VT had a significant influence on the expression of key genes involved in the Akt signaling pathway, inhibited gluconeogenesis through the Akt/Foxo1/Pck2 signaling pathway, and reduced fatty acid synthesis via the SREBP1c/Fasn signaling pathways. In conclusion, VT has great potential as a dietary supplement to ameliorate glucose and lipid metabolic disorders via the Akt signaling pathway in T2D rats.

Glucagon-Like Peptide-1 Receptor Agonists and Strategies To Improve Their Efficiency

Type 2 diabetes mellitus (T2DM) is increasing in global prevalence and is associated with serious health problems (e.g., cardiovascular disease). Various treatment options are available for T2DM, including the incretin hormone glucagon-like peptide-1 (GLP-1). GLP-1 is a therapeutic peptide secreted from the intestines following food intake, which stimulates the secretion of insulin from the pancreas. The native GLP-1 has a very short plasma half-life, owning to renal clearance and degradation by the enzyme dipeptidyl peptidase-4. To overcome this issue, various GLP-1 agonists with increased resistance to proteolytic degradation and reduced renal clearance have been developed, with several currently marketed. Strategies, such as controlled release delivery systems, methods to reduce renal clearance (e.g., PEGylation and conjugation to antibodies), and methods to improve proteolytic stability (e.g., stapling, cyclization, and glycosylation) provide means to further improve the ability of GLP-1 analogs. These will be discussed in this literature review.

Honokiol Improves Insulin Resistance, Hepatic Steatosis, and Inflammation in Type 2 Diabetic db/db Mice

This study focuses on the effect of honokiol (HON) on glucose homeostasis, insulin resistance, dyslipidemia, hepatic steatosis, and inflammation in type 2 diabetic db/db mice. Male C57BL/KsJ-db/db mice were fed a normal diet with or without HON (0.02%, w/w) or pioglitazone (PIO, anti-diabetic agent, 0.01%, w/w) for 5 weeks. Blood biomarker, tissue morphology and enzymatic and genetic parameters were determined. PIO significantly decreased food intake, fasting blood glucose, and glycosylated hemoglobin (HbA1c) levels, but markedly increased body weight, adipose tissue weight, and plasma leptin levels. HON did not significantly affect food intake, body weight, or levels of plasma leptin and blood glucose. However, HON led to significant decreases in adipose tissue weight, plasma insulin, blood HbA1c and HOMA-IR levels and improved glucose tolerance. The anti-diabetic and anti-adiposity effects of HON were partially related to the inhibition of gluconeogenic enzymes and their mRNA expression in the liver; and the inhibition of lipogenic enzymes in adipose tissue, respectively. Unlike PIO, HON did not affect dyslipidemia, but ameliorated hepatic steatosis by inhibiting hepatic lipogenic enzymes activity. Moreover, HON exhibited anti-inflammatory effects similar to PIO. These results suggest that HON can protect against type 2 diabetes by improving insulin resistance, glucose and lipid metabolism, and inflammation.

C1q/TNF-related protein-3 and glucose homeostasis

Adipokines are cytokines produced by adipocytes that may mediate inflammatory processes, whilst adipocyte-derived proteins may have the converse effect. C1q/TNF-related protein-3 or CTRP3 is a novel adipokine that is expressed and released by most types of human tissues including adipose tissue. This adipokine, considered as an adiponectin, can normalize blood glucose by several mechanisms. In addition, it can modulate the expression/secretion of other cytokine and adipokines leading to lower insulin resistance in peripheral tissues. Beneficial effects of CTRP3 against hyperglycemia-induced complications in the kidney and eye have been reported. In this review, we have presented the latest findings on the in vitro and in vivo hypoglycemic effects of CTRP3, followed by the findings on the preventive/therapeutic effects of CTRP3 adipokines against diabetes related complications.

Empagliflozin and kidney outcomes in Asian patients with type 2 diabetes and established cardiovascular disease: Results from the EMPA-REG OUTCOME® trial

AIMS/INTRODUCTION

In the EMPA-REG OUTCOME® trial, empagliflozin added to standard of care improved clinically relevant kidney outcomes by 39%, slowed progression of chronic kidney disease, and reduced albuminuria in patients with type 2 diabetes and established cardiovascular disease. This exploratory analysis investigated the effects of empagliflozin on the kidneys in Asian patients.

MATERIALS AND METHODS

Participants in the EMPA-REG OUTCOME® trial were randomized (1:1:1) to empagliflozin 10 mg, 25 mg or a placebo. In patients of Asian race, we analyzed incident or worsening nephropathy (progression to macroalbuminuria, doubling of serum creatinine, initiation of renal-replacement therapy or renal death) and its components, estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio changes, and renal safety.

RESULTS

Of 7,020 treated patients, 1,517 (26.1%) were Asian. In this subgroup, consistent with the overall trial population, empagliflozin reduced the risk of incident or worsening nephropathy (hazard ratio 0.64, 95% confidence interval 0.49-0.83), progression to macroalbuminuria (hazard ratio 0.64, 95% confidence interval 0.49-0.85) and the composite of doubling of serum creatinine, initiation of renal-replacement therapy or renal death (hazard ratio 0.48, 95% confidence interval 0.25-0.92). Furthermore, empagliflozin-treated participants showed slower eGFR decline versus placebo, and showed rapid urine albumin-to-creatinine ratio reduction at week 12, maintained through week 164, with effects most pronounced in those with baseline microalbuminuria or macroalbuminuria. The kidney safety profile of empagliflozin in the Asian subgroup was similar to the overall trial population.

CONCLUSIONS

In Asian patients from the EMPA-REG OUTCOME® trial, empagliflozin improved kidney outcomes, slowed eGFR decline and lowered albuminuria versus placebo, consistent with the overall trial population findings.

Microvascular complications among patients with diabetes: An emerging health problem in Saudi Arabia

Diabetes mellitus, besides disrupting the carbohydrate metabolism process, also induces vascular disease and impacts nearly all the types and sizes of blood vessels. In fact, vascular complications cause majority of the morbidity, hospitalizations and mortality of patients with diabetes mellitus. Retinopathy, nephropathy and neuropathy (microvascular complications) impact hundreds of millions of diabetics and normally target those having long-term or uncontrolled forms of the disease; however, these disorders can also exist at the time of diagnosis or in those yet to be diagnosed. The Kingdom of Saudi Arabia is the biggest country in the Middle East that occupies around four-fifths of the Arabian Peninsula supporting a population of more than 33.3 million people. The prevalence of diabetes mellitus is increasing at an alarming rate in Saudi Arabia. Over 25% of the adult population is suffering and that figure is projected to more than double by 2030. In fact, diabetes mellitus has approximately registered a 10-fold upsurge in the past three decades in Saudi Arabia. However, the prevalence and risk factors of microvascular complications in diabetes mellitus patients have not yet been clearly documented in Saudi Arabia. Hence, in this review, we aim to provide an overview of the microvascular complications among patients with diabetes in Saudi Arabia, utilizing data from the currently available published literature. This is an attempt to facilitate the government and healthcare systems aware of the enormous worth of prevention, early detection and appropriate management of such microvascular complications.

Gut microbial metabolites in obesity, NAFLD and T2DM

Evidence is accumulating that the gut microbiome is involved in the aetiology of obesity and obesity-related complications such as nonalcoholic fatty liver disease (NAFLD), insulin resistance and type 2 diabetes mellitus (T2DM). The gut microbiota is able to ferment indigestible carbohydrates (for example, dietary fibre), thereby yielding important metabolites such as short-chain fatty acids and succinate. Numerous animal studies and a handful of human studies suggest a beneficial role of these metabolites in the prevention and treatment of obesity and its comorbidities. Interestingly, the more distal colonic microbiota primarily ferments peptides and proteins, as availability of fermentable fibre, the major energy source for the microbiota, is limited here. This proteolytic fermentation yields mainly harmful products such as ammonia, phenols and branched-chain fatty acids, which might be detrimental for host gut and metabolic health. Therefore, a switch from proteolytic to saccharolytic fermentation could be of major interest for the prevention and/or treatment of metabolic diseases. This Review focuses on the role of products derived from microbial carbohydrate and protein fermentation in relation to obesity and obesity-associated insulin resistance, T2DM and NAFLD, and discusses the mechanisms involved.

Clinical and radiographic indices around narrow diameter implants placed in different glycemic-level patients

BACKGROUND

Studies assessing peri-implant clinical and marginal bone resorption (MBR) around narrow diameter implants (NDIs) placed in different glycemic levels are uninvestigated.

OBJECTIVE

The present 3-year retrospective follow-up investigation was designed to explore clinical and radiographic status of NDIs placed in individuals with different glycemic control levels.

MATERIALS AND METHODS

Patients with serum hemoglobin A1c (HbA1c) levels ≥6.5% (Group-1), 5.7%-6.4% (Group-2), and 4.0%-5.0% (Group-3) were included. Clinical indices evaluating bleeding on probing (BOP), plaque scores (PI), peri-implant probing depth (PD), and MBR were recorded around NDIs at 1-, 2-, and 3-year follow-up. Serum HbA1c test was carried out for all patients to assess the profile of glycosylated hemoglobin at 1 and 3 years of follow-up.

RESULTS

A significant reduction in mean HbA1c levels from year 1 to year 3 follow-up period was seen in Group-1 only. PI varied from 0.40 in Group 1 at 2 year and 0.42 at 3-year follow-up to 0.18 at 2-year (P = 0.032) and 0.17 at 3-year (P = 0.018) follow-up, respectively. Greater BOP was noted in Group 1 (0.53) as compared with Group 2 (0.42) and Group 3 (0.21) (P = 0.048) at 3-year follow-up. PD after 3 year ranged from 2.04 mm in Group 3 to 2.32 mm in Group 1 that showed statistically significant difference (P = 0.037). No statistical significant differences were observed in MBR at any time point between the groups.

CONCLUSION

The results of this short-term follow-up study indicate that NDIs show clinical and radiographic stability, provided oral cleanliness and glycemic levels are relatively maintained. Further long-term clinical studies are needed to evaluate implant stability over the period along with controlled glycemic status.

Regulation of insulin resistance by targeting the insulin-like growth factor 1 receptor with microRNA-122-5p in hepatic cells

Insulin resistance (IR) is a common etiology of type 2 diabetes (T2D) defined by a state of decreased reactivity to insulin in multiple organs, such as the liver. This study aims to investigate how microRNA-122-5p (miR-122) regulates the hepatic IR in vitro. We first found that the miR-122 level was upregulated in the liver of rats fed with a high-fat diet and injected with streptozotocin (T2D rats), while the expression level of insulin-like growth factor 1 receptor (IGF-1R), a potential target of miR-122, was downregulated in the diabetic liver. In vitro, glucosamine-induced IR was introduced in HepG2 hepatic cells, and the levels of miR-122 and IGF-1R were further assessed. An increase of miR-122 level and a decrease of IGF-IR level were observed in IR hepatic cells, which was the same as that in the diabetic liver. Results of the luciferase reporter assay validated IGF-1R as a direct target of miR-122. Moreover, in IR HepG2 cells, antagonizing miR-122 with its specific inhibitor enhanced glucose uptake and suppressed the expression of glucose 6-phosphatase and phosphoenolpyruvate carboxykinase, two key enzymes in regulating gluconeogenesis. Such alterations induced by the miR-122 inhibitor in IR hepatic cells were impaired when IGF-1R was simultaneously knocked down. In addition, the PI3K/Akt pathway was deactivated in IR cells, and then reactivated with miR-122 inhibitor transfection. In conclusion, our study demonstrates that miR-122 is able to regulate IR in hepatic cells by targeting IGF-1R.

Resveratrol Promotes Diabetic Wound Healing via SIRT1-FOXO1-c-Myc Signaling Pathway-Mediated Angiogenesis

Background/Aims: Diabetic non-healing skin ulcers represent a serious challenge in clinical practice, in which the hyperglycemia-induced disturbance of angiogenesis, and endothelial dysfunction play a crucial role. Resveratrol (RES), a silent information regulator 1 (SIRT1) agonist, can improve endothelial function and has strong pro-angiogenic properties, and has thus become a research focus for the treatment of diabetic non-healing skin ulcers; however, the underlying mechanism by which RES regulates these processes remains unclear. Therefore, the present study was intended to determine if RES exerts its observed protective role in diabetic wound healing by alleviating hyperglycemia-induced endothelial dysfunction and the disturbance of angiogenesis.

Methods: We investigated the effects of RES on cell migration, cell proliferation, apoptosis, tube formation, and the underlying molecular mechanisms in 33 mM high glucose-stimulated human umbilical vein endothelial cells (HUVECs) by semi-quantitative RT-PCR, western blot analysis, terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) staining, and immunofluorescence in vitro. We further explored the role of RES on endothelial dysfunction and wound healing disturbance in db/db mice by TUNEL staining, immunofluorescence, and photography in vivo.

Results: We observed an obvious inhibition of hyperglycemia-triggered endothelial dysfunction and a disturbance of angiogenesis, followed by the promotion of diabetic wound healing via RES, along with restoration of the activity of the hyperglycemia-impaired SIRT1 signaling pathway. Pretreatment with EX-527, a SIRT1 inhibitor, abolished the RES-mediated endothelial protection and pro-angiogenesis action, and then delayed diabetic wound healing. Furthermore, examination of the overexpression of forkhead box O1 (FOXO1), a transcription factor substrate of SIRT1, in HUVECs and db/db mice revealed that RES activated SIRT1 to restore hyperglycemia-triggered endothelial dysfunction and disturbance of angiogenesis, followed by the promotion of diabetic wound healing in a c-Myc-dependent manner. Pretreatment with 10058-F4, a c-Myc inhibitor, repressed RES-mediated endothelial protection, angiogenesis, and diabetic wound healing.

Conclusion: Our findings indicate that the positive role of RES in diabetic wound healing via its SIRT1-dependent endothelial protection and pro-angiogenic effects involves the inhibition of FOXO1 and the de-repression of c-Myc expression.

Association of C-peptide with diabetic vascular complications in type 2 diabetes

AIM

Fasting serum C-peptide is a biomarker of insulin production and insulin resistance, but its association with vascular complications in type 2 diabetes mellitus (T2DM) has never been fully elucidated. This study aimed to investigate whether C-peptide is associated with cardiovascular disease (CVD) and diabetic retinopathy (DR).

METHODS

A total of 4793 diabetes patients were enrolled from seven communities in Shanghai, China, in 2018. CVD was defined as a self-reported combination of previous diagnoses, including coronary heart disease, myocardial infarction and stroke. DR was examined using fundus photographs. Logistic regression analyses were performed, and multiple imputed data were used to obtain stabilized estimates.

RESULTS

Prevalence of CVD increased with increasing C-peptide levels (Q1, Q2, Q3 and Q4: 33%, 34%, 37% and 44%, respectively; P_{for trend} < 0.001), whereas DR prevalence decreased with increasing C-peptide quartiles (Q1, Q2, Q3 and Q4: 21%, 19%, 15% and 12%, respectively; P_{for trend} < 0.001). On logistic regression analysis, C-peptide levels were significantly associated with CVD prevalence (1.27, 95% CI: 1.13-1.42; P < 0.001) and C-peptide quartiles (Q1: reference; Q2: 1.31, 95% CI: 1.00-1.70; Q3: 1.53, 95% CI: 1.16-2.01; Q4: 1.76, 95% CI: 1.32-2.34; P_{for trend} < 0.001). Given the interaction between C-peptide and BMI and the association between C-peptide and CVD (P_{for interaction} = 0.015), study participants were divided into two subgroups based on BMI which revealed that the association persisted despite different BMI statuses. However, DR prevalence decreased with increasing C-peptide levels (0.73, 95% CI: 0.62-0.86; P < 0.001) and quartiles (Q1: reference; Q2: 1.00, 95% CI: 0.76-1.33; Q3: 0.69, 95% CI: 0.50-0.94; Q4: 0.51, 95% CI: 0.36-0.72; P_{for trend} < 0.001).

CONCLUSION

C-peptide was positively associated with CVD, but inversely associated with DR progression. The association between C-peptide and CVD could be due to associated metabolic risk factors.

Diabetic retinopathy: Focus on NADPH oxidase and its potential as therapeutic target

Diabetic retinopathy is a common complication of diabetes that affects the retina due to a sustained high blood sugar level. Recent studies have demonstrated that high glucose-driven oxidative stress plays an important role in the microvascular complications of retina in diabetes. Oxidative stress occurs due to the excess of reactive oxygen species, which causes oxidative damage to retina, leading to the leak of tiny blood vessels, or acts as signaling molecules to trigger neovascularization, resulting in new fragile vessels. NADPH oxidase (NOX) is a key enzymatic source of reactive oxygen species in the retina, and it is involved in the early as well as the advanced stage of diabetic retinopathy. To date, at least 7 NOX isoforms, including NOX1 to NOX5, dual oxidase1 and dual oxidase 2, have been identified. It has been shown that NOX isoforms exert different roles in the pathogenesis of diabetic retinopathy. Intervention of NOX by its inhibitors or modulators shows beneficial effect on improving the retinal functions in the models of diabetic retinopathy in vivo or in vitro. Thereby, NOX might be a potential target for the therapy of diabetic retinopathy. The present review focuses on the role of NOX, particularly the NOX isoforms, in promoting the development of diabetic retinopathy. In addition, NOX isoforms as potential targets for therapy of diabetic retinopathy are also discussed.

S1PR2 antagonist ameliorate high glucose-induced fission and dysfunction of mitochondria in HRGECs via regulating ROCK1

Aims

Sphingosine-1-phosphate receptor 2 (S1PR2) is a G-protein-coupled receptor that regulates sphingosine-1-phosphate-triggered cellular response. However, the role of S1PR2 in diabetes-induced glomerular endothelial cell dysfunction remains unclear. This study aims to investigate the effect of S1PR2 blockade on the morphology and function of mitochondria in human renal glomerular endothelial cells (HRGECs).

Methods

HRGECs were pretreated with a S1PR2 antagonist (JTE-013) or a Rho-associated coiled coil-containing protein kinase 1 (ROCK1) inhibitor (Y27632) for 30 min and then cultured with normal glucose (5.5 mM) or high glucose (30 mM) for 72 h. The protein expression levels of RhoA, ROCK1, and Dynmin-related protein-1(Drp1) were evaluated by immunoblotting; mitochondrial morphology was observed by electron microscopy; intracellular levels of ATP, ROS, and Ca²⁺ were measured by ATPlite, DCF-DA, and Rhod-2 AM assays, respectively. Additionally, the permeability, apoptosis, and migration of cells were determined to evaluate the effects of S1PR2 and ROCK1 inhibition on high glucose-induced endothelial dysfunction.

Results

High glucose induced mitochondrial fission and dysfunction, indicated by increased mitochondrial fragmentation, ROS generation, and calcium overload but decreased ATP production. High glucose also induced endothelial cell dysfunction, indicated by increased permeability and apoptosis but decreased migration. However, inhibition of either S1PR2 or ROCK1 almost completely blocked these high glucose-mediated cellular responses. Furthermore, inhibiting S1PR2 resulted in the deceased expression of RhoA, ROCK1, and Drp1 while inhibiting ROCK1 led to the downregulated expression of Drp1.

Conclusions

S1PR2 antagonist modulates the morphology and function of mitochondria in HRGECs via the positive regulation of the RhoA/ROCK1/Drp1 signaling pathway, suggesting that the S1PR2/ROCK1 pathway may play a crucial role in high glucose milieu.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1323-0) contains supplementary material, which is available to authorized users.

Association of Diabetes With All-Cause and Cause-Specific Mortality in Asia: A Pooled Analysis of More Than 1 Million Participants

IMPORTANCE

Asia is home to the largest diabetic populations in the world. However, limited studies have quantified the association of diabetes with all-cause and cause-specific mortality in Asian populations.

OBJECTIVES

To evaluate the association of diabetes with all-cause and cause-specific mortality in Asia and to investigate potential effect modifications of the diabetes-mortality associations by participants' age, sex, education level, body mass index, and smoking status.

DESIGN, SETTING, AND PARTICIPANTS

This pooled analysis incorporated individual participant data from 22 prospective cohort studies of the Asia Cohort Consortium conducted between 1963 and 2006. A total of 1 002 551 Asian individuals (from mainland China, Japan, South Korea, Singapore, Taiwan, India, and Bangladesh) were followed up for more than 3 years. Cohort-specific hazard ratios and 95% confidence intervals for all-cause and cause-specific mortality were estimated using Cox regression models and then pooled using random-effects meta-analysis. Analysis was conducted between January 10, 2018, and August 31, 2018.

EXPOSURES

Doctor-diagnosed diabetes, age, sex, education level, body mass index, and smoking status.

MAIN OUTCOMES AND MEASURES

All-cause and cause-specific mortality.

RESULTS

Of 1 002 551 participants (518 537 [51.7%] female; median [range] age, 54.0 [30.0-98.0] years), 148 868 deaths were ascertained during a median (range) follow-up of 12.6 (3.0-38.9) years. The overall prevalence of diabetes reported at baseline was 4.8% for men and 3.6% for women. Patients with diabetes had a 1.89-fold risk of all-cause death compared with patients without diabetes (hazard ratio [HR], 1.89; 95% CI, 1.74-2.04), with the highest relative risk of death due to diabetes itself (HR, 22.8; 95% CI, 18.5-28.1), followed by renal disease (HR, 3.08; 95% CI, 2.50-3.78), coronary heart disease (HR, 2.57; 95% CI, 2.19-3.02), and ischemic stroke (HR, 2.15; 95% CI, 1.85-2.51). The adverse diabetes-mortality associations were more evident among women (HR, 2.09; 95% CI, 1.89-2.32) than among men (HR, 1.74; 95% CI, 1.62-1.88) (P for interaction < .001) and more evident among adults aged 30 to 49 years (HR, 2.43; 95% CI, 2.08-2.84) than among adults aged 70 years and older (HR, 1.51; 95% CI, 1.40-1.62) (P for interaction < .001). A similar pattern of association was found between diabetes and cause-specific mortality, with significant variations noted by sex and age.

CONCLUSIONS AND RELEVANCE

This study found that diabetes was associated with increased risk of death from several diseases among Asian populations. Development and implementation of diabetes management programs are urgently needed to reduce the burden of diabetes in Asia.

A Positive Causal Influence of IL-18 Levels on the Risk of T2DM: A Mendelian Randomization Study

A large number of clinical studies have shown that interleukin-18 (IL-18) plasma levels are positively correlated with the pathogenesis and development of type 2 diabetes mellitus (T2DM), but it remains unclear whether IL-18 causes T2DM, primarily due to the influence of reverse causality and residual confounding factors. Genome-wide association studies have led to the discovery of numerous common variants associated with IL-18 and T2DM and opened unprecedented opportunities for investigating possible associations between genetic traits and diseases. In this study, we employed a two-sample Mendelian randomization (MR) method to analyze the causal relationships between IL-18 plasma levels and T2DM using IL18-related SNPs as genetic instrumental variables (IVs). We first selected eight SNPs that were significantly associated with IL-18 but independent of T2DM. We then used these SNPs as IVs to evaluate their effects on T2DM using the inverse-variance weighted (IVW) method. Finally, we conducted sensitivity analysis and MR-Egger regression analysis to evaluate the heterogeneity and pleiotropic effects of each variant. The results based on the IVW method demonstrate that high IL-18 plasma levels significantly increase the risk of T2DM, and no heterogeneity or pleiotropic effects appeared after the sensitivity and MR-Egger analyses.

Characteristics of Patients with Diabetes Initiating Sodium Glucose Co-transporter-2 Inhibitors (SGLT2i): Real-World Results from Three Administrative Databases in Japan

INTRODUCTION

The aim of this study was to evaluate the characteristics of new users of sodium glucose co-transporter-2 inhibitors (SGLT2i) in comparison with those of new users of other oral antidiabetic drugs (OADs) using data retrieved from three administrative databases in Japan.

METHODS

This study included adult patients from each database who started an OAD between 2014 and 2017. Outpatients who started SGLT2i therapy were included in the SGLT2i cohort. The remaining outpatients were grouped according to the OAD class of their earliest initial prescription after no use of the index OAD during the 6-month pre-index period. Diabetes-related complications were evaluated using the Diabetes Complication Severity Index.

RESULTS

In total, 176,355 patients in the hospital-based administrative database (H-dataset), 98,361 in the pharmacy claims database (P-dataset) and 37,786 in the insurance claims database (I-dataset) were analyzed. In the H-dataset, SGLT2i users, compared with users of other OADs, tended to be younger (mean age at index: 57.7 vs. 60.3-69.2 years) and to have a higher prevalence of hypercholesterolemia (73.5 vs. 55.2-71.4%), a higher mean body weight (74.4 vs. 60.5-70.8 kg), a higher body mass index (27.6 vs. 23.5-26.4 kg/m²) and a higher glycated hemoglobin level (8.4 vs. 7.4-8.1%). There were no distinct differences in the prevalence of complications between SGLT2i users and users of other OADs in the H-dataset. Similar trends were noted in the other datasets.

CONCLUSION

Patients initiating SGLT2i therapy differed in several characteristics from new users of other OADs. SGLT2i were prescribed more frequently to younger patients, those at increased cardiovascular risk or those with poorer glycemic control.

FUNDING

Astellas Pharma Inc., Tokyo, Japan.

Veiled Potential of Secretagogin in Diabetes: Correlation or Coincidence?

Secretagogin (SCGN) is a calcium sensor protein enriched in neuroendocrine cells in general and pancreatic β-cells in particular. SCGN regulates insulin secretion through several Ca²⁺-dependent interactions. Recent studies implicate SCGN in the β-cell physiology and extracellular insulin function, making it an intriguing candidate in diabetes research. Here, we propose a conjoining theme of diversified SCGN function in diabetes pathology. In our opinion, SCGN is an attractive therapeutic candidate ascribed by its role in β-cell maintenance and neuronal functions and in the efficacy of insulin. To scrutinize the therapeutic prospects of SCGN, we abridge putative diabetes-related properties of SCGN and put forth strategies to determine the precise role of SCGN in the pathogenesis/preclusion of diabetes.

Fluoride Exposure Induces Inhibition of Sodium/Iodide Symporter (NIS) Contributing to Impaired Iodine Absorption and Iodine Deficiency: Molecular Mechanisms of Inhibition and Implications for Public Health

The sodium iodide symporter (NIS) is the plasma membrane glycoprotein that mediates active iodide transport in the thyroid and other tissues, such as the salivary, gastric mucosa, rectal mucosa, bronchial mucosa, placenta and mammary glands. In the thyroid, NIS mediates the uptake and accumulation of iodine and its activity is crucial for the development of the central nervous system and disease prevention. Since the discovery of NIS in 1996, research has further shown that NIS functionality and iodine transport is dependent on the activity of the sodium potassium activated adenosine 5'-triphosphatase pump (Na+, K+-ATPase). In this article, I review the molecular mechanisms by which F inhibits NIS expression and functionality which in turn contributes to impaired iodide absorption, diminished iodide-concentrating ability and iodine deficiency disorders. I discuss how NIS expression and activity is inhibited by thyroglobulin (Tg), tumour necrosis factor alpha (TNF-α), transforming growth factor beta 1 (TGF-β1), interleukin 6 (IL-6) and Interleukin 1 beta (IL-1β), interferon-γ (IFN-γ), insulin like growth factor 1 (IGF-1) and phosphoinositide 3-kinase (PI3K) and how fluoride upregulates expression and activity of these biomarkers. I further describe the crucial role of prolactin and megalin in regulation of NIS expression and iodine homeostasis and the effect of fluoride in down regulating prolactin and megalin expression. Among many other issues, I discuss the potential conflict between public health policies such as water fluoridation and its contribution to iodine deficiency, neurodevelopmental and pathological disorders. Further studies are warranted to examine these associations.

Patterns of Glycemic Variability During a Diabetes Self-Management Educational Program

Background: Variations in blood glucose levels over a given time interval is termed as glycemic variability (GV). Higher GV is associated with higher diabetes-related complications. The current study was done with the aim of detecting the sensitivity of various GV indices among individuals with type 2 diabetes mellitus of different glycemic control status. Methods: We performed a longitudinal study among individuals with type 2 diabetes mellitus (T2DM) who were participating in a two-week diabetes self-management education (DSME) program. Participants were categorized by their HbA1c as poor (≥8%), acceptable (7%–8%), and optimal control (<7%). Continuous glucose monitoring (CGM) sensors recorded interstitial glucose every 15 min from day 1. The evaluated GV measures include standard deviation (SD), coefficient of variation (CV), mean amplitude of glycemic excursion (MAGE), continuous overlapping net glycemic action (CONGA), mean of daily difference for inter-day variation (MODD), high blood glucose index (HBGI), and low blood glucose index (LBGI). Results: A total of 41 study participants with 46347 CGM values were available for analysis. Of 41 participants, 20 (48.7%) were in the poor, 10 (24.3%) in the acceptable, and 11 (26.8%) in the optimal control group. The GV indices (SD; CV; MODD; MAGE; CONGA; HBGI) of poorly controlled (77.43; 38.02; 45.82; 216.63; 14.10; 16.62) were higher than acceptable (50.02; 39.32; 30.79; 138.01; 8.87; 5.56) and optimal (34.15; 29.46; 24.56; 126.15; 8.67; 3.13) control group. Glycemic variability was reduced in the poorly and acceptably controlled groups by the end of the 2-week period. There was a rise in LBGI in the optimally controlled group, indicating pitfalls of tight glycemic control. Conclusion: Indices of glycemic variability are useful complements, and changes in it can be demonstrated within short periods.

Synthesis of Rosmarinic Acid Amides as Antioxidative and Hypoglycemic Agents

Type 2 diabetes mellitus (T2DM) is an important metabolic disorder for which there is an urgent need for new antidiabetic drugs. α-Glucosidase inhibition is an established protocol for T2DM therapy. Because hyperglycemia causes oxidative tissue damage, the development of agents with both α-glucosidase inhibition and antioxidant activity from natural or natural-derived polyphenols such derivatives of rosmarinic acid (RA) represents an attractive therapeutic option. We report a study on amides 1-10 derived from RA and their evaluation for yeast α-glucosidase inhibition and antioxidant activity (DPPH and ORAC tests). All amides showed higher inhibitory activity than that of RA, were by far more potent than the antidiabetic drug acarbose, and proved to be effective antioxidants. A molecular docking study displayed significant binding interactions of RA amides with the active site of α-glucosidase. This in silico optimization study led to the design and synthesis of amides 9 (IC50 = 42.3 μM) and 10 (IC50 = 35.2 μM), showing the most potent α-glucosidase inhibition and good antioxidative properties. A kinetic study showed that 10 acts as a mixed type inhibitor.

"Wasting away": Diabetes, food insecurity, and medical insecurity in the Somali Region of Ethiopia

Most research on diabetes has taken place in cities or in high-income countries, even though most diabetes deaths occur in low and middle-income countries, and diabetes disproportionately affects the poor. This research, by contrast, investigates rising concerns about diabetes among Somalis in eastern Ethiopia--in communities where obesity is rare and people face chronic food insecurity, forced displacement, recurrent humanitarian crises, and lack of access to medical care. Findings presented in this article build on ethnographic research with Somalis in eastern Ethiopia since 2007, and include anthropometric and demographic data collection with Somali diabetes patients and select adult siblings of these patients (n = 108) plus in-depth ethnographic interviews with a subset of the diabetes patients, their siblings, and medical providers serving Somali communities (n = 29) in July-August 2018. Most Somali patients we spoke with shared symptoms of progressive weight loss, weakness, and loss of teeth--or what people called "wasting away"--even when complying with prescribed pharmaceutical regimens and/or insulin. Diabetes and "wasting away" were characterized by Somalis as humoral pathologies; but rather than a consequence of obesity or pathological weight gain, these were perceived to be a consequence of stress, trauma, anger, displacement, loss of healthy fatness, and lack of access to fresh and healthy food over their lifetimes. Somalis' simultaneous experiences of progressive nutritional wasting and adult-onset diabetes echo how "tropical diabetes" was defined and experienced for thousands of years prior to the development of effective early diagnostics and biomedical treatments. This analysis therefore suggests heterogeneity and overlaps within and between categories of "type 1" and "type 2 diabetes" in populations with differential exposures to stress, crisis, and poverty. Exposures to food insecurity and medical insecurity, in particular, are pathogenic, and shape diabetes patients' clinical presentations and prognoses, as well as local etiologies and patterns of disease.

Heart failure and diabetes: The confrontation of two major epidemics of the 21st century

There is a bidirectional association between heart failure (HF) and type 2 diabetes mellitus (DM2), which has resulted in an exponential increase in the combination of the 2 diseases in a single patient. This combination is one of many common causes that lead to the pathophysiological pathways resulting in the deleterious effect of DM2 on HF. The inevitable clinical consequence is that, when faced with this situation, patients present worse symptoms and a poorer prognosis than patients with HF but without DM2. We should therefore consider how to treat DM2 in patients with HF and how to treat HF in patients with DM2. In this review, we highlight the latest published data on this issue.

Urocortin 2 Gene Transfer Reduces the Adverse Effects of a Western Diet on Cardiac Function in Mice

Diabetes mellitus is associated with increased risk of heart failure. It has been previously demonstrated in mice that a single injection of adeno-associated virus 8 encoding urocortin 2 (AAV8.UCn2) increases glucose disposal in models of insulin resistance and improves the function of the failing heart. The present study tested the hypothesis that UCn2 gene transfer would reduce diabetes-related left ventricular (LV) dysfunction. Eight-week-old C57BL6 male mice were fed a Western diet (WD; 45% fat, 35% carbohydrate) for 40 weeks. At week 30, they received saline or AAV8.UCn2 (2 × 10¹³ genome copies/kg) via intravenous injection. Ten weeks after gene transfer, fasting blood glucose, glucose tolerance, and cardiac function were measured via echocardiography and in vivo measurement of LV contractile function, and the results were compared to those of mice fed normal chow (NC; 10% fat; 70% carbohydrate). The contents of key LV signaling proteins were also measured to probe mechanisms. WD increased 12 h fasting glucose (WD: 190 ± 11 mg/dL, n = 8; NC: 105 ± 12 mg/dL, n = 7; p = 0.0004). WD tended to reduce LV peak +dP/dt (p = 0.08) and LV peak -dP/dt (p = 0.05). LV ejection fraction was unchanged. Among WD-fed mice, UCn2 gene transfer reduced 12 h fasting glucose (WD-UCn2: 149 ± 6 mg/dL, n = 8; WD-Saline: 190 ± 11 mg/dL, n = 8; p = 0.012), increased LV peak +dP/dt (p < 0.001) and LV peak -dP/dt (p = 0.013), and reduced Tau (p < 0.02), indicating beneficial effects on systolic and diastolic LV function. In addition, among WD-fed mice, UCn2 gene transfer increased LV ejection fraction (p < 0.005) and the velocity of circumferential fiber shortening (p = 0.0005). Finally, a reduction was seen in fatty infiltration of the liver in WD-fed mice that had received UCn2 gene transfer. LV samples from WD-UCn2 mice showed increased phosphorylation of the protein kinase A catalytic domain (p = 0.03). In conclusion, UCn2 gene transfer increased LV systolic and diastolic function and reduced blood glucose in mice with diabetes-related LV dysfunction, indicating that UCn2 gene transfer may be of potential therapeutic benefit.

Severe Depressive Episode with Psychotic Symptoms and Type 2 Diabetes: A 2010-2017 Longitudinal Study

BACKGROUND There have been few studies published on the prevalence of severe depressive episode in people with type 2 diabetes (T2DM) or its role in adherence to dietary recommendations. We examined the Polish National Health Fund (NFZ) database estimates of all medical visits from 2010 to 2017 to determine the trend and the epidemiology of severe depressive episode in T2DM. MATERIAL AND METHODS The NFZ database was used. We defined the T2DM group diagnosed with both T2DM and severe depressive episode according to the ICD-10 codes. The annual prevalence of severe depressive episode was estimated according to the T2DM diagnosis status, and the age groups were stratified into 8 groups. RESULTS Relative risk for depression (regardless of severity of symptoms) in T2DM is 1.347 [95%CI: 1.342-1.353]. The frequency trend of severe depressive episode with or without psychotic symptoms remains relatively stable. In the case of mild and moderate depressive episode, a downward trend was noted, but they are still the most frequent mood disorders diagnosed. Patients with T2DM aged 20 to 40, for whom the peak of coexistence of these illnesses was noted, are the group particularly vulnerable to depression. Depression also remains on a relatively high but stable level for patients over 60 years of age. CONCLUSIONS The coexistence of depressive episodes in T2DM is a key challenge for medicine and public health. Measures aimed at early identification of patients with T2DM prone to depression need to be taken. Creating multidisciplinary care teams in diabetes management is also necessary.

Increased Ratio of Global O-GlcNAcylation to Tau Phosphorylation at Thr212 Site Is Associated With Better Memory Function in Patients With Type 2 Diabetes

Objective: Aberrant O-GlcNAc modification has been implicated in type 2 diabetes mellitus (T2DM) and the pathogenesis of neurodegenerative diseases via competition with tau phosphorylation. We aimed to investigate the association between global O-GlcNAcylation, tau phosphorylation levels and mild cognitive impairment (MCI) in the whole blood of patients with T2DM.

Methods: Sociodemographic, clinical characteristics and cognitive performances of the enrolled T2DM subjects were extensively assessed. Global O-GlcNAcylation and tau phosphorylation levels in the whole blood were also determined using Western blot.

Results: Forty-eight T2DM subjects, including 24 with MCI and 24 with normal cognition, were enrolled in this study. Compared with cognitively normal controls, T2DM with MCI subjects displayed decreased global O-GlcNAcylation level, but increased tau phosphorylation levels (all p < 0.05). To reflect the combined effect, the ratios of global O-GlcNAcylation to tau phosphorylation levels, including specific sites, such as Ser396, Ser404, Thr212, and Thr231, were all significantly decreased in MCI subjects (all p < 0.05). Further multivariable logistic regression analysis revealed that high glycated hemoglobin A1c was an independent risk factor, whereas increased O-GlcNAc/p-T212 was an independent protective factor for MCI in patients with T2DM (odds ratio [OR] = 2.452, 95% confidence interval [CI] 1.061–5.668, p = 0.036; OR = 0.028, 95%CI 0.002–0.388, p = 0.008, respectively). With regard to each cognitive domain, O-GlcNAc/p-T212 was positively correlated with the score of Auditory Verbal Learning Test-delayed recall (r = 0.377, p = 0.010).

Conclusion: Our study suggests that increased ratio of global O-GlcNAcylation to tau phosphorylation at Thr212 site in the whole blood is associated with decreased risk of MCI, especially with better memory function in T2DM subjects.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier ChiCTR-OCC-15006060.

Peroxisome proliferator-activated receptor A/G reprogrammes metabolism associated with lipid accumulation in macrophages

INTRODUCTION

Macrophage metabolism contributes to the progression of metabolic diseases, and peroxisome proliferator-activated receptors (PPARs) play vital roles in macrophage metabolism and the treatment of metabolic diseases. However, the role of PPARs in metabolic reprogramming related to lipid accumulation in macrophages, a key pathological event in metabolic diseases, remains unclear.

OBJECTIVES

We aimed to identify PPAR-mediated metabolic reprogramming and potential therapeutic targets associated with lipid accumulation in macrophages.

METHODS

Following treatment with oleate, oleate + WY-14643 and oleate + pioglitazone to induce alterations in PPAR signaling, lipids and relevant metabolism, macrophage samples were analyzed employing an untargeted metabolomics based on gas chromatography-mass spectrometry.

RESULTS

The metabolomics approach revealed that multiple metabolic pathways were altered during lipid accumulation in oleate-treated macrophages and responsive to WY-14643 and pioglitazone treatment. Notably, levels of most metabolites involved in amino acid metabolism and nucleotide metabolism were accumulated in oleate-treated macrophages, and these effects were alleviated or abolished by PPARA/G activation. Additionally, during oleate-induced lipid accumulation and lipid lowering with WY-14643 and pioglitazone in macrophages, levels of most amino acids were positively associated with neutral lipid, total cholesterol, cholesterol ester, total free fatty acid and triglyceride levels but negatively associated with expression of genes related to PPARA/G signaling. Furthermore, glycine was found to be a potential biomarker for assessing lipid accumulation and the lipid-lowering effects of PPARA/G in oleate-treated macrophages.

CONCLUSION

The results of this study revealed a high correlation of amino acid metabolism with lipid accumulation and the lipid-lowering effects of PPARA/G in macrophages.

CANadian CAnagliflozin REgistry: Effectiveness and safety of canagliflozin in the treatment of type 2 diabetes mellitus in Canadian clinical practice

AIM

There is limited information concerning the effects of canagliflozin (CANA), a sodium-glucose co-transporter 2 inhibitor (SGLT2i) in a real-world clinical setting in Canada. CanCARE is a 12-month, prospective, observational analysis to demonstrate the effectiveness and safety of CANA in usual clinical practice in Canada.

MATERIALS AND METHODS

SGLT2i-naïve adult patients with type 2 diabetes mellitus (T2DM) (n = 527) on a stable antihyperglycemic agent (AHA) regimen with glycated hemoglobin (A1C) ≥ 7%, an estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73m2 , were initiated on CANA as part of their usual treatment approach, and were followed for a period of 12 months. The primary effectiveness objective was the mean change in HbA1c from baseline to 6 and 12 months.

RESULTS

Significant improvement from baseline in mean HbA1c levels were observed at 6 months (-0.90%; 95% CI, -1.02, -0.78) and at 12 months (-1.04%; 95% CI, -1.15, -0.92), regardless of duration of diabetes or background AHA treatment regimen. Similarly, significant decreases in systolic blood pressure (-4.65 mm Hg); body weight (-3.24 kg), waist circumference (-2.91 cm) and body mass index (-1.15 kg/m2 ) were observed at 12 months. Additionally, 40.5% of patients achieved the double endpoint (≥0.5% HbA1c reduction and ≥ 3% weight loss), while 24.3% of patients achieved the triple composite endpoint (≥0.5% HbA1c reduction, ≥3% weight loss and ≥ 4 mm Hg systolic blood pressure reduction). No unexpected adverse events were reported.

CONCLUSION

CANA provided sustained clinically meaningful improvements in cardiometabolic parameters in this study in a real-world setting, confirming findings from randomized controlled trials.

Diabetes and work: The need of a close collaboration between diabetologist and occupational physician

AIM

The Italian Society of Occupational Medicine (SIML), the Italian Diabetes Society (SID) and the Association of Diabetologists (AMD) joined a working group that produced a consensus paper aimed to assess the available evidence regarding the interplay between specific working conditions, including shift- and night-time work, working activities at high risk of accidents and work at heights, working tasks requiring high-energy expenditure, working activities at extreme temperatures and diabetes.

DATA SYNTHESIS

Diabetes is a group of metabolic disorders caused by defects in insulin secretion and/or action affecting millions of people worldwide, many of whom are or wish to be active members of the workforce. Although diabetes, generally, does not prevent a person from properly performing his/her working tasks, disease complications can significantly compromise a person's ability to work. Therefore, it appears evident the need to understand the relationship between occupational risk factors and diabetes. The working group included in the document some practical recommendations useful to ensure diabetic workers the possibility to safely and effectively undertake their jobs and to adequately manage and treat their disease, also in the workplace. In this perspective concerted action of all the workplace preventive figures, occupational physicians and diabetologists should be strongly encouraged.

CONCLUSIONS

Further studies are necessary to define workplace-based interventions, which should be minimally invasive towards the work organization, allowing diabetic workers to fully realize their work skills while improving their wellbeing at work.

In Vivo Rodent Models of Type 2 Diabetes and Their Usefulness for Evaluating Flavonoid Bioactivity

About 40% of the world’s population is overweight or obese and exist at risk of developing type 2 diabetes mellitus (T2D). Obesity is a leading pathogenic factor for developing insulin resistance (IR). It is well established that IR and a progressive decline in functional β-cell mass are hallmarks of developing T2D. In order to mitigate the global prevalence of T2D, we must carefully select the appropriate animal models to explore the cellular and molecular mechanisms of T2D, and to optimize novel therapeutics for their safe use in humans. Flavonoids, a group of polyphenols, have drawn great interest for their various health benefits, and have been identified in naturally occurring anti-diabetic compounds. Results from many clinical and animal studies demonstrate that dietary intake of flavonoids might prove helpful in preventing T2D. In this review, we discuss the currently available rodent animal models of T2D and analyze the advantages, the limitations of each T2D model, and highlight the potential anti-diabetic effects of flavonoids as well as the mechanisms of their actions.

C-reactive protein for predicting cardiovascular and all-cause mortality in type 2 diabetic patients: A meta-analysis

AIMS

There is interest in using blood C-reactive protein (CRP) to predict adverse prognosis outcomes patients with type 2 diabetes. This meta-analysis aimed to investigate the association between elevated baseline CRP level and unfavorable outcomes in type 2 diabetes patients.

MATERIALS/METHODS

PubMed and Embase databases were systematically searched for studies on the association of elevated baseline CRP level with cardiovascular mortality and all-cause mortality from their inception to July 2018. Pooled risk ratio (RR) with 95% confidence intervals (CI) was calculated for the highest versus the lowest CRP level.

RESULTS

Six prospective cohort studies and two post hoc analyses of randomized controlled trials involving 22,322 type 2 diabetes patients were included. Meta-analysis indicated that type 2 diabetes patients with the highest CRP level had a greater risk of all-cause mortality (RR 2.03; 95% CI 1.49-2.75) and cardiovascular mortality (RR 1.76; 95% CI 1.46-2.13). Subgroups analysis indicated that the increased cardiovascular and all-cause mortality risk was consistently found in different study design, follow-up duration or patients with or without cardiovascular risk/established cardiovascular disease subgroups.

CONCLUSIONS

This meta-analysis indicates that elevated baseline serum CRP level is independently associated with future cardiovascular and all-cause mortality in type 2 diabetes patients.

Prenatal Malnutrition-Induced Epigenetic Dysregulation as a Risk Factor for Type 2 Diabetes

Type 2 diabetes (T2D) is commonly regarded as a disease originating from lifestyle-related factors and typically occurring after the age of 40. There is, however, consistent experimental and epidemiological data evidencing that the risk for developing T2D may largely depend on conditions early in life. In particular, intrauterine growth restriction (IUGR) induced by poor or unbalanced nutrient intake can impair fetal growth and also cause fetal adipose tissue and pancreatic β-cell dysfunction. On account of these processes, persisting adaptive changes can occur in the glucose-insulin metabolism. These changes can include reduced ability for insulin secretion and insulin resistance, and they may result in an improved capacity to store fat, thereby predisposing to the development of T2D and obesity in adulthood. Accumulating research findings indicate that epigenetic regulation of gene expression plays a critical role in linking prenatal malnutrition to the risk of later-life metabolic disorders including T2D. In animal models of IUGR, changes in both DNA methylation and expression levels of key metabolic genes were repeatedly found which persisted until adulthood. The causal link between epigenetic disturbances during development and the risk for T2D was also confirmed in several human studies. In this review, the conceptual models and empirical data are summarized and discussed regarding the contribution of epigenetic mechanisms in developmental nutritional programming of T2D.

Effects of MTNR1B genetic variants on the risk of type 2 diabetes mellitus: A meta-analysis

Background

Whether melatonin receptor 1B (MTNR1B) variants are associated with type 2 diabetes mellitus (T2DM) remains unclear. Therefore, we performed this meta‐analysis to better explore correlations between MTNR1B variants and T2DM.

Methods

Literature research was performed in PubMed, Medline, and Embase. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

Results

Totally 21 studies were enrolled to analyses. Pooled overall analyses showed that MTNR1B rs10830963 variant was significantly correlated with the susceptibility to T2DM (allele model: p = 0.02, OR = 0.97, 95% CI 0.95–1.00). Further subgroup analyses by ethnicity of participants revealed that rs10830963 variant was significantly correlated with the susceptibility to T2DM in South Asians, but not in Caucasians or East Asians. No any other positive results were found in overall and subgroup analyses.

Conclusions

Our findings indicated that MTNR1B rs10830963 variant might serve as a genetic biomarker of T2DM, especially in South Asians.