Projected number of people with diagnosed Type 2 diabetes in Germany in 2040

Skull base osteomyelitis: HBO as a therapeutic concept Effects on clinical and radiological results

INTRODUCTION

Skull base osteomyelitis is a rare but potentially life-threatening disease. It usually occurs as a complication of severe otitis externa or infection in the nasopharynx, often in immunocompromised patients. The therapeutic strategy is complex, patient-specific and requires interdisciplinary cooperation.

MATERIAL AND METHOD

A retrospective evaluation of all patients with skull base osteomyelitis at the Department of Otorhinolaryngology of the University Hospital Duesseldorf from 2006 to 2023 was carried out. It was investigated which factors, in addition to treatment regimens (antibiotic therapy with i.v./oral antibiotics, surgical debridement and HBO therapy) have an influence on the clinical, laboratory and morphological outcome of the patients.

RESULTS

A total of 42 patients who received interdisciplinary treatment in our clinic were included in the study, of whom 71.4% were male and 28.6% female. The tissue samples showed an inflammatory process, with detection of Pseudomonas aeruginosa in 68.4% of patients. A total of 61.9% of patients presented cranial nerve deficits, most frequently facial nerve palsy. A total of 66.7% of patients received HBO therapy. Of these, n = 20/23 patients (87%) with HBO improved and achieved regression in the follow-up imaging. Known patient-specific factors were confirmed and HBO was emphasized as an important component of the multimodal therapy concept. HBO appears to be justified and should continue to be included in the treatment regimen in the future. For this reason, patients with SBO should be sent to a center that offers HBO therapy.

Future prevalence of type 2 diabetes in Germany: a projection until 2040 including incidence trends observed during the SARS-CoV-2 pandemic

Introduction

Previous studies indicate that the prevalence of type 2 diabetes (T2D) will increase substantially over the coming decades. One projection from 2019 estimated an increase in prevalence in Germany by 54% to 77% (depending on future trends in incidence and mortality) between 2015 and 2040. We aim to update this projection by incorporating recently published trends in T2D incidence in Germany that include the changes during the SARS-CoV-2 pandemic.

Materials and methods

We used a partial differential equation that describes the illness-death model to project the age- and sex-specific T2D prevalence among adults between 2015 and 2040. This required input data for the age- and sex-specific incidence, mortality of the general population, mortality rate ratio of people with vs. without T2D and prevalence in the initial year of the projection. We considered five scenarios with different future trends in incidence and their impact on prevalence. Using the most recently available data on T2D incidence, we assumed that the incidence remains constant as observed in 2021 for the whole projection horizon (first scenario). In further scenarios, we assumed that the observed age- and sex-specific trends in incidence between 2015 and 2021 would continue until 2025 (second scenario), 2030 (third scenario), 2035 (fourth scenario) and 2040 (fifth scenario). One additional scenario assumed that the age-specific prevalence remains constant.

Results

Observed trends in incidence suggest a decrease between 2015 and 2017, and a slight upward trend thereafter until 2021 in most age groups. Depending on how long these observed increases in incidence continue, the number of people with T2D in Germany will increase from 6.8 million in 2015 to between 10.9 million and 14.2 million in 2040. These numbers correspond to increases in prevalence from 10.5% in 2015 to between 15.5% and 20.1% in 2040. In the constant prevalence scenario, the overall prevalence and number of people with T2D in 2040 was 11.4% and 8.1 million, respectively.

Conclusions

The future prevalence of T2D in Germany strongly depends on how long the recently observed increasing trend in T2D incidence will continue, which warrants close monitoring of these trends in post-pandemic years.

Incidence of type 2 diabetes and metabolic syndrome by Occupation - 10-Year follow-up of the Gutenberg Health Study

BACKGROUND

In view of demographic change, rising retirement age, and a growing shortage of skilled workers, it is increasingly important to prevent widespread diseases such as type 2 diabetes or its risk factor metabolic syndrome. Since the workplace is an important setting for preventive measures and little is known about incident cases in the working population, the aim of this study was to identify vulnerable occupational groups for whom these interventions are particularly appropriate. Therefore, we investigated the 10-year incidence of type 2 diabetes and metabolic syndrome across occupational groups in Germany.

METHODS

Employees of the population-based Gutenberg-Health-Study (GHS) were examined at baseline (2007-2012) and 10 years later. We calculated age- and sex-standardised incidence rates and standardised incidence ratios (SIR) with a 95% confidence interval (CI) for occupations, job complexity levels, and supervisory and managerial positions. 5954 persons at risk for type 2 diabetes and 5103 at risk for metabolic syndrome were observed.

RESULTS

Between baseline and follow-up, 388 cases of type 2 diabetes and 1104 cases of metabolic syndrome occurred, and standardised incidences were 6.9% and 22.6%, respectively. The highest incidence of type 2 diabetes was observed in the occupational group "food production and processing" (20.7%) with a threefold increased incidence (SIR = 3.0, 95% CI 1.8-4.7) compared to the total working population of the GHS. Employees in "metal production, processing and construction" had the highest incidence of metabolic syndrome and a two times higher SIR (48.5%; SIR = 2.1, 95% CI 1.4-2.9). There was also a high incidence of both type 2 diabetes and metabolic syndrome in "cleaners" (16.5% and 34.8%) and "drivers and mobile plant operators" (14.8% and 41.2%). An increased incidence of type 2 diabetes and metabolic syndrome was observed with decreasing job complexity levels.

CONCLUSIONS

This study shows wide differences in the incidence of type 2 diabetes and metabolic syndrome between occupational groups and highlights the vulnerability of certain occupations. As the workplace is an important platform for interventions, the findings of this study could guide the development of more nuanced and effective workplace health initiatives to promote a healthier workforce for the future.

Projections of anxiety disorder prevalence during and beyond the COVID-19 pandemic in Germany using the illness-death model

BACKGROUND

Although there is now substantial evidence on the acute impacts of the COVID-19 pandemic on anxiety disorders, the long-term population impact of the pandemic remains largely unexplored.

AIMS

To quantify a possible longitudinal population-level impact of the pandemic by projecting the prevalence of anxiety disorders through 2030 among men and women aged up to 95 years in Germany under scenarios with varying impacts of the pandemic on the incidence of anxiety disorders.

METHOD

We used a three-state illness-death model and data from the Global Burden of Disease Study to model historical trends of the prevalence and incidence of anxiety disorders. The German population projections determined the initial values for projections. The COVID-19 incidence rate data informed an additional incidence model, which was parameterised with a wash-in period, delay, wash-out period, incidence increase level and decay constant.

RESULTS

When no additional increase in the incidence during the pandemic waves during 2020-2022 was assumed, it was estimated that 3.86 million women (9.96%) and 2.13 million men (5.40%) would have anxiety disorders in 2030. When increases in incidence following pandemic waves were assumed, the most extreme scenario projected 5.67 million (14.02%) women and 3.30 million (8.14%) men with the mental disorder in 2030.

CONCLUSIONS

Any increased incidence during the pandemic resulted in elevated prevalence over the projection period. Projection of anxiety disorder prevalence based on the illness-death model enables simulations with varying assumptions and provides insight for public health planning. These findings should be refined as trend data accumulate and become available.

Preferences of people with diabetes for diabetes care in Germany: a discrete choice experiment

OBJECTIVES

The objective of this study is to elicit health care preferences of people with diabetes and identify classes of people with different preferences.

METHODS

A discrete choice experiment was conducted among people with diabetes in Germany comprising attributes of role division in daily diabetes care planning, type of lifestyle education, support for correct medication intake, consultation frequency, emotional support, and time spent on self-management. A conditional logit model and a latent class model were used to elicit preferences toward diabetes care and analyze preference heterogeneity.

RESULTS

A total of 76 people with diabetes, recruited in two specialized diabetes care centers in Germany (mean age 51.9 years, 37.3% women, 49.1% type 2 diabetes mellitus, 50.9% type 1 diabetes mellitus), completed the discrete choice experiment. The most important attributes were consultation frequency, division in daily diabetes care planning, and correct medication intake. The latent class model detected preference heterogeneity by identifying two latent classes which differ mainly with respect to lifestyle education and medication intake.

CONCLUSION

While the majority of people with diabetes showed preferences in line with current health care provision in Germany, a relevant subgroup wished to strengthen lifestyle education and medication intake support with an aid or website.

Projected number of people with multiple sclerosis in Germany between 2015 and 2040

BACKGROUND

The global prevalence of multiple sclerosis has shown a marked rise in recent decades, with Germany reporting the highest prevalence among European countries. This study aims to project the future number of people with multiple sclerosis in Germany until 2040 which is necessary for effective resource allocation and health care planning.

METHODS

Based on data from the German statutory health insurance, the age- and sex-specific prevalence of multiple sclerosis was estimated applying mathematical relations between prevalence, incidence rate, and mortality rate. Subsequently, the projected prevalence was applied to the age structure of the German population between 2015 and 2040 to calculate the future number of people with multiple sclerosis. Several temporal trend scenarios pertaining to the incidence and mortality rate were compared.

RESULTS

Application of current age-specific prevalence estimates combined with the projected population structure in 2040, results in a decline of 8% in the number of people with multiple sclerosis. More realistic scenarios that reflect on trends in mortality and incidence rates, project between 453,000 (+75%) and 477,000 (+85%) multiple sclerosis cases in 2040. It is expected that females will be affected nearly 2.5 times more frequently than males in 2040.

CONCLUSION

The findings indicate a substantial rise in the prevalence of multiple sclerosis, ranging from 75% to 85% in 2040 compared to 2015. Assuming a constant age-specific prevalence between 2015 and 2040 without any temporal trends in mortality and incidence rates may underestimate the actual number of cases and consequently, future requirements for healthcare resources.

Progression of Heart Failure in People with Type 2 Diabetes in Germany: An Analysis Using German Health Insurance Claims Data

Background: Individuals with type 2 diabetes (T2D) show high risk of heart failure (HF). Left ventricular ejection fraction is a major factor for disease progression. In Germany, no recent longitudinal data are available. Objectives: To (1) measure the proportion of individuals with T2D who acquire HF over 2 years and (2) categorize ejection fraction using routine data and an algorithm, and (3) understand progression of HF in 5-year follow-up. Methods: This descriptive, retrospective study used longitudinal data from German statutory health insurance claims. A model using coded data classified the patients with HF into ejection fraction (EF) categories. Individuals were selected during 2013, with an inclusion period from 2014 to 2015 and a follow-up from 2016 to 2020. Baseline characteristics included demographic data, disease stage, comorbidities, and risk factors. Follow-up criteria included major adverse cardiac events (MACEs), EF category, and mortality. Disease progression was visualized by Sankey plots. Results: Among the 173 195 individuals with T2D identified in 2013, 6725 (median age, 74 years) developed HF in 2014 or 2015. 34.4% of individuals had MACEs, and 42.9% died over 5 years. Myocardial infarction (42%) was the most common event, followed by stroke (32%) and hospitalization (28%). A total of 5282 (78.54%) patients were classified into preserved EF and 1443 (21.46%) into reduced EF. Survival after 5 years was 71% in HF for preserved EF patients, and 29% in the HF for those with reduced EF. Conclusion: Heart failure is relevant in individuals with diabetes. A high number of patients may likely not survive a 5-year period. Validation of the model with German data is highly desirable. New ways of close monitoring could help improve outcomes.

Unlocking Potential: Personalized Lifestyle Therapy for Type 2 Diabetes Through a Predictive Algorithm-Driven Digital Therapeutic

BACKGROUND

We present a digital therapeutic (DTx) using continuous glucose monitoring (CGM) and an advanced artificial intelligence (AI) algorithm to digitally personalize lifestyle interventions for people with type 2 diabetes (T2D).

METHOD

A study of 118 participants with non-insulin-treated T2D (HbA1c ≥ 6.5%) who were already receiving standard care and had a mean baseline (BL) HbA1c of 7.46% (0.93) used the DTx for three months to evaluate clinical endpoints, such as HbA1c, body weight, quality of life and app usage, for a pre-post comparison. The study also included an assessment of initial long-term data from a second use of the DTx.

RESULTS

After three months of using the DTx, there was an improvement of 0.67% HbA1c in the complete cohort and -1.08% HbA1c in patients with poorly controlled diabetes (BL-HbA1c ≥ 7.0%) compared with standard of care (P < .001). The number of patients within the therapeutic target range (< 7.0%) increased from 38% to 60%, and 33% were on the way to remission (< 6.5%). Patients who used the DTx a second time experienced a reduction of -0.76% in their HbA1c levels and a mean weight loss of -6.84 kg after six months (P < .001) compared with BL.

CONCLUSIONS

These results indicate that the DTx has clinically relevant effects on glycemic control and weight reduction for patients with both well and poorly controlled diabetes, whether through single or repeated usage. It is a noteworthy improvement in T2D management, offering a non-pharmacological, fully digital solution that integrates biofeedback through CGM and an advanced AI algorithm.

Projecting the economic burden of type 1 and type 2 diabetes mellitus in Germany from 2010 until 2040

BACKGROUND

The aim is to estimate age- and sex-specific direct medical costs related to diagnosed type 1 and type 2 diabetes in Germany between 2010 and 2040.

METHODS

Based on nationwide representative epidemiological routine data from 2010 from the statutory health insurance in Germany (almost 80% of the population's insurance) we projected age- and sex-specific healthcare expenses for type 1 and 2 diabetes considering future demographic, disease-specific and cost trends. We combine per capita healthcare cost data (obtained from aggregated claims data from an almost 7% random sample of all German people with statutory health insurance) together with the demographic structure of the German population (obtained from the Federal Statictical Office), diabetes prevalence, incidence and mortality. Direct per capita costs, total annual costs, cost ratios for people with versus without diabetes and attributable costs were estimated. The source code for running the analysis is publicly available in the open-access repository Zenodo.

RESULTS

In 2010, total healthcare costs amounted to more than €1 billion for type 1 and €28 billion for type 2 diabetes. Depending on the scenario, total annual expenses were projected to rise remarkably until 2040 compared to 2010, by 1-281% for type 1 (€1 to €4 billion) and by 8-364% for type 2 diabetes (€30 to €131 billion). In a relatively probable scenario total costs amount to about €2 and €79 billion for type 1 and type 2 diabetes in 2040, respectively. Depending on annual cost growth (1% p.a. as realistic scenario vs. 5% p.a. as very extreme setting), we estimated annual per capita costs of €6,581 to €12,057 for type 1 and €5,245 to €8,999 for type 2 diabetes in 2040.

CONCLUSIONS

Diabetes imposes a large economic burden on Germany which is projected to increase substantially until 2040. Temporal trends in the incidence and cost growth are main drivers of this increase. This highlight the need for urgent action to prepare for the potential development and mitigate its consequences.

Identification with Characters of a National Narrative Health Communication Campaign Targeting Type 2 Diabetes

Type 2 diabetes mellitus (T2DM) has a high prevalence in Germany. Tailored health communication campaigns are part of preventing T2DM at a societal level, with narrative approaches as a promising communication strategy. The aim of this study was to qualitatively examine identification with characters as a potential narrative effect mechanism within a national T2DM communication campaign (Slogan: "Diabetes - not only a question of type"). In doing so, characters' liking and perceived similarity were explored as antecedents of identification. For this purpose, nine focus groups comprising a total of 76 participants diagnosed with T2DM were conducted. Two of these focus groups consisted entirely of participants of Turkish descent. An assessment was developed to measure the extent to which participants liked, perceived themselves to be similar to, and identified with different characters presented via three videoclip formats (live action, animated cartoons, and celebrity testimonials) from a national diabetes communication campaign. Live action and celebrity testimonial characters were mostly perceived as likeable. However, level of identification was low, and participants felt an overall lack of similarity regarding both personal and disease-related characteristics as compared to these characters. Animated cartoons were perceived as less stigmatizing, but also as less engaging. The study indicates that liking without a feeling of similarity to a character is not sufficient to elicit identification. Further, the reinforcement of harmful T2DM stereotypes should be avoided in health communications to prevent reactance and to increase generalizability.

Incidence trend of type 2 diabetes from 2012 to 2021 in Germany: an analysis of health claims data of 11 million statutorily insured people

AIMS/HYPOTHESIS

The aim of the study is to describe the time trend of type 2 diabetes incidence in the largest state of Germany, Bavaria, from 2012 to 2021, and to compare the incidence rates during the pandemic period (2020-2021) to the pre-pandemic period (2012-2019).

METHODS

This secondary data analysis uses health claims data provided by the Bavarian Association of Statutory Health Insurance Physicians (KVB), covering approximately 11 million insurees, accounting for 85% of the total population of Bavaria, Germany. Newly diagnosed type 2 diabetes cases in adults (≥20 years) coded as E11 (Diabetes mellitus, Type 2) or E14 (Unspecified diabetes mellitus) under ICD-10, German modification (ICD-10-GM) for the study period 2012 to 2021 were included. Annual and quarterly age-standardised incidence rates (ASIR) stratified by sex, age and region were calculated using the European standard population. Sex-specific crude incidence rates (CIR) were calculated using 10-year age groups. Regression analyses adjusted for time trends, seasonal effects, and pandemic effects were used to analyse the incidence trend and to assess the effect of the pandemic.

RESULTS

Overall, 745,861 new cases of type 2 diabetes were diagnosed between 2012 and 2021: 50.4% (376,193 cases) in women. The male/female ratio remained stable over the observation period, while the median age at diagnosis decreased from 61 to 58 years in men and from 66 years to 61 years in women. ASIR were consistently higher for men compared with women, with the yearly difference remaining stable over time (2012: 18%; 2021: 20%). An overall decreasing trend in ASIR was observed during the study period, with a strong decrease from 2012 to 2017, followed by a less pronounced decline from 2018 to 2021 for both sexes. For men, ASIR decreased from 1514 per 100,000 person-years in 2012 to 995 per 100,000 person-years in 2021 (4.6% average annual reduction), and for women from 1238 per 100,000 person-years in 2012 to 796 per 100,000 person-years in 2021 (4.8% average annual reduction). This downward trend was also observed for age groups above 50 years. Regression analyses showed no significant change in incidence rates during the pandemic period (2020 and 2021) compared with the pre-pandemic period.

CONCLUSIONS/INTERPRETATION

For the first time, a 10-year incidence trend of type 2 diabetes is reported for Germany, showing a strong decline from 2012 to 2017, followed by a less pronounced decline from 2018 to 2021. The incidence trend of type 2 diabetes appears not to have been affected by the first 2 years of the COVID-19 pandemic. Despite an overall increasing prevalence, the incidence is decreasing, potentially resulting from robust screening by family physicians, reducing the median age at diagnosis by 3 to 5 years. However, further investigation is needed to fully identify the reasons for the declining incidence trend. Continued incidence monitoring is necessary to identify the long-term trend and the potential effect of the pandemic on diagnoses of type 2 diabetes.

Depression, anxiety, and health-related quality of life in normal weight, overweight and obese individuals with diabetes: a representative study in Germany

OBJECTIVE

Diabetes in the course of lifetime is related to a higher risk for mental disorders. The present study addresses the comparison of individuals with diabetes and non-diabetic individuals in depressive symptoms, generalized anxiety symptoms, and health-related quality of life. Furthermore, mediator effect of BMI and health-related quality of life (HRQOL) on the association between diabetes, depression, and generalized anxiety was analyzed.

METHODS

In this cross-sectional study, the three questionnaires PHQ-9, GAD-7, EQ-5D-5L were measured in a representative sample of the German population (N = 2386). In addition, the presence of diabetes and BMI were assessed via self-report.

RESULTS

There were higher values in depressive and anxiety symptoms as well as lower score in HRQOL in individuals with diabetes compared to non-diabetic individuals. Obese individuals with diabetes showed the highest rates in depressive symptoms and generalized anxiety as well as lowest score in HRQOL. With regard to the mediator analyses, association between diabetes, depressive symptoms, and anxiety symptoms is partially mediated by the BMI and fully mediated by the HRQOL.

CONCLUSIONS

In conclusion, individuals with diabetes have an increased risk in the development of depressive and anxiety symptoms as well as lower health-related quality of life. Future research and strategies in the public health policies among individuals with diabetes should take into account that the association between diabetes, depression, and anxiety is mediated by BMI and HRQOL.

Type 2 diabetes in the employed population: do rates and trends differ among nine occupational sectors? An analysis using German health insurance claims data

BACKGROUND

Socioeconomic inequalities in type 2 diabetes (T2D) are well established in the literature. However, within the background of changing work contexts associated with digitalization and its effect on lifestyle and sedentary behavior, little is known on T2D prevalence and trends among different occupational groups. This study aims to examine occupational sector differences in T2D prevalence and trends thereof between 2012 and 2019.

METHODS

The study was done on 1.683.644 employed individuals using data from the German statutory health insurance provider in Lower Saxony, the "Allgemeine Ortskrankenkasse Niedersachsen" (AOKN). Predicted probabilities for T2D prevalence in four two-year periods between 2012 and 2019 were estimated based on logistic regression analyses for nine occupational sectors. Prevalence ratios were calculated to illustrate the effect of time period on the prevalence of T2D among the nine occupational sectors. Analyses were stratified by gender and two age groups.

RESULTS

Results showed differences among occupational sectors in the predicted probabilities for T2D. The occupational sectors "Transport, logistics, protection and security" and "Health sector, social work, teaching & education" had the highest predicted probabilities, while those working in the sector "Agriculture" had by far the lowest predicted probabilities for T2D. Over all, there appeared to be a rising trend in T2D prevalence among younger employed individuals, with gender differences among occupational sectors.

CONCLUSION

The study displayed different vulnerability levels among occupational sectors with respect to T2D prevalence overall and for its rising trend among the younger age group. Specific occupations within the vulnerable sectors need to be focused upon in further research to define specific target groups to which T2D prevention interventions should be tailored.

Peripheral Arterial Disease and the Diabetic Foot Syndrome: Neuropathy Makes the Difference! A Narrative Review

Background: In vascular medicine, peripheral arterial disease (PAD) and diabetic foot syndrome (DFS) are often considered synonymous with respect to the need for revascularization. In PAD patients, clinical symptoms reflect the degree of atherosclerotic disease, since peripheral innervation, including pain sensation, is not usually compromised. In DFS patients, however, symptoms of relevant foot ischemia are often absent and progression of ischemia goes unnoticed owing to diabetic polyneuropathy, the loss of nociception being the main trigger for foot ulcers. This review analyzes the fundamental differences between PAD and DFS against the background of polyneuropathy. Methods: The literature research for the 2014 revision of the German evidence-based S3-PAD-guidelines was extended to 2023. Results: Vascular examination is imperative for both, PAD and DFS. Stage-dependent revascularization is of utmost importance in PAD patients, especially those suffering from critical limb-threatening ischemia (CLTI). Successful therapy of DFS goes further, including infection and metabolic control, wound management, offloading the foot and lifelong prophylaxis in the course of a multidisciplinary treatment concept. Revascularization is not needed in all cases of DFS. Conclusions: There are fundamental differences between PAD and DFS with respect to pathophysiology, the anatomical distribution of arterial occlusive processes, the clinical symptoms, the value of diagnostic tools such as the ankle-brachial index, and classification. Also, therapeutic concepts differ substantially between the two patient populations.

Insurance barriers and inequalities in health care access: evidence from dual practice

BACKGROUND

We investigate access disparities in pharmaceutical care among German patients with type 2 diabetes, focusing on differences between public and private health insurance schemes. The primary objectives include investigating whether patients with private health insurance experience enhanced access to antidiabetic care and analyzing whether the treatment received by public and private patients is influenced by the practice composition, particularly the proportion of private patients.

METHODS

We estimate fixed effect regression models, to isolate the effect of insurance schemes on treatment choices. We utilize data from a prescriber panel comprising 681 physicians collectively serving 68,362 patients undergoing antidiabetic treatments.

RESULTS

The analysis reveals a significant effect of the patient's insurance status on antidiabetic care access. Patients covered by private insurance show a 10-percentage-point higher likelihood of receiving less complex treatments compared to those with public insurance. Furthermore, the composition of physicians' practices plays a crucial role in determining the likelihood of patients receiving less complex treatments. Notably, the most pronounced disparities in access are observed in practices mirroring the regional average composition.

CONCLUSIONS

Our findings underscore strategic physician navigation across diverse health insurance schemes in ambulatory care settings, impacting patient access to innovative treatments.

Quality assessment of glucose measurement with regard to epidemiology and clinical management of diabetes mellitus in Germany

Background

During the last decade, Germany has seen an increased prevalence and a redistribution from undetected to diagnosed diabetes mellitus. Due to this substantial epidemiological development, the number of people with documented type 2 diabetes was 8.7 million in 2022. An estimated two million undiagnosed subjects are to be added. Beyond that, the life expectancy of diabetic subjects is increasing due to more responsive health systems in terms of care. Possible reasons include improved screening of at-risk individuals, the introduction of HbA1c for diagnosis in 2010, and the higher use of risk scores. Additionally, quality aspects of the laboratory methodology should be taken into consideration.

Methods

Epidemiology and clinical management of diabetes in Germany are presented in the light of publications retrieved by a selective search of the PubMed database. Additionally, the data from German external quality assessment (EQA) surveys for the measurands glucose in plasma and HbA1c in whole blood, reviewed from 2010 until 2022, were evaluated. Above this, data concerning the analytical performance of near-patient glucometer devices, according to the ISO norm 15197:2013, were analyzed.

Results

Two laboratory aspects are in good accordance with the observation of an increase in the diabetes mellitus prevalence when retrospectively reviewing the period 2010 to 2022: First, the analytical performance according to the ISO norm 15197:2013 of the glucometer devices widely used by patients with diabetes for the glucose self-testing, has improved during this period. Secondly, concerning the EQA program of INSTAND, the number of participating laboratories raised significantly in Germany. The spreads of variations of the specified results for plasma glucose remained unchanged between 2010 and 2022, whereas for HbA1c a significant decrease of the result scattering could be observed.

Conclusion

These retrospectively established findings testify to an excellent analytical quality of laboratory diagnostics for glucose and HbA1c throughout Germany which may be involved in a better diagnosis and therapy of previously undetected diabetes mellitus.

A population-based projection of psoriatic arthritis in Germany until 2050: analysis of national statutory health insurance data of 65 million German population

The population-based prevalence of psoriatic arthritis (PsA) is still unclear and not well described globally. The aim of this study was to conduct a population-based prevalence projection and provide long-term future estimations of PsA patients in Germany until 2050, using the illness-death model and based on historical data. We analyzed the national statutory health insurance data of 65 million population in the German Institute for Medical Documentation and Information between January 2009 and December 2012. We constructed an estimation of the PsA burden among the German population using the relevant epidemiological parameters to project the numbers of patients with PsA in Germany until 2050 under five possible scenarios by varying the incidence and mortality. The overall conservatively estimated prevalence of PsA in Germany in 2019 was 0.31% (95% CI 0.28-0.36%). Women contribute a higher prevalence than men in all five scenarios. In the assumed scenarios with increased incidence, the prevalence of PsA at 60 years of age could rise from 1% in 2019 to more than 3% in 2050 for both genders, with the increase particularly pronounced for women, reaching around 3.5%. However, in the assumed scenarios with decreasing incidence, the prevalence curve may flatten and begin a decreasing trend from 2035 to 2050 for both genders, achieving a prevalence of less than 1% in 2050. Our research is to generate assumed population-based data on PsA in Germany that can serve as a reference for public health stakeholders to prepare an optional intervention. We would expect worryingly high numbers in the coming decades if preventive strategies are not implemented. In the long term, it will be necessary to implement preventive strategies to identify predictors and treat psoriasis symptoms early in order to delay or even prevent the transition of psoriasis to PsA.

Implementing nutritional medicine into medical curricula: A student-initiated course improves knowledge and attitudes

BACKGROUND & AIMS

Although the risks and opportunities of nutrition in health trajectories are well known, it is rarely addressed in doctors' daily routine. This is partly related to physicians' lack of confidence in their ability to provide nutritional counselling, possibly due to insufficient training in medical school. Our study aimed at assessing the status quo of nutrition in the German medical curricula and the impact of a recently implemented, student-initiated online teaching initiative on perceived competence, knowledge and attitudes.

METHODS

"Eat This!" was the first Germany-wide initiative for online nutritional medicine (NM) education, consisting of 11 digital lectures on nutrition basics, nutrition medicine and public health nutrition. The contact time with NM during studies as well as the effects on students' attitudes towards NM, their self-perceived competence in NM and their nutrition knowledge were assessed from October 2020 to February 2021 in a cross-sectional as well as a prospective study using online questionnaires.

RESULTS

Over 1500 medical students from 42 German faculties participated in the lecture series and the online survey. One hundred and twenty-two students formed a control group. Although considering the topic relevant, students rated their training in NM as insufficient, in terms of both quality and quantity. Initially, they did not feel able to counsel patients and rated their knowledge as low. However, self-ratings and the score in a 33-item multiple-choice test knowledge improved by participating in Eat This! as did their attitude towards nutrition and planetary health. No such changes were observed in the control group of 122 students not attending the course.

CONCLUSION

Our results show that education in NM at German medical schools is perceived insufficient despite high student interest. But even low-threshold educational options like "Eat This!" can improve students' perceived competence, knowledge, and attitudes, and thus be an efficient and cost-effective way to address related deficits.

Effectiveness of the Telemedical Lifestyle Intervention Program TeLIPro for Improvement of HbA1c in Type 2 Diabetes: A Randomized-Controlled Trial in a Real-Life Setting

The effectiveness of the multimodal Telemedical Lifestyle Intervention Program (TeLIPro) was proven in the advanced stages of type 2 diabetes mellitus (T2DM). Since its therapeutic potential focusing on telemedical coaching without using a formula diet is unknown, we evaluated improvements in HbA1c, HbA1c normalisation rate, cardiometabolic risk factors, quality-of-life, and eating behaviour in real life. In this randomized-controlled trial, AOK Rhineland/Hamburg insured T2DM patients (n = 1163) were randomized (1:1) into two parallel groups, and 817 received the allocated intervention. In addition to routine care, all participants got scales, step counters, and access to an online portal. The TeLIPro group additionally received equipment for self-monitoring of blood glucose and telemedical coaching. Data were collected at baseline, after 6 and 12 months of intervention as well as after a 6-month follow-up. The primary endpoint after 12 months was (i) the estimated treatment difference (ETD) in HbA1c change and (ii) the HbA1c normalisation rate in those with diabetes duration < 5 years. The TeLIPro group demonstrated significantly stronger improvements in HbA1c (ETD -0.4% (-0.5; -0.2); p < 0.001), body weight, body-mass-index, quality-of-life, and eating behaviour, especially in T2DM patients with diabetes duration ≥ 5 years (ETD -0.5% (-0.7; -0.3); p < 0.001). The HbA1c normalisation rate did not significantly differ between groups (25% vs. 18%). Continuous addition of TeLIPro to routine care is effective in improving HbA1c and health-related lifestyle in T2DM patients with longer diabetes duration in real life.

Health and economic impact of improved glucose, blood pressure and lipid control among German adults with type 2 diabetes: a modelling study

AIMS/HYPOTHESIS

The aim of this study was to estimate the long-term health and economic consequences of improved risk factor control in German adults with type 2 diabetes.

METHODS

We used the UK Prospective Diabetes Study Outcomes Model 2 to project the patient-level health outcomes and healthcare costs of people with type 2 diabetes in Germany over 5, 10 and 30 years. We parameterised the model using the best available data on population characteristics, healthcare costs and health-related quality of life from German studies. The modelled scenarios were: (1) a permanent reduction of HbA1c by 5.5 mmol/mol (0.5%), of systolic BP (SBP) by 10 mmHg, or of LDL-cholesterol by 0.26 mmol/l in all patients, and (2) achievement of guideline care recommendations for HbA1c (≤53 mmol/mol [7%]), SBP (≤140 mmHg) or LDL-cholesterol (≤2.6 mmol/l) in patients who do not meet the recommendations. We calculated nationwide estimates using age- and sex-specific quality-adjusted life year (QALY) and cost estimates, type 2 diabetes prevalence and population size.

RESULTS

Over 10 years, a permanent reduction of HbA1c by 5.5 mmol/mol (0.5%), SBP by 10 mmHg or LDL-cholesterol by 0.26 mmol/l led to per-person savings in healthcare expenditures of €121, €238 and €34, and 0.01, 0.02 and 0.015 QALYs gained, respectively. Achieving guideline care recommendations for HbA1c, SBP or LDL-cholesterol could reduce healthcare expenditure by €451, €507 and €327 and gained 0.03, 0.05 and 0.06 additional QALYs in individuals who did not meet the recommendations. Nationally, achieving guideline care recommendations for HbA1c, SBP and LDL-cholesterol could reduce healthcare costs by over €1.9 billion.

CONCLUSIONS/INTERPRETATION

Sustained improvements in HbA1c, SBP and LDL-cholesterol control among diabetes patients in Germany can lead to substantial health benefits and reduce healthcare expenditures.

[From diabetes to sleep apnea: what obesity complications should we look for?]

The prevalence of obesity has increased worldwide. For Germany, according to the "Study on Adult Health in Germany" (DEGS1) of the Robert Koch Institute from the years 2008-2011, the prevalence of a BMI ≥25 kg/m² was 67,1% for men and 53,0% for women, whereby the proportion of obesity, i.e. a BMI ≥30 kg/m² is 23, 3% for men and 23,9% for women. Compared to 1998, the prevalence of obesity in the same group was 18, 8% for men and 21,7% for women. Because of the increasing prevalence of overweight and obesity, the number of patients with obesity-associated comorbidities is correspondingly increasing. There is a close association between obesity and an increased risk of metabolic diseases, cardiovascular diseases, but also musculoskeletal diseases, some types of cancer and mental comorbidities. In addition, obesity might also lead to restrictions in activities of daily living, reduced quality of life, unemployment and early retirement. A knowledge of obesity-associated sequelae is therefore essential in order to specifically look for them, treat them and thereby improve patient care and ultimately morbidity and mortality of patients with obesity.

Diabetes incidence in Austria: The role of famines on diabetes and related NCDs

Undernutrition in early life associates with increased risk for type 2 diabetes in later life. Whether similar associations hold for other diseases remains unclear. We aim to quantify how perinatal exposure to famines relates to the risk of becoming incident with type 2 diabetes in later life. Using population-wide medical claims data for Austrians aged >50y, yearly diabetes incidence was measured in an epidemiological progression model. We find incidence rates that increase from 2013 to 2017 and observe two famine-related birth cohorts of 5,887 patients with incidence rate increases for diabetes of up to 78% for males and 59% for females compared to cohorts born two years earlier. These cohorts show increased risks for multiple other diagnoses as well. Public health efforts to decrease diabetes must not only focus on lifestyle factors but also emphasize the importance of reproductive health and adequate nutrition during pregnancy and early postnatal life.

Perceived Chronic Stress Is Associated With the German Diabetes Risk Score Among Adults Without Known Diabetes in Germany

OBJECTIVE

There is evidence that psychological distress increases the risk of type 2 diabetes (T2D), but implications for prevention remain elusive. We examined the association between chronic stress and the German Diabetes Risk Score (GDRS) among adults without diabetes in Germany.

METHODS

The study population consisted of 4654 persons aged 18 to 64 years without known diabetes drawn from the German Health Interview and Examination Survey for Adults (2008-2011). The predicted 5-year T2D risk (in percent) was estimated using the GDRS. Perceived chronic stress was assessed by the Screening Scale of the Trier Inventory for the Assessment of Chronic Stress and categorized into "up to average," "above average," and "high." The cross-sectional association of chronic stress with log-transformed GDRS (expressed as geometric mean ratio [GMR]) was analyzed in multivariable linear regression models. Covariables included age, sex, community size, region, educational level, living alone, social support, depression, and alcohol use.

RESULTS

The mean predicted 5-year T2D risk rates were 2.7%, 2.9%, and 3.0% for chronic stress up to average, above average, and high chronic stress, respectively. Adjusted mean predicted 5-year risk was significantly higher among persons with chronic stress above average (GMR = 1.10, 95% confidence interval = 1.02-1.19) and high stress (GMR = 1.21, 95% CI = 1.06-1.39) compared with persons with chronic stress up to average. No interactions with sex or other covariables were found.

CONCLUSIONS

Perceived chronic stress is independently associated with an increased predicted T2D risk in cross-sectional analysis and should be considered as T2D risk factor in longitudinal studies.

Future number of people with diagnosed type 1 diabetes in Germany until 2040: an analysis based on claims data

INTRODUCTION

We aim to project the number of people with diagnosed type 1 diabetes in Germany between 2010 and 2040.

RESEARCH DESIGN AND METHODS

We first estimate the age-specific and sex-specific incidence and prevalence of type 1 diabetes in Germany in 2010 using data from 65 million insurees of the German statutory health insurance. Then, we use the illness-death model to project the prevalence of type 1 diabetes until 2040. We alter the incidence and mortality underlying the illness-death model in several scenarios to explore the impact of possible temporal trends on the number of people with type 1 diabetes.

RESULTS

Applying the prevalence from 2010 to the official population projections of Germany's Federal Statistical Office yields a total number of 252 000 people with type 1 diabetes in Germany in 2040 (+1% compared with 2010). Incorporating different annual trends of the incidence and mortality in the projection model results in a future number of people with type 1 diabetes between 292 000 (+18%) and 327 000 (+32%).

CONCLUSIONS

For the first time in Germany, we provide estimates for the incidence, prevalence, and number of people with diagnosed type 1 diabetes for the whole German population between 2010 and 2040. The relative increase of the people with type 1 diabetes ranges from 1% to 32% in 2040 compared with 2010. The projected results are mainly influenced by temporal trends in the incidence. Ignoring these trends, that is, applying a constant prevalence to population projections, probably underestimates future chronic disease numbers.

Diabetes in all hospitalized cases in Germany 2015-2019 and impact of the first COVID-19 year 2020

OBJECTIVE

To analyze the proportion of diabetes among all hospitalized cases in Germany between 2015 and 2020.

METHODS

Using the nationwide Diagnosis-Related-Groups statistics, we identified among all inpatient cases aged ≥ 20 years all types of diabetes in the main or secondary diagnoses based on ICD-10 codes, as well all COVID-19 diagnoses for 2020.

RESULTS

From 2015 to 2019, the proportion of cases with diabetes among all hospitalizations increased from 18.3% (3.01 of 16.45 million) to 18.5% (3.07 of 16.64 million). Although the total number of hospitalizations decreased in 2020, the proportion of cases with diabetes increased to 18.8% (2.73 of 14.50 million). The proportion of COVID-19 diagnosis was higher in cases with diabetes than in those without in all sex and age subgroups. The relative risk (RR) for a COVID-19 diagnosis in cases with vs without diabetes was highest in age group 40-49 years (RR in females: 1.51; in males: 1.41).

CONCLUSIONS

The prevalence of diabetes in the hospital is twice as high as the prevalence in the general population and has increased further with the COVID-19 pandemic, underscoring the increased morbidity in this high-risk patient group. This study provides essential information that should help to better estimate the need for diabetological expertise in inpatient care settings.

Spatio-Temporal Trends in the Incidence of Type 2 Diabetes in Germany

BACKGROUND

There are no data on recent trends in the incidence rate of type 2 diabetes (T2D) in Germany. The aim of this study was to determine the sex-, age-, and region-specific trends in the T2D incidence rate between 2014 and 2019.

METHODS

Based on nationwide data from statutorily insured persons in Germany, negative binomial regression models were used to analyze age- and sex-specific trends in the T2D incidence rate. Age- and sex-adjusted trends were calculated for 401 administrative districts using a Bayesian spatio-temporal regression model.

RESULTS

During the period concerned, approximately 450 000 new cases of T2D were observed each year among some 63 million persons. Taking all age groups together, the incidence rate decreased in both women and men, from 6.9 (95% confidence interval [6.7; 7.0]) and 8.4 [8.2; 8.6] respectively per 1000 persons in 2014 to 6.1 [5.9; 6.3] and 7.7 [7.5; 8.0] per 1000 persons in 2019. This corresponds to an annual reduction of 2.4% [1.5; 3.2] for women and 1.7% [0.8; 2.5] for men. The incidence rate increased in the age group 20-39 years. The age- and sex-adjusted incidence rate decreased in almost all districts, although regional differences persisted.

CONCLUSION

The T2D incidence rate should be closely monitored to see whether the decreasing trend continues. One must not forget that the prevalence can rise despite decreasing incidence. For this reason, the findings do not necessarily mean a decrease in the disease burden of T2D and the associated demand on healthcare resources.

[Photo-based examination for diabetic eye pathologies in a German ophthalmological practice without personal doctor-patient contact]

BACKGROUND

An increasing number of patients suffering from diabetes require regular ophthalmological check-ups to diagnose and/or treat potential diabetic retinal disease. Some countries have already implemented systematic fundus assessments including artificial intelligence-based programs in order to detect sight-threatening retinopathy. The aim of this study was to improve the detection of diabetic fundus changes in Germany without examination by a doctor and to create an easy access to ophthalmological examinations.

MATERIAL AND METHODS

In this prospective monocentric study 93 patients in need for a routine check-up for diabetic retinopathy were included. The study participants took up an offer of an examination (visual examination, non-mydriatic camera-based fundus examination) without doctor-patient contact. Patient satisfaction with the organization and examinations was assessed using a questionnaire.

RESULTS

The mean age was 53.5 years (SD 13.6 years, 49.5% female) and 17 eyes (18.3%) showed a diabetic retinopathy which was detected using a camera-based examination. Within the small sample, no patient had to repeat the examination due to poor image quality. All categories of the questionnaire showed a good to very good satisfaction, indicating a high acceptance of the other examination form that took place at the ophthalmologist's premises.

CONCLUSION

In our study in an ophthalmological practice a high level of acceptance among the patients interested in the screening for diabetic retinopathy without any direct patient-doctor contact was achieved. Our study shows a very good acceptance and feasibility. Future use of artificial intelligence in clinical practice may help to be able to screen many more patients as in this study imaging quality was very good.

Estimating incidence of type 1 and type 2 diabetes using prevalence data: the SEARCH for Diabetes in Youth study

BACKGROUND

Incidence is one of the most important epidemiologic indices in surveillance. However, determining incidence is complex and requires time-consuming cohort studies or registries with date of diagnosis. Estimating incidence from prevalence using mathematical relationships may facilitate surveillance efforts. The aim of this study was to examine whether a partial differential equation (PDE) can be used to estimate diabetes incidence from prevalence in youth.

METHODS

We used age-, sex-, and race/ethnicity-specific estimates of prevalence in 2001 and 2009 as reported in the SEARCH for Diabetes in Youth study. Using these data, a PDE was applied to estimate the average incidence rates of type 1 and type 2 diabetes for the period between 2001 and 2009. Estimates were compared to annual incidence rates observed in SEARCH. Precision of the estimates was evaluated using 95% bootstrap confidence intervals.

RESULTS

Despite the long period between prevalence measures, the estimated average incidence rates mirror the average of the observed annual incidence rates. Absolute values of the age-standardized sex- and type-specific mean relative errors are below 8%.

CONCLUSIONS

Incidence of diabetes can be accurately estimated from prevalence. Since only cross-sectional prevalence data is required, employing this methodology in future studies may result in considerable cost savings.

Diabetic retinopathy as the leading cause of blindness and early predictor of cascading complications-risks and mitigation

Proliferative diabetic retinopathy (PDR) the sequel of diabetic retinopathy (DR), a frequent complication of diabetes mellitus (DM), is the leading cause of blindness in the working-age population. The current screening process for the DR risk is not sufficiently effective such that often the disease is undetected until irreversible damage occurs. Diabetes-associated small vessel disease and neuroretinal changes create a vicious cycle resulting in the conversion of DR into PDR with characteristic ocular attributes including excessive mitochondrial and retinal cell damage, chronic inflammation, neovascularisation, and reduced visual field. PDR is considered an independent predictor of other severe diabetic complications such as ischemic stroke. A "domino effect" is highly characteristic for the cascading DM complications in which DR is an early indicator of impaired molecular and visual signaling. Mitochondrial health control is clinically relevant in DR management, and multi-omic tear fluid analysis can be instrumental for DR prognosis and PDR prediction. Altered metabolic pathways and bioenergetics, microvascular deficits and small vessel disease, chronic inflammation, and excessive tissue remodelling are in focus of this article as evidence-based targets for a predictive approach to develop diagnosis and treatment algorithms tailored to the individual for a cost-effective early prevention by implementing the paradigm shift from reactive medicine to predictive, preventive, and personalized medicine (PPPM) in primary and secondary DR care management.

Projections of Type 1 and Type 2 Diabetes Burden in the U.S. Population Aged <20 Years Through 2060: The SEARCH for Diabetes in Youth Study

OBJECTIVE

To project the prevalence and number of youths with diabetes and trends in racial and ethnic disparities in the U.S. through 2060.

RESEARCH DESIGN AND METHODS

Based on a mathematical model and data from the SEARCH for Diabetes in Youth study for calendar years 2002-2017, we projected the future prevalence of type 1 and type 2 diabetes among youth aged <20 years while considering different scenarios of future trends in incidence.

RESULTS

The number of youths with diabetes will increase from 213,000 (95% CI 209,000; 218,000) (type 1 diabetes 185,000, type 2 diabetes 28,000) in 2017 to 239,000 (95% CI 209,000; 282,000) (type 1 diabetes 191,000, type 2 diabetes 48,000) in 2060 if the incidence remains constant as observed in 2017. Corresponding relative increases were 3% (95% CI -9%; 21%) for type 1 diabetes and 69% (95% CI 43%; 109%) for type 2 diabetes. Assuming that increasing trends in incidence observed between 2002 and 2017 continue, the projected number of youths with diabetes will be 526,000 (95% CI 335,000; 893,000) (type 1 diabetes 306,000, type 2 diabetes 220,000). Corresponding relative increases would be 65% (95% CI 12%; 158%) for type 1 diabetes and 673% (95% CI 362%; 1,341%) for type 2 diabetes. In both scenarios, substantial widening of racial and ethnic disparities in type 2 diabetes prevalence are expected, with the highest prevalence among non-Hispanic Black youth.

CONCLUSIONS

The number of youths with diabetes in the U.S. is likely to substantially increase in future decades, which emphasizes the need for prevention to attenuate this trend.

Economic Effects of Fixed-Dose Versus Loose-Dose Combination Therapy for Type 2 Diabetes Patients

OBJECTIVE

We examined the effects of fixe-dose combinations (FDCs) versus loose-dose combinations (LDCs) on costs from the payer and patient perspective and investigated potential channels contributing to differences in costs between the two modes of treatment.

METHODS

We investigated administrative data from 2017 to 2020 on diabetes patients in Germany. After using prospensity-score matching to remove dissimilarities between FDC and LDC patients, we compared changes in costs with a difference-in-differences approach. We analyzed pharmaceutical costs, inpatient and outpatient costs, other costs and total healthcare costs from the payer perspective, and co-payments from the patient perspective.

RESULTS

The sample comprised 1117 FDC and 1272 LDC patients. Regression analysis revealed that FDC therapy significantly increased antidiabetic pharmaceutical spending in the first year by 5.5% (p < 0.01), but decreased co-payments by 33% (p < 0.01) in the first and 44% (p < 0.01) in the second year. We also observed a trend towards higher outpatient spending in the first year. No significant differences were found with respect to inpatient or other costs. The increase in antidiabetic pharmaceutical spending did not contribute to a significant increase in total healthcare expenditure. We identified a shift of co-payments to the payer and higher adherence as possible mechanisms behind the increase in antidiabetic pharmaceutical spending.

CONCLUSION

Although FDC therapy increased disease-specific pharmaceutical spending in the short term, this increase did not lead to differences in total healthcare costs from the payer perspective. From the patient perspective, FDC therapy may be the preferred treatment approach, because of significant saving in co-payments, which is likely attributable to the elimination of one co-payment and therefore a shift in costs to the payer.

Dimini (Diabetes mellitus? – Ich nicht!): Aktivierung der Gesundheitskompetenz von Versicherten mit erhöhtem Risiko für Diabetes mellitus Typ 2 mittels Coaching in der Vertragsarztpraxis

Einleitung Lebensstilveränderungen können das Risiko, an Diabetes mellitus Typ 2 (DMT2) zu erkranken, senken. Im Rahmen des Innovationsfondprojektes Dimini (Diabetes mellitus? Ich nicht!) wurde untersucht, ob Menschen mit einem erhöhten Diabetesrisiko frühzeitig und niedrigschwellig in der hausärztlichen Praxis identifiziert werden können und ob die Lebensstilintervention Dimini zu einer verbesserten Gesundheitskompetenz sowie einer Gewichtsreduktion führt.

Methodik Dimini (01NVF17012) wurde vom 1. Juni 2017 bis zum 30. November 2020 in hausärztlichen Praxen in Hessen und in Schleswig-Holstein in Form einer randomisierten kontrollierten Studie umgesetzt. Zum Einschluss der Versicherten führten die Hausärztinnen und Hausärzte u.a. bei metabolisch auffälligen Personen ein Risikoscreening mittels FINDRISK-Tests durch (t0). Der 15-monatige Beobachtungszeitraum umfasste für die Interventionsgruppe eine dreimonatige Lebensstilintervention, optionale Coaching-Termine und drei Kontrolltermine in der Interventions- und Kontrollgruppe, zu denen die Datenerhebung erfolgte. Es wurden u.a. die Endpunkte Körpergewicht, Gesundheitskompetenz und der Grad der Zielerreichung untersucht.

Ergebnisse Von den 3349 Personen, die mit dem FINDRISK gescreent wurden, hatten 1430 (42,8%) Personen ein erhöhtes DMT2-Risiko (FINDRISK ≥ 12). Davon wurden 1170 Personen eingeschlossen. Das Durchschnittsgewicht sank im Interventionsverlauf (t0 zu t3) signifikant um 1,6 kg (1,1%) (V = 106721, p < 0,001). Der Mann-Whitney-U-Test (W = 49265, p = 0,036) zeigte eine signifikant größere Gewichtsabnahme in der Interventionsgruppe (IG) (Mt0-t3 = 2,06 kg, SD = 6,97) als in der Kontrollgruppe (KG) (Mt0-t3 = 1,18 kg, SD = 5,88). Die Gesundheitskompetenz verbesserte sich im Verlauf der Intervention nicht signifikant. 21 Teilnehmende (7,2%) erreichten ihr Gewichtsziel, 55 (18,8%) übertrafen und 217 (74,1%) verfehlten es. Das Ziel, 30 Minuten am Tag aktiv zu sein, erreichten laut eigenen Angaben 177 Teilnehmende (79,4%).

Schlussfolgerung Die Studie zeigt das Potential von flächendeckenden Risikoscreenings zur Früherkennung von Menschen mit erhöhtem DMT2-Risiko sowie einen geringen positiven Effekt der Intervention auf die Gewichtsreduktion. Subgruppenspezifische Präventionsansätze sollten im Anschluss an das Screening angeboten werden. Diese sollten bestehende Strukturen und verschiedene (ärztliche und therapeutische) Disziplinen und Fachrichtungen einbinden. Eine stärkere Ausrichtung des Gesundheitswesens hinsichtlich Gesundheitsförderung und Prävention scheint notwendig.

Continuous Glucose Monitoring and Physical Activity

Continuous glucose monitoring (CGM) use has several potential positive effects on diabetes management. These benefits are, e.g., increased time in range (TIR), optimized therapy, and developed documentation. Physical activity is a recommended intervention tool in diabetes management, especially for people with type 2 diabetes (T2D). The benefits of physical activity for people with diabetes can be seen as an improvement of glycemic control, glycemic variability, and the reduction of insulin resistance. In relation to the physical activity of people with T2D, the benefits of CGM use can even be increased, and CGM can be a helpful tool to prevent adverse events due to physical activity of people with diabetes, such as hypoglycemic events and nocturnal hypoglycemia after sports. This narrative review aims to provide solid recommendations for the use of CGM in everyday life physical activities based on the noted benefits and to give a general overview of the guidelines on physical activity and CGM use for people with diabetes.

Physical Activity Treatment in Adults with Type 2 Diabetes Mellitus per National Treatment Guidelines for Germany: A Telephone-Survey-Based Analysis

Physical activity (PA) is effective in the prevention of type 2 diabetes mellitus (T2DM). According to the German national treatment guidelines for T2DM, PA is recommended at all stages of the treatment process. Adults with T2DM were recruited within the cross-sectional telephone survey 'Disease knowledge and information needs-Diabetes mellitus (2017)'. Self-reported data on socio-demographic characteristics, previous and current T2DM treatment, and PA behavior were collected. Using multivariable logistic regression models, the correlation between PA treatment (referrals and recommendations) and PA was investigated. Overall, 1149 adults diagnosed with T2DM are included in the analysis. Of the participants, 66.7% reported having ever received PA as part of their T2DM treatment with 61% of the participants reporting PA treatment at the time of the initial T2DM diagnosis and 54% at the time of the interview. Women, older participants, and those with a lower educational level were less likely to have ever been treated with PA. Currently being treated with PA as part of the T2DM treatment was associated with higher rates of achieving the World Health Organization's PA recommendations (≥150 min per week) (OR = 1.95, 95% CI: 1.42-2.68), as well as ever being treated with PA (OR = 1.74, 95% CI: 1.20-2.38). The analyses showed that PA treatment plays a role in the treatment process of T2DM, but not all patient subgroups benefit in the same way. Efforts to increase PA treatment as part of T2DM treatment are needed, especially for those who are currently not treated with PA. Further research is needed to better understand the type of PA (e.g., structured or unstructured) undertaken by adults with T2DM to develop tailored PA interventions for adults with T2DM and for those in vulnerable subgroups.

A stakeholders' pathway towards a future land use and food system in Germany

Food systems contribute considerably to greenhouse gas (GHG) emissions and influence land use. In Germany, many strategies have been proposed by policy-makers to reduce negative impacts and make the food system more sustainable. It is unclear how close the suggested policies, when bundled, will bring the food and land use system towards the targeted goals; and what stakeholders from non-policy-making organizations consider realistic changes in the German food system. We thus surveyed different stakeholder groups on their opinions about realistic changes in the food and land use system in Germany up to 2050, developed four stakeholder pathways, and used an accounting tool to determine the effect of each pathway on indicators such as land use, GHG emissions, and biodiversity conservation potential. The assessment showed that GHG emissions from agricultural activities and land use are reduced from 66 to - 2-22 TgCO2e by 2050, while the area where natural processes predominate increases from 19 to 27-32%, and the resilience of the food system is not negatively influenced. The change is caused mainly by a diet-change-induced reduction of livestock production and agricultural area transformation into areas with higher carbon sequestration rates. If followed, the common stakeholder pathway (based on all stakeholder responses) would thus lead towards a sustainable food and land use system, but only if the underlying assumption of a drastic diet change towards more plant-based products comes true. Stakeholders from the academic and public sectors were more likely to assume that such a change was realistic than stakeholders from the private sector.

Illness-Death Model as a Framework for Chronic Disease Burden Projection: Application to Mental Health Epidemiology

Introduction

Estimates of future disease burden supports public health decision-making. Multistate modeling of chronic diseases is still limited despite a long history of mathematical modeling of diseases. We introduce a discrete time approach to the illness-death model and a recursion formula, which can be utilized to project chronic disease burden. We further illustrate an example of the technique applied to anxiety disorders in Germany.

Materials and Equipment

The illness-death model is a multistate model that relates prevalence, incidence, mortality, and remission. A basic recursion formula that considers prevalence, incidence, mortality among the susceptible, and mortality among the diseased can be applied to irreversible chronic diseases such as diabetes. Among several mental disorders, remission plays a key role and thus an extended recursion formula taking remission into account is derived.

Methods

Using the Global Burden of Disease Study 2019 data and population projections from the Federal Statistical Office of Germany, a total number of individuals with anxiety disorders by sex in Germany from 2019 to 2030 was projected. Regression models were fitted to historical data for prevalence and incidence. Differential mortality risks were modeled based on empirical evidence. Remission was estimated from prevalence, incidence, and mortality, applying the extended recursion formula. Sex- and age-specific prevalence of 2019 was given as the initial value to estimate the total number of individuals with anxiety disorders for each year up to 2030. Projections were also made through simple extrapolation of prevalence for comparison.

Results

From 2019 to 2030, we estimated a decrease of 52,114 (-1.3%) individuals with anxiety disorders among women, and an increase of 166,870 (+8.5%) cases among men, through the illness-death model approach. With prevalence extrapolation, an increase of 381,770 (+9.7%) among women and an increase of 272,446 (+13.9%) among men were estimated.

Discussion

Application of the illness-death model with discrete time steps is possible for both irreversible chronic diseases and diseases with possible remissions, such as anxiety disorders. The technique provides a framework for disease burden prediction. The example provided here can form a basis for running simulations under varying transition probabilities.

Type 2 diabetes mellitus and cognitive decline in older adults in Germany - results from a population-based cohort

Background

A large body of evidence supports a link between type 2 diabetes mellitus (T2DM) and cognitive function, including dementia. However, longitudinal studies on the association between T2DM and decline of cognitive function are scarce and reported mixed results, and we hence set out to investigate the cross-sectional and longitudinal association between T2DM and global as well as domain-specific cognitive performance.

Methods

We used multivariable regression models to assess associations of T2DM with cognitive performance and cognitive decline in a subsample of a population-based prospective cohort study (ESTHER). This subsample (n = 732) was aged 70 years and older and had participated in telephone-based cognitive function assessment (COGTEL) measuring global and domain-specific cognitive performance during the 5- and 8-year follow-up.

Results

Total COGTEL scores of patients with prevalent T2DM were 27.4 ± 8.3 and 29.4 ± 8.7 at the 5- and 8-year measurements, respectively, and were roughly two points lower than those of T2DM-free participants after adjustment for age and sex. In cross-sectional models, after adjustment for several potential confounders, performance in verbal short-term and long-term memory tasks was statistically significantly lower in participants with T2DM, but the association was attenuated after further adjustment for vascular risk factors. The difference in total COGTEL scores reflecting global cognitive function by T2DM status after full adjustment for confounders and vascular risk factors was equivalent to a decrement in global cognitive function associated with a four-year age difference. In longitudinal models, a statistically significantly stronger cognitive decline in patients with T2DM was observed for working memory.

Conclusions

In this sample of older individuals, T2DM was associated with worse performance and stronger decline in a cognitive function test. Memory-related domains were found to be particularly sensitive to T2DM. Further large-scale prospective studies are needed to clarify potential T2DM-related predictors of cognitive decline and possible consequences on the abilities to perform patient self-management tasks in diabetes care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03151-y.

Healthcare Resource Utilization and Associated Costs in New Users of Empagliflozin versus DPP-4 Inhibitors and GLP-1 Agonists: A Comparative Analysis Based on Retrospective Real-World Data from German Sickness Funds

Purpose

Achieving good glycemic control in type 2 diabetes (T2DM) may require individualized pharmacological approaches. We aimed to compare direct healthcare costs in patients treated with empagliflozin (EMPA) compared to dipeptidyl peptidase-4 inhibitors (DPP-4i) or glucagon-like peptide-1 receptor agonists (GLP-1-RA).

Patients and Methods

This German claims data study included continuously insured persons with at least two outpatient diagnoses and/or one inpatient diagnosis of T2DM if they started EMPA, DPP-4i, or GLP-1-RA in 2015-2018. Healthcare costs were assessed from therapy initiation until the end of data availability, death, or therapy discontinuation and compared among propensity score-matched cohorts.

Results

Of 24,465 patients included, 3285 received EMPA, 19,443 DPP-4i, and 1747 GLP-1-RA. Matched cohorts were balanced on baseline characteristics (EMPA versus DPP-4i: n1/n2 = 3100/3100 and EMPA versus GLP-1-RA: n3/n4 = 1346/1346). Mean total costs after start of DPP-4i were €7009 (95%-CI: 6573-7444) versus €4274 (3982-4566) for EMPA. Costs associated with GLP-1-RA treatment were also significantly higher compared with EMPA (€6851 [6183-7518] versus €4895 [4345-5445]).

Conclusion

Although the individual clinical patient profile and physician assessment are paramount in treatment decisions, substantial differences in the economic impact of different antidiabetic therapies should be considered.

Feasibility and Acceptability of the HOME Model to Promote Self-Management Among Ethnic Minority Elderly with Type 2 Diabetes Mellitus in Rural Thailand: A Pilot Study

Introduction:

Ethnic minority elderly (EME) people are recognized as a vulnerable group who have higher prevalence of type 2 diabetes mellitus (T2DM) than the majority of the population. The aim of this study was to explore the feasibility, acceptability, and effect of the HOME model (Home intervention; Online monitoring; Multidisciplinary approach; and Equity and education) specifically for enhancing self-management activities, glycemic control, and satisfaction of EME with T2DM in rural areas in Thailand.

Methods:

In this quasi-experimental study, a single group used a pre-test and post-test, which were conducted as a pilot study to examine the effect of the HOME model.

Results:

Overall, 23 dyads of EME with T2DM and their family caregivers completed the 12-week intervention. They reported that the HOME model was helpful and motivating, and they reported satisfaction with the service provided. EME with T2DM showed significant reduction of blood glucose level, and significant improvement in self-management activities, happiness, and satisfaction compared with baseline. Family caregivers had also significant improvements in happiness and reported satisfaction with the HOME model.

Conclusion:

The primary evidence suggested that the HOME model was acceptable and feasible for EME with T2DM and their families in rural Thailand.

Potential of prevention strategies for the modifiable risk factor type 2 diabetes with relation to the future number of dementia patients in Germany- a multi-state projection through 2040

BACKGROUND

We assess the impact of prevention strategies regarding type 2 diabetes as a modifiable risk factor for dementia and its consequences for the future number of dementia patients in Germany.

METHODS

We used a random sample of health claims data (N = 250,000) of insured persons aged 50+ drawn in 2014, and data on population size and death rates in 2015 from the Human Mortality Database. Using exponential hazard models, we calculated age- and sex-specific transition probabilities and death rates between the states (no diabetes/no dementia, diabetes/no dementia, no diabetes/dementia, diabetes/dementia). In multi-state projections, we estimated the future number of dementia cases aged 75+ through 2040 depending on the development of the incidence of diabetes among persons without diabetes and without dementia, and the dementia incidence among persons with and without diabetes.

RESULTS

In 2015 there were 1.53 million people with dementia aged 75+ in Germany. A relative annual reduction in death rates of 2.5% and in dementia incidence in persons without diabetes of 1% will increase this number to 3.38 million by 2040. A relative reduction of diabetes incidence by 1% annually would decrease dementia cases by around 30,000, while a reduction of dementia incidence among people with diabetes by 1% would result in 220,000 fewer dementia cases. Both prevention strategies combined would prevent 240,000 dementia cases in 2040.

CONCLUSIONS

The increase in life expectancy is decisive for the future number of people with dementia. Strategies of better diabetes treatment have the potential to lower the increase in the number of dementia patients in the coming decades.

Impact of a Digital Lifestyle Intervention on Diabetes Self-Management: A Pilot Study

The aim of this study was to provide preliminary evidence on the impact of the digital health application Vitadio on improving glycemic control in patients with type 2 diabetes mellitus. This was a 3-month, prospective, multicenter, open-label trial with an intraindividual control group. Participants received a digital lifestyle intervention. HbA1c levels were observed at 3 time points: retrospectively, at 3 months before app use; at baseline, at the start of usage; and 3 months after the start of use. In addition, changes in other metabolic parameters (fasting glucose, body weight, and waist circumference), patient reported outcomes (quality of life, self-efficacy, and depression), and data generated within the app (frequency of use, steps, and photos of meals) were evaluated. Repeated measures analysis of variance with the Bonferroni correction was used to assess the overall difference in HbA1c values between the intervention and the intraindividual control group, with p < 0.05 considered significant. Participants (n = 42) were 57 ± 7.4 years old, 55% male, and with a mean baseline HbA1c of 7.9 ± 1.0%. An average HbA1c reduction of −0.9 ± 1.1% (p < 0.001) was achieved. The digital health application was effective in significantly reducing body weight (−4.3 ± 4.5 kg), body mass index (−1.4 ± 1.5 kg/m2), waist circumference (−5.7 ± 15 cm), and fasting glucose (−0.6 ± 1.3 mmol/L). The digital therapy achieved a clinically meaningful and significant HbA1c reduction as well as a positive effect on metabolic parameters. These results provide preliminary evidence that Vitadio may be effective in supporting patient diabetes management by motivating patients to adopt healthier lifestyles and improving their self-management.

Future prevalence of type 2 diabetes—A comparative analysis of chronic disease projection methods

Background

Accurate projections of the future number of people with chronic diseases are necessary for effective resource allocation and health care planning in response to changes in disease burden.

Aim

To introduce and compare different projection methods to estimate the number of people with diagnosed type 2 diabetes (T2D) in Germany in 2040.

Methods

We compare three methods to project the number of males with T2D in Germany in 2040. Method 1) simply combines the sex- and age-specific prevalence of T2D in 2010 with future population distributions projected by the German Federal Statistical Office (FSO). Methods 2) and 3) additionally account for the incidence of T2D and mortality rates using partial differential equations (PDEs). Method 2) models the prevalence of T2D employing a scalar PDE which incorporates incidence and mortality rates. Subsequently, the estimated prevalence is applied to the population projection of the FSO. Method 3) uses a two-dimensional system of PDEs and estimates future case numbers directly while future mortality of people with and without T2D is modelled independently from the projection of the FSO.

Results

Method 1) projects 3.6 million male people with diagnosed T2D in Germany in 2040. Compared to 2.8 million males in 2010, this equals an increase by 29%. Methods 2) and 3) project 5.9 million (+104% compared to 2010) and 6.0 million (+116%) male T2D patients, respectively.

Conclusions

The results of the three methods differ substantially. It appears that ignoring temporal trends in incidence and mortality may result in misleading projections of the future number of people with chronic diseases. Hence, it is essential to include these rates as is done by method 2) and 3).

Sex-specific impact of major depressive disorder on 12-year change in glycaemic status: Results from a nationwide cohort study of adults without diabetes in Germany

AIMS

There is evidence for an increased type 2 diabetes (T2D) risk associated with depression, but its role for diabetes prevention remains unclear. This study aimed to add insight by investigating the impact of major depressive disorder (MDD) on prospective glycaemic changes.

METHODS

The study was based on a cohort of n = 1,766 adults without diabetes (776 men, 990 women; 18-65 years of age) who participated in the mental health supplement of the German National Health Interview and Examination Survey (GNHIES98-MHS, 1997-1999) and in a follow-up survey (DEGS1, 2008-2011). Glycaemic status was defined as normoglycaemia [HbA1c < 39 mmol/mol (<5.7%)], prediabetes [39 ≤ HbA1c < 48 mmol/mol (5.7-6.4%)] and diabetes [HbA1c ≥ 48 mmol/mol (≥ 6.5%), diagnosed diabetes, or antidiabetic medication], and glycaemic changes categorized as 'remission', 'stability' and 'progression'. Baseline MDD was assessed via a modified German version of the WHO Composite International Diagnostic Interview. Multivariable logistic regressions were applied to analyse the association of MDD with glycaemic changes and incident T2D, adjusting for socio-demographics, lifestyle conditions, chronic diseases, antidepressant use and mental health care.

RESULTS

MDD prevalence was 21.4% for women and 8.9% for men. Among women, MDD was associated with a lower chance for remission (RRR 0.43; 95% CI 0.23, 0.82). Among men, MDD was not significantly related to glycaemic changes. MDD had no significant effect on incident T2D (men: OR 1.58; 0.55, 4.52; women: OR 0.76; 0.37, 1.58).

CONCLUSIONS

Findings of the current study highlight the role of depression in T2D prevention, particularly among women.

Sex Differences in Fecal Microbiota Correlation With Physiological and Biochemical Indices Associated With End-Stage Renal Disease Caused by Immunoglobulin a Nephropathy or Diabetes

This study investigated the sex-specific differences in the correlation between intestinal microbiota and end-stage renal disease. Here, we compared the differences in the gut microbiota of male and female healthy controls (HC) and patients with end-stage renal disease (ESRD) caused by immunoglobulin A (IgA) nephropathy (ESRD-IgAN) or type-2 diabetes mellitus (ESRD-T2DM) using high-throughput sequencing of the 16S rRNA gene. We also analyzed the correlation between gut microbiota and clinical immune indicators. We assigned 8, 10, 5, 7, 11, and 20 volunteers to female HC, ESRD-IgAN, and ESRD-T2DM, and male HC, ESRD-IgAN, and ESRD-T2DM, respectively. The results showed sex-specific differences in both physiological and biochemical indices and intestinal microbiota composition, as well as the correlation between them. The correlations between physiological and biochemical indices in men were significantly lower than those in women, especially for indices related to immunity, blood glucose, and cardiac color sonography. Urine output, lymphocyte ratio, serum albumin, blood calcium, dialysis status, serum urea nitrogen, urine protein, and diabetes significantly correlated with male fecal microbiota composition, whereas only creatinine and 2-h post-prandial blood glucose significantly correlated with female fecal microbiota composition. The top 50 dominant operational taxonomic units showed a stronger correlation with physiological and biochemical indices in samples obtained from females than from males. These differences highlight sex-specific differences in the effectiveness of ESRD prevention and treatments via regulating intestinal microbiota.

Diabetes free life expectancy and years of life lost associated with type 2 diabetes: projected trends in Germany between 2015 and 2040

BACKGROUND

Type 2 diabetes (T2D) causes substantial disease burden and is projected to affect an increasing number of people in coming decades. This study provides projected estimates of life years free of type 2 diabetes (T2D) and years of life lost ([Formula: see text]) associated with T2D for Germany in the years 2015 and 2040.

METHODS

Based on an illness-death model and the associated mathematical relation between prevalence, incidence and mortality, we projected the prevalence of diagnosed T2D using currently available data on the incidence rate of diagnosed T2D and mortality rates of people with and without diagnosed T2D. Projection of prevalence was achieved by integration of a partial differential equation, which governs the illness-death model. These projected parameters were used as input values to calculate life years free of T2D and [Formula: see text] associated with T2D for the German population aged 40 to 100 years in the years 2015 and 2040, while accounting for different assumptions on future trends in T2D incidence and mortality.

RESULTS

Assuming a constant incidence rate, women and men at age 40 years in 2015 will live approximately 38 years and 33 years free of T2D, respectively. Up to the year 2040, these numbers are projected to increase by 1.0 years and 1.3 years. Assuming a decrease in T2D-associated excess mortality of 2% per year, women and men aged 40 years with T2D in 2015 will be expected to lose 1.6 and 2.7 years of life, respectively, compared to a same aged person without T2D. In 2040, these numbers would reduce by approximately 0.9 years and 1.6 years. This translates to 10.8 million and 6.4 million [Formula: see text] in the German population aged 40-100 years with prevalent T2D in 2015 and 2040, respectively.

CONCLUSIONS

Given expected trends in mortality and no increase in T2D incidence, the burden due to premature mortality associated with T2D will decrease on the individual as well as on the population level. In addition, the expected lifetime without T2D is likely to increase. However, these trends strongly depend on future improvements of excess mortality associated with T2D and future incidence of T2D, which should motivate increased efforts of primary and tertiary prevention.

Diabetes in the Hospital

BACKGROUND

Comprehensive data on the frequency of diabetes mellitus among hospitalized patients in Germany have not been published to date.

METHODS

Among all inpatient cases aged ≥20 years that were documented in the German DRG statistics for 2015-2017, we analyzed the frequencies of five types of diabetes (type 1, type 2, other/pancreatic diabetes, "rare diabetes" with an ICD code of E12 or E14, gestational diabetes) and of prediabetes, stratified by sex and age group. The presence of any of these conditions was ascertained from the corresponding ICD-10 code among the main diagnoses (reasons for admission) or secondary diagnoses. We also compared the length of hospital stay, in-hospital mortality, and the frequency of various categories of main diagnosis in cases with and without diabetes in each age group.

RESULTS

In the period 2015-2017, approximately 18% of the 16.4 to 16.7 million inpatient cases carried a main or secondary diagnosis of diabetes (in 2017: type 2, 17.1%; type 1, 0.5%). Diabetes was more common in male cases than in female cases (in 2017: type 2, 19.7% vs. 14.8%; type 1, 0.5% vs. 0.4%). In 2017, the greatest difference in length of hospital stay between patients with and without diabetes was for patients with type 1 diabetes aged 40-49 (7.3 vs. 4.5 days), while the greatest difference in in-hospital mortality was for patients with type 2 diabetes aged 70-79 (3.7% vs. 2.8%). From the age of 30 (age category 30-39), diseases of the cardiovascular system, and from the age of 50 (age category 50-59), diseases of the respiratory or urogenital systems were more frequently listed as a reason for admission in cases with than in those without diabetes.

CONCLUSION

The fact that diabetes is twice as prevalent in hospitalized cases as in the general population underscores the high morbidity associated with the disease and the greater need of persons with diabetes for in-hospital care, as the population of multimorbid diabetes patients continues to grow older.

ACTonDiabetes-a guided psychological internet intervention based on Acceptance and Commitment Therapy (ACT) for adults living with type 1 or 2 diabetes: results of a randomised controlled feasibility trial

OBJECTIVES

This two-group randomised controlled trial evaluates the feasibility of an Acceptance and Commitment Therapy (ACT)-based internet intervention for diabetes distress in people with diabetes type 1 or type 2. Participants were assigned to a guided self-help intervention (EG) or waitlist control group (CG).

SETTING

Recruitment took place following an open recruitment strategy including different diabetes centres, self-help groups and social media platforms.

PARTICIPANTS

Eligibility criteria comprised being 18 years of age or older, self-reported diagnosis of type 1 or type 2 diabetes, internet access, sufficient German language skills and written informed consent.

INTERVENTION

ACTonDiabetes is an internet-based and mobile-based intervention and comprises an introduction and seven modules (one module per week, processing time about 45-60 min). Intervention contents are based on ACT.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants were assessed before and 8 weeks after randomisation. Primary outcome was feasibility (trial recruitment, acceptability). Potential group differences in diabetes distress and other outcomes at follow-up were analysed using linear regression models with baseline values as predictors. All analyses were based on an intention-to-treat principle, potential negative effects were analysed on per-protocol basis.

RESULTS

From October 2017 to April 2018, N=42 people with diabetes consented and were randomised (EG n=21, CG n=21). Forty-three per cent of the EG completed all treatment modules within 8 weeks. Across modules, formative user feedback revealed that contents could be optimised regarding comprehensibility (34%), individualisation (20%) and text amount (21%). Overall, 57% of participants dropped out prior to full treatment completion. There were reductions of diabetes distress in the EG (d=0.65, p=0.042).

CONCLUSIONS

Modifications of the intervention content according to the user feedback will be performed to further improve acceptability. Mechanisms to foster intervention adherence should be considered for lowering the attrition rate. ACTonDiabetes is feasible for the implementation in a confirmatory trial.

TRIAL REGISTRATION NUMBER

WHO International Clinical Trials Registry Platform via the German Clinical Trials Register (DRKS) (DRKS00013193).