1
|
Wijeweera C, Muhfaza U, Lord RV, Petocz P, Chen J, Preda V. Socioeconomic status and the effect of prolonged pandemic confinement on anthropometric and glycaemic outcomes in adults with type 2 diabetes mellitus. Prim Care Diabetes 2024; 18:308-318. [PMID: 38448261 DOI: 10.1016/j.pcd.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/03/2023] [Accepted: 02/09/2024] [Indexed: 03/08/2024]
Abstract
AIM This systematic review and meta-analysis aimed to investigate the impact of COVID19 lockdown on the anthropometric and glycaemic outcomes of adults with type 2 diabetes mellitus (T2DM) and assess whether socioeconomic status (SES) was relevant to these changes. METHODS A search of three databases was conducted. Meta-analyses using random effects models were undertaken to combine anthropometric and glycaemic measures pre- and post-confinement. Subgroup analyses according to SES were also conducted. RESULTS This systematic review of 19 articles demonstrated that prolonged pandemic-related confinement is associated with a deterioration in both anthropometric and glycaemic outcomes among adults with T2DM. Furthermore, SES was found to be relevant to these changes. Specifically, BMI (kg/m2) showed an increase in mean difference of 0.72 (95% CI; 0.13, 1.31; p<0.05) between pre and post lockdown cohorts. High income countries displayed a greater increase in BMI compared to their lower middle-income counterparts. Regarding, fasting blood glucose (FBG), a statistically significant difference was observed in the upper middle-income group (mean difference: 5.10; 95% CI: 2.92, 7.27), and high-income group (mean difference: 6.03; 95% CI: 0.04, 12.02). There were no significant changes to weight, waist circumference, or HbA1C over the lockdown period. CONCLUSION Our findings suggest adults with T2DM may have received less effective care over the lockdown period, particularly in high income countries. Clinics and care providers may need to adopt more intensive contact and treatment plans in the post lockdown period to prevent lasting impacts on disease progression and metabolic sequelae.
Collapse
Affiliation(s)
- Chandana Wijeweera
- Macquarie University Faculty of Medicine and Health Sciences, Australia.
| | - Ummul Muhfaza
- Healthy Weight Clinic, Macquarie University Hospital, Macquarie Park, Australia
| | - Reginald V Lord
- Department of Surgery, University of Notre Dame School of Medicine, Sydney Australia
| | - Peter Petocz
- Macquarie University, Department of Statistics, Macquarie Park, Australia
| | - Juliana Chen
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Veronica Preda
- Healthy Weight Clinic, Macquarie University Hospital, Macquarie Park, Australia
| |
Collapse
|
2
|
Lakić B, Škrbić R, Uletilović S, Mandić-Kovačević N, Grabež M, Šarić MP, Stojiljković MP, Soldatović I, Janjetović Z, Stokanović A, Stojaković N, Mikov M. Beneficial Effects of Ursodeoxycholic Acid on Metabolic Parameters and Oxidative Stress in Patients with Type 2 Diabetes Mellitus: A Randomized Double-Blind, Placebo-Controlled Clinical Study. J Diabetes Res 2024; 2024:4187796. [PMID: 38455850 PMCID: PMC10919985 DOI: 10.1155/2024/4187796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/15/2024] [Accepted: 02/15/2024] [Indexed: 03/09/2024] Open
Abstract
Background Oxidative stress and inflammation are closely related pathophysiological processes, both occurring in type 2 diabetes mellitus (T2DM). In addition to the standard treatment of T2DM, a potential strategy has been focused on the use of bile acids (BAs) as an additional treatment. Ursodeoxycholic acid (UDCA), as the first BA used in humans, improves glucose and lipid metabolism and attenuates oxidative stress. The aim of this study was to evaluate the potential metabolic, anti-inflammatory, and antioxidative effects of UDCA in patients with T2DM. Methods This prospective, double-blind, placebo-controlled clinical study included 60 patients with T2DM, randomly allocated to receive UDCA or placebo. Subjects were treated with 500 mg tablets of UDCA or placebo administered three times per day (total dose of 1500 mg/day) for eight weeks. Two study visits, at the beginning (F0) and at the end (F1) of the study, included the interview, anthropometric and clinical measurements, and biochemical analyses. Results UDCA treatment showed a significant reduction in body mass index (p = 0.024) and in diastolic blood pressure (p = 0.033), compared to placebo. In addition, there was a statistically significant difference in waist circumference in the UDCA group before and after treatment (p < 0.05). Although no statistical significance was observed at the two-month follow-up assessment, an average decrease in glucose levels in the UDCA group was observed. After two months of the intervention period, a significant decrease in the activity of liver enzymes was noticed. Furthermore, a significant reduction in prooxidative parameters (TBARS, NO2-, H2O2) and significant elevation in antioxidative parameters such as SOD and GSH were found (p < 0.001). Conclusions The eight-week UDCA administration showed beneficial effects on metabolic and oxidative stress parameters in patients with T2DM. Thus, UDCA could attenuate the progression and complications of diabetes and should be considered as an adjuvant to other diabetes treatment modalities. This trial is registered with NCT05416580.
Collapse
Affiliation(s)
- Biljana Lakić
- Department of Family Medicine, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
- Primary Health Care Centre, Banja Luka, Bosnia and Herzegovina
| | - Ranko Škrbić
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
- Centre for Biomedical Research, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Snežana Uletilović
- Department of Medical Biochemistry and Chemistry, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Nebojša Mandić-Kovačević
- Department of Pharmacy, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Milkica Grabež
- Department of Hygiene, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | | | - Miloš P. Stojiljković
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
- Centre for Biomedical Research, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Ivan Soldatović
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Zorica Janjetović
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Nataša Stojaković
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Momir Mikov
- Centre for Biomedical Research, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| |
Collapse
|
3
|
Molló À, Vlacho B, Gratacòs M, Mata-Cases M, Rubinat E, Berenguera Ossó A, Cos FX, Franch-Nadal J, Khunti K, Mauricio D. A multicomponent health care intervention is associated with improved glycaemic control in subjects with poorly controlled type 2 diabetes compared with routine care: The INTEGRA study. Diabetes Obes Metab 2023; 25:3549-3559. [PMID: 37608473 DOI: 10.1111/dom.15250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/28/2023] [Accepted: 08/02/2023] [Indexed: 08/24/2023]
Abstract
AIM The INTEGRA study evaluated whether a specially designed multicomponent health care intervention improved glycaemic control in subjects with poorly controlled type 2 diabetes compared with standard of care practice. RESEARCH DESIGN AND METHODS Pragmatic study in subjects from primary care centres with type 2 diabetes and glycated haemoglobin (HbA1c) >9% (75 mmol/mol). The multifaceted intervention (N = 225 subjects) included a diabetes-focused visit encouraging therapeutic intensification by health care professionals. Retrospective data from matched controls (N = 675) were obtained from electronic medical records of a primary care database. The primary outcome was to compare the change in HbA1c values between the groups at 12 months of follow-up. RESULTS The mean HbA1c decreased substantially in both groups after 3 months, and the mean reduction was significantly greater in the intervention group than in the usual care group after 12 months [mean difference -0.66% (-7 mmol/mol), 95% CI -0.4, -1.0; p < .001]. A larger percentage of participants in the intervention group achieved HbA1c <7% and <8% goals (15.5% vs. 5.3% and 29.3% vs. 13.5%, respectively; p < .001). The improvement in HbA1c levels was sustained throughout the study only in the intervention arm. Glucose-lowering therapy was more frequently intensified in patients in the intervention group at the initial and final time points of the study (between 0-3 and 6-12 months; p < .001), with a significant increase in the number of patients prescribed ≥2 antidiabetic therapies (p < .001). CONCLUSIONS A multifaceted intervention oriented at reducing therapeutic inertia by primary care physicians was associated with greater improvement in glycaemic control compared with patients treated as per usual care.
Collapse
Affiliation(s)
- Àngels Molló
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Bogdan Vlacho
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - Mònica Gratacòs
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Manel Mata-Cases
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - Esther Rubinat
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Health Care Research Group (GRECS), Lleida Institute for Biomedical Research Dr. Pifarré Foundation IRB Lleida, University of Lleida, Lleida, Spain
- Department of Nursing & Physiotherapy, Serra Hunter Lecture, University of Lleida, Lleida, Spain
- Society, Health, Education and Culture Research Group (GESEC) of the University of Lleida, Lleida, Spain
| | - Anna Berenguera Ossó
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Departament d'Infermeria, Universitat de Girona, Girona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Francesc Xavier Cos
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Innovation Office at Institut Català de la Salut, Barcelona, Spain
| | - Josep Franch-Nadal
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Dídac Mauricio
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Universitari de la Santa Creu i Sant Pau, IIB Sant Pau, Barcelona, Spain
- Department of Medicine, University of Vic-Central University of Catalonia, Vic, Spain
| |
Collapse
|
4
|
Schweitzer GG, Beckner DC, Smith GI, Klein S. Short-term Intensive Lifestyle Therapy in a Worksite Setting Improves Cardiometabolic Health in People With Obesity. J Endocr Soc 2023; 7:bvad048. [PMID: 37153109 PMCID: PMC10161138 DOI: 10.1210/jendso/bvad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Indexed: 05/09/2023] Open
Abstract
Context The Pritikin Program, which provides intensive lifestyle therapy, has been shown to improve cardiometabolic outcomes when provided as a residential program. Objective The purpose of the present study was to conduct a short-term, randomized, controlled trial to evaluate the feasibility and clinical efficacy of treatment with the Pritikin Program in an outpatient worksite setting. Methods Cardiometabolic outcomes were evaluated in people with overweight/obesity and ≥2 metabolic abnormalities (high triglycerides, low high-density lipoprotein (HDL) cholesterol, high blood pressure, HbA1c > 5.7%), before and after they were randomized to 6 weeks of standard care (n = 26) or intensive lifestyle therapy, based on the Pritikin Program (n = 28). Participants in the lifestyle intervention group were provided all food as packed-out meals and participated in group nutrition, behavioral education, cooking classes, and exercise sessions 3 times per week at a worksite location. Results Compared with standard care, intensive lifestyle therapy decreased body weight (-5.0% vs -0.5%), HbA1c (-15.5% vs +2.3%), plasma total cholesterol (-9.8% vs +7.7%), low-density lipoprotein cholesterol (-10.3% vs +9.3%) and triglyceride (-21.7% vs +3.0%) concentrations, and systolic blood pressure (-7.0% vs 0%) (all P values < .02), and increased exercise tolerance (time to exhaustion walking on a treadmill by +23.7% vs +4.5%; P < .001). Conclusion This study demonstrates the feasibility and clinical effectiveness of short-term, intensive outpatient lifestyle therapy in people with overweight/obesity and increased risk of coronary heart disease when all food is provided and the intervention is conducted at a convenient worksite setting.
Collapse
Affiliation(s)
- George G Schweitzer
- Center for Human Nutrition, Washington University School of Medicine, St. Louis, MO 63110, USA
| | | | - Gordon I Smith
- Center for Human Nutrition, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Samuel Klein
- Center for Human Nutrition, Washington University School of Medicine, St. Louis, MO 63110, USA
| |
Collapse
|
5
|
Prins PJ, Noakes TD, Buga A, D’Agostino DP, Volek JS, Buxton JD, Heckman K, Jones DW, Tobias NE, Grose HM, Jenkins AK, Jancay KT, Koutnik AP. Low and high carbohydrate isocaloric diets on performance, fat oxidation, glucose and cardiometabolic health in middle age males. Front Nutr 2023; 10:1084021. [PMID: 36845048 PMCID: PMC9946985 DOI: 10.3389/fnut.2023.1084021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 01/24/2023] [Indexed: 02/11/2023] Open
Abstract
High carbohydrate, low fat (HCLF) diets have been the predominant nutrition strategy for athletic performance, but recent evidence following multi-week habituation has challenged the superiority of HCLF over low carbohydrate, high fat (LCHF) diets, along with growing interest in the potential health and disease implications of dietary choice. Highly trained competitive middle-aged athletes underwent two 31-day isocaloric diets (HCLF or LCHF) in a randomized, counterbalanced, and crossover design while controlling calories and training load. Performance, body composition, substrate oxidation, cardiometabolic, and 31-day minute-by-minute glucose (CGM) biomarkers were assessed. We demonstrated: (i) equivalent high-intensity performance (@∼85%VO2max), fasting insulin, hsCRP, and HbA1c without significant body composition changes across groups; (ii) record high peak fat oxidation rates (LCHF:1.58 ± 0.33g/min @ 86.40 ± 6.24%VO2max; 30% subjects > 1.85 g/min); (iii) higher total, LDL, and HDL cholesterol on LCHF; (iv) reduced glucose mean/median and variability on LCHF. We also found that the 31-day mean glucose on HCLF predicted 31-day glucose reductions on LCHF, and the 31-day glucose reduction on LCHF predicted LCHF peak fat oxidation rates. Interestingly, 30% of athletes had 31-day mean, median and fasting glucose > 100 mg/dL on HCLF (range: 111.68-115.19 mg/dL; consistent with pre-diabetes), also had the largest glycemic and fat oxidation response to carbohydrate restriction. These results: (i) challenge whether higher carbohydrate intake is superior for athletic performance, even during shorter-duration, higher-intensity exercise; (ii) demonstrate that lower carbohydrate intake may be a therapeutic strategy to independently improve glycemic control, particularly in those at risk for diabetes; (iii) demonstrate a unique relationship between continuous glycemic parameters and systemic metabolism.
Collapse
Affiliation(s)
- Philip J. Prins
- Department of Exercise Science, Grove City College, Grove City, PA, United States,*Correspondence: Philip J. Prins,
| | - Timothy D. Noakes
- Department of Medical and Wellness Science, Cape Peninsula University of Technology, Cape Town, South Africa
| | - Alex Buga
- Department of Human Sciences, The Ohio State University, Columbus, OH, United States
| | - Dominic P. D’Agostino
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, FL, United States
| | - Jeff S. Volek
- Department of Human Sciences, The Ohio State University, Columbus, OH, United States
| | - Jeffrey D. Buxton
- Department of Exercise Science, Grove City College, Grove City, PA, United States
| | - Kara Heckman
- Nebraska Methodist Health System, Omaha, NE, United States
| | - Dalton W. Jones
- Department of Exercise Science, Grove City College, Grove City, PA, United States
| | - Naomi E. Tobias
- Department of Exercise Science, Grove City College, Grove City, PA, United States
| | - Holly M. Grose
- Department of Exercise Science, Grove City College, Grove City, PA, United States
| | - Anna K. Jenkins
- Department of Exercise Science, Grove City College, Grove City, PA, United States
| | - Kelli T. Jancay
- Department of Exercise Science, Grove City College, Grove City, PA, United States
| | - Andrew P. Koutnik
- Human Healthspan, Resilience, and Performance, Institute for Human and Machine Cognition, Pensacola, FL, United States,Andrew P. Koutnik,
| |
Collapse
|
6
|
Comparing the effectiveness of Family Support for Health Action (FAM-ACT) with traditional community health worker-led interventions to improve adult diabetes management and outcomes: study protocol for a randomized controlled trial. Trials 2022; 23:841. [PMID: 36192769 PMCID: PMC9527393 DOI: 10.1186/s13063-022-06764-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/17/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Diabetes self-management education and support (DSMES) programs have struggled to deliver sustainable, effective support for adults with diabetes (AWDs) to improve self-management behaviors, achieve glycemic goals, and reduce risk for complications. One largely untapped resource for this support is AWDs' social networks. Fifty to 75% of AWDs have an unpaid family member or friend ("support person") who provides ongoing help with diabetes management. However, DSMES interventions to date lack structured and effective approaches to directly engage support persons in AWDs' diabetes management. METHODS This parallel arm randomized trial is designed to determine the effectiveness of Family Support for Health Action (FAM-ACT), a novel community health worker (CHW)-delivered program focused on educating and supporting patients with type 2 diabetes (T2D) and their support persons (SPs), relative to an established, CHW-delivered, individual patient-focused DSMES and care management (I-DSMES) intervention. Both interventions were developed using a community-based participatory research (CBPR) approach. The study will be conducted in partnership with an urban Federally Qualified Health Center (FQHC) serving a low-income, Latino/a community, with target enrollment of 268 dyads consisting of an FQHC patient with T2D with high HbA1c and an SP. Patient-SP dyads will be randomized to receive FAM-ACT or I-DSMES over 6 months. The primary outcome is change in patient HbA1c from baseline to 6 months. Secondary patient outcomes include 12-month change in HbA1c, changes in patient blood pressure, diabetes self-management behaviors, diabetes distress, patient activation, diabetes self-efficacy, and perceptions of and satisfaction with SP support for diabetes. Secondary SP outcomes include self-efficacy for helping the patient with diabetes management and SP distress about the patient's diabetes. We also will assess the effect of the COVID-19 pandemic on patient's ability to manage diabetes. DISCUSSION This study will inform scalable, evidence-based approaches that leverage family support to help AWDs improve and sustain self-management strategies that underpin optimal management of multiple diabetes complication risk factors. The protocol is designed for and evaluated with a low-income and predominantly Latino/a community, which may increase applicability to other similar communities. The COVID-19 pandemic presented several challenges to study protocol and intervention delivery; modifications made to address these challenges are described. TRIAL REGISTRATION ClinicalTrials.gov NCT03812614. Registered on 18 January 2019.
Collapse
|
7
|
Roach LA, Woolfe W, Bastian B, Neale EP, Francois ME. Systematic literature review: should a bedtime snack be used to treat hyperglycemia in type 2 diabetes? Am J Clin Nutr 2022; 116:1251-1264. [PMID: 36083989 PMCID: PMC9630881 DOI: 10.1093/ajcn/nqac245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/15/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Consuming a bedtime snack is often recommended for people with type 2 diabetes. OBJECTIVE This systematic review aims to evaluate the evidence from intervention studies to determine whether consuming a bedtime snack improves fasting hyperglycemia and/or overall glycemic control in individuals with type 2 diabetes. Methods: PubMed, Medline (EBSCO), Cochrane Library and CINAHL Plus (EBSCO) databases were searched until July 20 2022. We included prospective studies in people with type 2 diabetes or prediabetes that included the intervention of a bedtime snack, consumed > 30 minutes after dinner and < 2 hours before bed and reported glycemic outcomes. RESULTS The systematic review included 16 studies. There was no consistent relationship between consumption of a bedtime snack and improved glycemic control, especially when a no snack control was included. Of the four studies that included the use of corn starch, a low dose seemed to have benefits over high dose corn starch in terms of improved nocturnal and fasting glucose levels. CONCLUSIONS Current advice to consume a bedtime snack is based on a limited number of intervention studies that often do not include a no snack control, nor have used a feasible bedtime snack option that could be translated into every day clinical practice. Further research is needed in type 2 diabetes patients treated with or without insulin.PROSPERO Registration Number: CRD42020182523.
Collapse
Affiliation(s)
| | - William Woolfe
- School of Medical, Indigenous and Health Sciences, Faculty of Science, Medicine and Health University of Wollongong, Wollongong, New South Wales, Australia
| | - Beenu Bastian
- School of Medical, Indigenous and Health Sciences, Faculty of Science, Medicine and Health University of Wollongong, Wollongong, New South Wales, Australia,Illawarra Shoalhaven Local Health District, Diabetes Service, Wollongong, New South Wales, Australia
| | - Elizabeth P Neale
- School of Medical, Indigenous and Health Sciences, Faculty of Science, Medicine and Health University of Wollongong, Wollongong, New South Wales, Australia,Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia
| | - Monique E Francois
- School of Medical, Indigenous and Health Sciences, Faculty of Science, Medicine and Health University of Wollongong, Wollongong, New South Wales, Australia,Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia
| |
Collapse
|
8
|
Sebők J, Édel Z, Dembrovszky F, Farkas N, Török Z, Balogh G, Péter M, Papp I, Balogi Z, Nusser N, Péter I, Hooper P, Geiger P, Erőss B, Wittmann I, Váncsa S, Vigh L, Hegyi P. Effect of HEAT therapy in patiEnts with type 2 Diabetes mellitus (HEATED): protocol for a randomised controlled trial. BMJ Open 2022; 12:e062122. [PMID: 35820741 PMCID: PMC9277369 DOI: 10.1136/bmjopen-2022-062122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The burden of type 2 diabetes mellitus (T2DM) is increasing worldwide. Heat therapy has been found effective in improving glycaemic control. However, to date, there is a lack of randomised controlled studies investigating the efficacy of heat therapy in T2DM. Therefore, we aim to investigate whether heat therapy with natural thermal mineral water can improve glycaemic control in patients with T2DM. METHODS AND ANALYSIS The HEAT therapy in patiEnts with type 2 Diabetes mellitus (HEATED) Study is a single-centre, two-arm randomised controlled trial being conducted at Harkány Thermal Rehabilitation Centre in Hungary. Patients with T2DM will be randomly assigned to group A (bath sessions in 38°C natural thermal mineral water) and group B (baths in thermoneutral water (30°C-32°C)). Both groups will complete a maximum of 5 weekly visits, averaging 50-60 visits over the 12-week study. Each session will last 30 min, with a physical check-up before the bath. At baseline, patients' T2DM status will be investigated thoroughly. Possible microvascular and macrovascular complications of T2DM will be assessed with physical and laboratory examinations. The short form-36 questionnaire will assess the quality of life. Patients will also be evaluated at weeks 4, 8 and 12. The primary endpoint will be the change of glycated haemoglobin from baseline to week 12. An estimated 65 patients will be enrolled per group, with a sample size re-estimation at the enrolment of 50% of the calculated sample size. ETHICS AND DISSEMINATION The study has been approved by the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (818-2/2022/EÜIG). Written informed consent is required from all participants. We will disseminate our results to the medical community and will publish our results in peer-reviewed journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT05237219.
Collapse
Affiliation(s)
- Judit Sebők
- 2nd Department of Internal Medicine, University of Pecs Medical School, Pécs, Hungary
| | - Zsófia Édel
- 2nd Department of Internal Medicine, University of Pecs Medical School, Pécs, Hungary
| | - Fanni Dembrovszky
- Institute for Translational Medicine, Szentágothai Research Centre, University of Pecs Medical School, Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Nelli Farkas
- Institute for Translational Medicine, Szentágothai Research Centre, University of Pecs Medical School, Pécs, Hungary
- Institute of Bioanalysis, University of Pecs Medical School, Pécs, Hungary
| | | | | | | | | | - Zsolt Balogi
- Institute of Biochemistry and Medical Chemistry, University of Pecs Medical School, Pécs, Hungary
| | - Nóra Nusser
- Harkány Thermal Rehabilitation Centre, Harkány, Hungary
| | - Iván Péter
- Harkány Thermal Rehabilitation Centre, Harkány, Hungary
| | - Philip Hooper
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Paige Geiger
- Department of Molecular and Integrative Physiology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Bálint Erőss
- Institute for Translational Medicine, Szentágothai Research Centre, University of Pecs Medical School, Pécs, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - István Wittmann
- 2nd Department of Internal Medicine, University of Pecs Medical School, Pécs, Hungary
| | - Szilárd Váncsa
- Institute for Translational Medicine, Szentágothai Research Centre, University of Pecs Medical School, Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | | | - Péter Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, University of Pecs Medical School, Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| |
Collapse
|
9
|
Khoo J, Hagemeyer CE, Henstridge DC, Kumble S, Wang TY, Xu R, Gani L, King T, Soh SB, Puar T, Au V, Tan E, Tay TL, Kam C, Teo EK. Effects of water stably-enriched with oxygen as a novel method of tissue oxygenation on mitochondrial function, and as adjuvant therapy for type 2 diabetes in a randomized placebo-controlled trial. PLoS One 2021; 16:e0254619. [PMID: 34260650 PMCID: PMC8279347 DOI: 10.1371/journal.pone.0254619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 06/07/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Diabetes mellitus is associated with inadequate delivery of oxygen to tissues. Cellular hypoxia is associated with mitochondrial dysfunction which increases oxidative stress and hyperglycaemia. Hyperbaric oxygenation therapy, which was shown to improve insulin sensitivity, is impractical for regular use. We evaluated the effects of water which is stably-enriched with oxygen (ELO water) to increase arterial blood oxygen levels, on mitochondrial function in the presence of normal- or high-glucose environments, and as glucose-lowering therapy in humans. METHODS We compared arterial blood oxygen levels in Sprague-Dawley rats after 7 days of ad libitum ELO or tap water consumption. Mitochondrial stress testing, and flow cytometry analysis of mitochondrial mass and membrane potential, were performed on human HepG2 cells cultured in four Dulbecco's Modified Eagle Medium media, made with ELO water or regular (control) water, at normal (5.5 mM) or high (25 mM) glucose concentrations. We also randomized 150 adults with type 2 diabetes (mean age 53 years, glycated haemoglobin HbA1c 8.9% [74 mmol/mol], average duration of diabetes 12 years) to drink 1.5 litres daily of bottled ELO water or drinking water. RESULTS ELO water raised arterial oxygen tension pO2 significantly (335 ± 26 vs. 188 ± 18 mmHg, p = 0.006) compared with tap water. In cells cultured in control water, mitochondrial mass and membrane potential were both significantly lower at 25 mM glucose compared with 5.5 mM glucose; in contrast, mitochondrial mass and membrane potential did not differ significantly at normal or high glucose concentrations in cells cultured in ELO water. The high-glucose environment induced a greater mitochondrial proton leak in cells cultured in ELO water compared to cells cultured in control medium at similar glucose concentration. In type 2 diabetic adults, HbA1c decreased significantly (p = 0.002) by 0.3 ± 0.7% (4 ± 8 mmol/mol), with ELO water after 12 weeks of treatment but was unchanged with placebo. CONCLUSIONS ELO water raises arterial blood oxygen levels, appears to have a protective effect on hyperglycaemia-induced reduction in mitochondrial mass and mitochondrial dysfunction, and may be effective adjuvant therapy for type 2 diabetes.
Collapse
Affiliation(s)
- Joan Khoo
- Department of Medicine, Changi General Hospital, Singapore, Singapore
| | | | - Darren C. Henstridge
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Health Sciences, University of Tasmania, Launceston, Tasmania, Australia
| | - Sumukh Kumble
- NanoBiotechnology Laboratory, Monash University, Melbourne, Victoria, Australia
| | - Ting-Yi Wang
- NanoBiotechnology Laboratory, Monash University, Melbourne, Victoria, Australia
| | - Rong Xu
- NanoBiotechnology Laboratory, Monash University, Melbourne, Victoria, Australia
| | - Linsey Gani
- Department of Medicine, Changi General Hospital, Singapore, Singapore
| | - Thomas King
- Department of Medicine, Changi General Hospital, Singapore, Singapore
| | - Shui-Boon Soh
- Department of Medicine, Changi General Hospital, Singapore, Singapore
| | - Troy Puar
- Department of Medicine, Changi General Hospital, Singapore, Singapore
| | - Vanessa Au
- Department of Medicine, Changi General Hospital, Singapore, Singapore
| | - Eberta Tan
- Department of Medicine, Changi General Hospital, Singapore, Singapore
| | - Tunn-Lin Tay
- Department of Medicine, Changi General Hospital, Singapore, Singapore
| | - Carmen Kam
- Clinical Trials and Research Unit, Changi General Hospital, Singapore, Singapore
| | - Eng-Kiong Teo
- Department of Medicine, Changi General Hospital, Singapore, Singapore
| |
Collapse
|
10
|
Raghuram N, Ram V, Majumdar V, SK R, Singh A, Patil S, Anand A, Judu I, Bhaskara S, Basa JR, Nagendra HR. Effectiveness of a Yoga-Based Lifestyle Protocol (YLP) in Preventing Diabetes in a High-Risk Indian Cohort: A Multicenter Cluster-Randomized Controlled Trial (NMB-Trial). Front Endocrinol (Lausanne) 2021; 12:664657. [PMID: 34177805 PMCID: PMC8231281 DOI: 10.3389/fendo.2021.664657] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Though several lines of evidence support the utility of yoga-based interventions in diabetes prevention, most of these studies have been limited by methodological issues, primarily sample size inadequacy. Hence, we tested the effectiveness of yoga-based lifestyle intervention against diabetes risk reduction in multicentre, large community settings of India, through a single-blind cluster-randomized controlled trial, Niyantrita Madhumeha Bharat Abhiyan (NMB). Research Design and Methods NMB-trial is a multicentre cluster-randomized trial conducted in 80 clusters [composed of rural units (villages) and urban units (Census Enumeration Blocks)] randomly assigned in a 1:1 ratio to intervention and control groups. Participants were individuals (age, 20-70 years) with prediabetes (blood HbA1c values in the range of 5.7-6.4%) and IDRS ≥ 60. The intervention included the practice of yoga-based lifestyle modification protocol (YLP) for 9 consecutive days, followed by daily home and weekly supervised practices for 3 months. The control cluster received standard of care advice for diabetes prevention. Statistical analyses were performed on an intention-to-treat basis, using available and imputed datasets. The primary outcome was the conversion from prediabetes to diabetes after the YLP intervention of 3 months (diagnosed based upon HbA1c cutoff >6.5%). Secondary outcome included regression to normoglycemia with HbA1c <5.7%. Results A total of 3380 (75.96%) participants were followed up at 3 months. At 3 months post-intervention, overall, diabetes developed in 726 (21.44%) participants. YLP was found to be significantly effective in halting progression to diabetes as compared to standard of care; adjusted RRR was 63.81(95% CI = 56.55-69.85). The YLP also accelerated regression to normoglycemia [adjusted Odds Ratio (adjOR) = 1.20 (95% CI, 1.02-1.43)]. Importantly, younger participants (≤40 years) were found to regress to normoglycemia more effectively than the older participants Pinteraction<0.001. Conclusion Based on the significant risk reduction derived from the large sample size, and the carefully designed randomized yoga-based intervention on high-risk populations, the study is a preliminary but strong proof-of-concept for yoga as a potential lifestyle-based treatment to curb the epidemic of diabetes. The observed findings also indicate a potential of YLP for diabetes prevention in low/moderate risk profile individuals that needs large-scale validation. Trial Registration Clinical Trial Registration Number: CTRI/2018/03/012804.
Collapse
Affiliation(s)
| | - Venkat Ram
- Apollo Medical College, Hyderabad, India
| | - Vijaya Majumdar
- Division of Life Sciences, Swami Vivekananda Yoga University, Bengaluru, India
| | - Rajesh SK
- Division of Life Sciences, Swami Vivekananda Yoga University, Bengaluru, India
| | - Amit Singh
- Division of Life Sciences, Swami Vivekananda Yoga University, Bengaluru, India
| | - Suchitra Patil
- Division of Life Sciences, Swami Vivekananda Yoga University, Bengaluru, India
| | - Akshay Anand
- Neuroscience Research Lab, Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ilavarasu Judu
- Division of Life Sciences, Swami Vivekananda Yoga University, Bengaluru, India
| | | | | | | |
Collapse
|
11
|
Holt RIG, Dritsakis G, Barnard-Kelly K, Thorne K, Whitehead A, Cohen L, Dixon E, Patel M, Newland-Jones P, Green M, Partridge H, Luthra S, Ohri S, Salhiyyah K, Lord J, Niven J, Cook A. The Optimising Cardiac Surgery ouTcOmes in People with diabeteS (OCTOPuS) randomised controlled trial to evaluate an outpatient pre-cardiac surgery diabetes management intervention: a study protocol. BMJ Open 2021; 11:e050919. [PMID: 34108175 PMCID: PMC8191627 DOI: 10.1136/bmjopen-2021-050919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/25/2021] [Accepted: 04/15/2021] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Cardiothoracic surgical outcomes are poorer in people with diabetes compared with those without diabetes. There are two important uncertainties in the management of people with diabetes undergoing major surgery: (1) how to improve diabetes management in the weeks leading up to an elective procedure and (2) whether that improved management leads to better postoperative outcomes. We previously demonstrated the feasibility of delivering the Optimising Cardiac Surgery ouTcOmes in People with diabeteS (OCTOPuS) intervention, an outpatient intervention delivered by diabetes healthcare professionals for people with suboptimally managed diabetes over 8-12 weeks before elective cardiac surgery. The present study will assess the clinical and cost-effectiveness of the intervention in cardiothoracic centres across the UK. METHODS AND ANALYSIS A multicentre, parallel group, single-blinded 1:1 individually randomised trial comparing time from surgery until clinically fit for discharge in adults with suboptimally managed type 1 diabetes or type 2 diabetes undergoing elective surgery between the OCTOPuS intervention and usual care (primary endpoint). Secondary endpoints will include actual time from surgery to discharge from hospital; days alive and either out of hospital or judged as clinically fit for discharge; mortality; time on intensive therapy unit (ITU)/ventilator; infections; acute myocardial infarction; change in weight; effect on postoperative renal function and incidence of acute kidney injury; change in HbA1c; frequency and severity of self-reported hypoglycaemia; operations permanently cancelled for suboptimal glycaemic levels; cost-effectiveness; psychosocial questionnaires. The target sample size will be 426 recruited across approximately 15 sites. The primary analysis will be conducted on an intention-to-treat population. A two-sided p value of 0.05 or less will be used to declare statistical significance for all analyses and results will be presented with 95% CIs. ETHICS AND DISSEMINATION The trial was approved by the South Central-Hampshire A Research Ethics Committee (20/SC/0271). Results will be disseminated through conferences, scientific journals, newsletters, magazines and social media. TRIAL REGISTRATION NUMBER ISRCTN10170306.
Collapse
Affiliation(s)
- Richard Ian Gregory Holt
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
- Southampton National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Kerensa Thorne
- Clinical Trial Units, University of Southampton, Southampton, UK
| | - Amy Whitehead
- Clinical Trial Units, University of Southampton, Southampton, UK
| | - Lauren Cohen
- Barnard Health - Health Psychology Research, Fareham, UK
| | - Elizabeth Dixon
- Clinical Trial Units, University of Southampton, Southampton, UK
| | - Mayank Patel
- Department of Diabetes and Endocrinology, University Hospital Southampton, Southampton, Hampshire, UK
| | - Philip Newland-Jones
- Department of Diabetes and Endocrinology, University Hospital Southampton, Southampton, Hampshire, UK
| | - Mark Green
- Department of Diabetes and Endocrinology, University Hospital Southampton, Southampton, Hampshire, UK
| | - Helen Partridge
- Diabetes and Endocrinology, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Bournemouth, UK
| | - Suvitesh Luthra
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, Hampshire, UK
| | - Sunil Ohri
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, Hampshire, UK
| | | | - Joanne Lord
- Southampton Health Technology Assessments Centre, University of Southampton, Southampton, Hampshire, UK
| | | | - Andrew Cook
- Wessex Institute, University of Southampton, Southampton, Hampshire, UK
| |
Collapse
|
12
|
Sabo R, Robins J, Lutz S, Kashiri P, Day T, Webel B, Krist A. Diabetes Engagement and Activation Platform for Implementation and Effectiveness of Automated Virtual Type 2 Diabetes Self-Management Education: Randomized Controlled Trial. JMIR Diabetes 2021; 6:e26621. [PMID: 33779567 PMCID: PMC8088852 DOI: 10.2196/26621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/10/2021] [Accepted: 02/28/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with type 2 diabetes require recommendations for self-management education and support. OBJECTIVE In this study, we aim to design the Diabetes Engagement and Activation Platform (DEAP)-an automated patient education tool integrated into primary care workflow-and examine its implementation and effectiveness. METHODS We invited patients aged 18-85 years with a hemoglobin A1c (HbA1c) level ≥8 to participate in a randomized controlled trial comparing DEAP with usual care. DEAP modules addressing type 2 diabetes self-management education and support domains were programmed into patient portals, each with self-guided educational readings, videos, and questions. Care teams received patient summaries and were alerted to patients with low confidence or requesting additional help. HbA1c, BMI, and systolic and diastolic blood pressure (DBP) were measured. RESULTS Out of the 680 patients invited to participate, 337 (49.5%) agreed and were randomized. All of the 189 intervention patients accessed the first module, and 140 patients (74.1%) accessed all 9 modules. Postmodule knowledge and confidence scores were high. Only 18 patients requested additional help from the care team. BMI was lower for intervention patients than controls at 3 months (31.7 kg/m2 vs 32.1 kg/m2; P=.04) and 6 months (32.5 kg/m2 vs 33.0 kg/m2; P=.003); improvements were even greater for intervention patients completing at least one module. There were no differences in 3- or 6-month HbA1c or blood pressure levels in the intent-to-treat analysis. However, intervention patients completing at least one module compared with controls had a better HbA1c level (7.6% vs 8.2%; P=.03) and DBP (72.3 mm Hg vs 75.9 mm Hg; P=.01) at 3 months. CONCLUSIONS The findings of this study concluded that a significant proportion of patients will participate in an automated virtual diabetes self-management program embedded into patient portals and health systems show promise in helping patients manage their diabetes, weight, and blood pressure. TRIAL REGISTRATION ClinicalTrials.gov NCT02957721; https://clinicaltrials.gov/ct2/show/NCT02957721.
Collapse
Affiliation(s)
- Roy Sabo
- Virginia Commonwealth University, Richmond, VA, United States
| | - Jo Robins
- Virginia Commonwealth University, Richmond, VA, United States
| | - Stacy Lutz
- Privia Health, LLC, Arlington, VA, United States
| | | | - Teresa Day
- Virginia Commonwealth University, Richmond, VA, United States
| | - Benjamin Webel
- Virginia Commonwealth University, Richmond, VA, United States
| | - Alex Krist
- Virginia Commonwealth University, Richmond, VA, United States
| |
Collapse
|
13
|
Kim T, Xie Y, Li Q, Artegoitia VM, Lebrilla CB, Keim NL, Adams SH, Krishnan S. Diet affects glycosylation of serum proteins in women at risk for cardiometabolic disease. Eur J Nutr 2021; 60:3727-3741. [PMID: 33770218 PMCID: PMC8437848 DOI: 10.1007/s00394-021-02539-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/11/2021] [Indexed: 02/06/2023]
Abstract
Background Glycoproteomics deals with glycoproteins that are formed by post-translational modification when sugars (like fucose and sialic acid) are attached to protein. Glycosylation of proteins influences function, but whether glycosylation is altered by diet is unknown. Objective To evaluate the effect of consuming a diet based on the Dietary Guidelines for Americans on circulating glycoproteins that have previously been associated with cardiometabolic diseases. Design Forty-four women, with one or more metabolic syndrome characteristics, completed an 8-week randomized controlled feeding intervention (n = 22) consuming a diet based on the Dietary Guidelines for Americans (DGA 2010); the remaining consumed a ‘typical American diet’ (TAD, n = 22). Fasting serum samples were obtained at week0 (baseline) and week8 (post-intervention); 17 serum proteins were chosen for targeted analyses. Protein standards and serum samples were analyzed in a UHPLC-MS protocol to determine peptide concentration and their glycan (fucosylation or sialylation) profiles. Data at baseline were used in correlational analyses; change in proteins and glycans following intervention were used in non-parametric analyses. Results At baseline, women with more metabolic syndrome characteristics had more fucosylation (total di-fucosylated proteins: p = 0.045) compared to women with a lesser number of metabolic syndrome characteristics. Dietary refined grain intake was associated with increased total fucosylation (ρ = − 0.530, p < 0.001) and reduced total sialylation (ρ = 0.311, p = 0.042). After the 8-week intervention, there was higher sialylation following the DGA diet (Total di-sialylated protein p = 0.018, poly-sialylated orosomucoid p = 0.012) compared to the TAD diet. Conclusions Based on this study, glycosylation of proteins is likely affected by dietary patterns; higher sialylation was associated with a healthier diet pattern. Altered glycosylation is associated with several diseases, particularly cancer and type 2 diabetes, and this study raises the possibility that diet may influence disease state by altering glycosylation. Clinical trial registration NCT02298725 at clinicaltrials.gov; https://clinicaltrials.gov/ct2/show/NCT02298725. Supplementary Information The online version contains supplementary material available at 10.1007/s00394-021-02539-7.
Collapse
Affiliation(s)
- Tyler Kim
- Global Disease Biology, University of California Davis, Davis, USA
| | - Yixuan Xie
- Department of Chemistry, University of California Davis, Davis, USA
| | - Qiongyu Li
- Department of Chemistry, University of California Davis, Davis, USA
| | - Virginia M Artegoitia
- Obesity and Metabolism Research Unit, USDA-WHNRC, 430 W. Health Sciences Drive, Davis, CA, 95616, USA
| | | | - Nancy L Keim
- Obesity and Metabolism Research Unit, USDA-WHNRC, 430 W. Health Sciences Drive, Davis, CA, 95616, USA.,Department of Nutrition, University of California Davis, Davis, USA
| | - Sean H Adams
- Department of Surgery, University of California Davis School of Medicine, Sacramento, USA.,Center for Alimentary and Metabolic Science, University of California Davis School of Medicine, Sacramento, USA
| | - Sridevi Krishnan
- Obesity and Metabolism Research Unit, USDA-WHNRC, 430 W. Health Sciences Drive, Davis, CA, 95616, USA. .,Department of Nutrition, University of California Davis, Davis, USA.
| |
Collapse
|
14
|
Li PF, Chen WL. Are the Different Diabetes Subgroups Correlated With All-Cause, Cancer-Related, and Cardiovascular-Related Mortality? J Clin Endocrinol Metab 2020; 105:5902292. [PMID: 32893854 DOI: 10.1210/clinem/dgaa628] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
CONTEXT Numerous studies have shown that cardiovascular disease (CVD) represents the most important cause of mortality among people with diabetes mellitus (DM). However, no studies have evaluated the risk of CVD-related mortality among different DM subgroups. OBJECTIVE We aimed to examine all-cause, CVD-related, and cancer-related mortality for different DM subgroups. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS We included participants (age ≥ 20 years) from the National Health and Nutrition Examination Survey III (NHANES III) data set. We evaluated the risks of all-cause and cause-specific (CVD and cancer) mortality among 5 previously defined diabetes subgroups: severe autoimmune diabetes (SAID), severe insulin-deficient diabetes (SIDD), severe insulin-resistant diabetes (SIRD), mild obesity-related diabetes (MOD), and mild age-related diabetes (MARD). PRIMARY OUTCOME MEASURE The hazard ratios (HRs) for all-cause and cause-specific (CVD and cancer) mortality were measured for each of the 5 DM subgroups. We also evaluated the odds ratios (ORs) for retinopathy and nephropathy in each subgroup. RESULTS A total of 712 adults were enrolled and the median follow-up time was 12.71 years (range, 0.25-18.08 years). The number of deaths in the 5 subgroups (SAID, SIDD, SIRD, MOD, and MARD) were 50, 75, 64, 7, and 18, respectively, and the number of CVD-related deaths in the 5 subgroups was 29, 30, 26, 2, and 11, respectively. Compared to the MOD subgroup, the adjusted HRs and 95% CIs of CVD-related mortality for the SAID, SIDD, SIRD, and MARD subgroups were 3.23 (95% CI, 0.77-13.61), 2.87 (95% CI, 0.68-12.06), 2.23 (95% CI, 0.53-9.50), and 4.75 (95% CI, 1.05-21.59), respectively (the HR for the MARD subgroup had a P value of .04). In addition, compared to the MARD subgroup, the adjusted ORs and 95% CIs for retinopathy in the SAID and SIDD groups were 2.38 (95% CI, 1.13-5.01, P = .02) and 3.34 (95% CI, 1.17-6.88, P = .001), respectively. The ORs for nephropathy were nonsignificant. CONCLUSIONS Our study of patients from the NHANES III data set indicated that among the different DM subgroups, the MARD subgroup tended to have a higher CVD-related mortality than the MOD subgroup. The all-cause and cancer-related mortality rates were similar across the different diabetes subgroups. In addition, compared to the MARD subgroup, the SAID and SIDD subgroups had a higher retinopathy risk, but there was no difference in nephropathy among the subgroups.
Collapse
Affiliation(s)
- Peng-Fei Li
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical School, Taipei, Taiwan, Republic of China
- Graduate Institute of Applied Science and Engineering, Fu-Jen Catholic University, Taipei, Taiwan, Republic of China
| | - Wei-Liang Chen
- Division of Family Medicine, Department of Family and Community Medicine, Tri-Service General Hospital; and School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Division of Geriatric Medicine, Department of Family and Community Medicine, Tri-Service General Hospital; and School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
- Department of Biochemistry, National Defense Medical Center, Taipei, Taiwan, Republic of China
| |
Collapse
|
15
|
Romera I, Conget I, Vazquez LA, Gentilella R, Lebrec J, Jódar E, Reviriego J. Once-weekly dulaglutide versus insulin glargine in the early control of fasting serum glucose and HbA1c. J Diabetes Complications 2020; 34:107575. [PMID: 32220551 DOI: 10.1016/j.jdiacomp.2020.107575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/14/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
AIMS To determine the early benefit:risk balance of dulaglutide versus insulin glargine in patients with type 2 diabetes mellitus (T2DM). METHODS This post hoc analysis used data from a randomized, open-label study (AWARD-2; modified intention-to-treat group) in which suboptimally controlled metformin + glimepiride-treated patients received dulaglutide 1.5 mg (n = 273) or insulin glargine (n = 262). Two composite endpoints were used: for weeks 2-20, fasting serum glucose (FSG) <130 mg/dL (<7.2 mmol/L) without hypoglycemia (blood glucose ≤70 mg/dL [≤3.9 mmol/L] or severe hypoglycemia); at week 26, patients with glycated hemoglobin (HbA1c) <7.0% (<53.0 mmol/mol) or reduction from baseline ≥1.0% (≥10.9 mmol/mol), no hypoglycemia (as defined above) and no weight gain. Odds ratios (ORs) were generated using logistic regression analysis. RESULTS The probability of reaching the FSG target without hypoglycemia was higher with dulaglutide than with insulin glargine at weeks 4 (OR 1.78; 95% confidence interval [CI] 1.22-2.60) and 8 (OR 1.69; 95% CI 1.15-2.48). The proportion of patients achieving the 26-week endpoint was higher with dulaglutide (37.4% vs. 10.3%; OR 5.28; 95% CI 3.28-8.48). CONCLUSIONS Dulaglutide's balanced efficacy-to-safety profile compares favorably with that of insulin glargine and is apparent soon after treatment initiation and after 6 months of therapy.
Collapse
Affiliation(s)
- Irene Romera
- Eli Lilly and Company, Avenida de la Industria 30, 28108 Alcobendas, Madrid, Spain.
| | - Ignacio Conget
- Diabetes Unit, Endocrinology and Nutrition Department, Hospital Clínic i Universitari, Carrer de Villarroel 170, 08036 Barcelona, Spain.
| | - Luis Alberto Vazquez
- Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Av. de Valdecilla, s/n. 39008, Santander, Spain
| | | | - Jeremie Lebrec
- HaaPACS GmbH, Bahnhofstr. N°19 C, 69198 Schriesheim, Germany.
| | - Esteban Jódar
- Hospital Universitario Quirón Salud, Calle Diego de Velázquez, 1, 28223 Pozuelo de Alarcón, Universidad Europea de Madrid, Madrid, Spain
| | - Jesús Reviriego
- Eli Lilly and Company, Avenida de la Industria 30, 28108 Alcobendas, Madrid, Spain.
| |
Collapse
|
16
|
Reducing the probability of falsely elevated HbA1c results in diabetic patients by applying automated and educative HbA1c re-testing intervals. Clin Biochem 2020; 80:14-18. [PMID: 32229197 DOI: 10.1016/j.clinbiochem.2020.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/23/2020] [Accepted: 03/24/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Too frequent HbA1c measurements may lead to unnecessary treatment modifications of diabetic patients. The aim of this study was to estimate the percentage of falsely elevated HbA1c results in two hospitals, Landeskrankenhaus/Uniklinikum Salzburg (LKH) and Landesklinik St. Veit (STV), as well as to retrospectively investigate the effect of an automated and an educative 60-day re-testing interval (RTI). METHODS The amount of estimated falsely elevated results (eFER), based on odds calculated using the baseline and the follow-up values and the time between these measurements, the number of HbA1c re-testings within 60 days as well as the overall number of ordered and performed HbA1c analyses were calculated. In LKH, an automated algorithm cancelling inappropriate HbA1c testing was applied, and in STV, educational actions were taken. RESULTS Before RTI-implementation, eFER were 0.9% and 2.1% and within-60-days-re-testing were 15.0% and 7.4% of cases in LKH and STV, respectively. After RTI-implementation, these numbers decreased to 0.2% (p < .001) and 1.8% (p = .869) and within-60-days-re-testing decreased to 1.1% (p < .001) and 3.6% (p = .003) in LKH and STV, respectively. Median monthly HbA1c measurements decreased by 15.8% (p < .001) and 21.1% (p = .002) in LKH and STV, respectively. CONCLUSION Both the educational and the automated 60-day-RTI were proven to be efficient in reducing overall HbA1c measurements, re-testing within 60 days and eFER.
Collapse
|
17
|
Mohd Yusof BN, Wan Zukiman WZHH, Abu Zaid Z, Omar N, Mukhtar F, Yahya NF, Mohd Shahar AS, Hasbullah FY, Liu Xin Yi R, Marczewska A, Hamdy O. Comparison of Structured Nutrition Therapy for Ramadan with Standard Care in Type 2 Diabetes Patients. Nutrients 2020; 12:nu12030813. [PMID: 32204476 PMCID: PMC7146585 DOI: 10.3390/nu12030813] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/14/2020] [Accepted: 03/17/2020] [Indexed: 01/20/2023] Open
Abstract
(1) Background: Structured nutrition therapy (NT) is essential for the management of type 2 diabetes (T2D), but the optimal delivery during Ramadan fasting remains unclear. The present study aimed to evaluate the effect of structured NT program versus standard care in patients with T2D during Ramadan. (2) Methods: The present study was an 8-week, parallel, non-randomized study with patients’ preference design involving 64 patients with T2D. The participants were asked to choose their preferred group, i.e., structured NT (Structured Ramadan NT, sRNT) or standard care (SC). The participants in the sRNT group received a Ramadan-focused nutrition plan, including a diabetes-specific formula throughout the study, whereas the patients in the SC group received standard nutrition care. Study outcomes included clinical outcomes and quality of life (QoL). Data was analyzed using two-way repeated-measures ANOVA and linear mixed-effects model. (3) Results: More than half of the participants (n = 38, 63%) chose sRNT as their preferred group. Both groups had comparable baseline characteristics. After 8-weeks of the respective intervention, participants in the sRNT group had lower levels of fasting plasma glucose (−0.9 ± 0.3 mmol/L vs. 0.2 ± 0.3 mmol/L, p < 0.05), triglycerides (−0.21 ± 0.08 mmol/L vs. 0.20 ± 0.17 mmol/L, p < 0.05), and self-monitoring glucose at pre-dawn (6.9 mmol/L vs. 7.8 mmol/L, p < 0.05) and pre-bedtime (7.6 mmol/L vs. 8.6 mmol/L, p < 0.05) than participants in the SC group. Although not different between groups, HbA1c levels decreased significantly in the sRNT (−0.72 ± 0.16%, p < 0.001) but not in the SC group (−0.35 ± 0.24%, p = 0.155). QoL and satisfaction scores improved significantly in sRNT group, but not in SC group. (4) Conclusions: The structured NT regimen for Ramadan is a feasible and beneficial program for T2D patients observing Ramadan fasting as it showed an improvement in clinical outcomes and QoL.
Collapse
Affiliation(s)
- Barakatun-Nisak Mohd Yusof
- Department of Nutrition & Dietetics, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia; (Z.A.Z.); (N.O.); (N.F.Y.); (A.S.M.S.); (F.Y.H.)
- Institute for Social Science Studies, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia;
- Correspondence:
| | | | - Zalina Abu Zaid
- Department of Nutrition & Dietetics, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia; (Z.A.Z.); (N.O.); (N.F.Y.); (A.S.M.S.); (F.Y.H.)
| | - Noraida Omar
- Department of Nutrition & Dietetics, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia; (Z.A.Z.); (N.O.); (N.F.Y.); (A.S.M.S.); (F.Y.H.)
| | - Firdaus Mukhtar
- Institute for Social Science Studies, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia;
- Department of Psychiatry, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
| | - Nor Farahain Yahya
- Department of Nutrition & Dietetics, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia; (Z.A.Z.); (N.O.); (N.F.Y.); (A.S.M.S.); (F.Y.H.)
| | - Aainaa Syarfa Mohd Shahar
- Department of Nutrition & Dietetics, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia; (Z.A.Z.); (N.O.); (N.F.Y.); (A.S.M.S.); (F.Y.H.)
| | - Farah Yasmin Hasbullah
- Department of Nutrition & Dietetics, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia; (Z.A.Z.); (N.O.); (N.F.Y.); (A.S.M.S.); (F.Y.H.)
| | | | | | - Osama Hamdy
- Joslin Diabetes Centre, Harvard Medical School, MA 02215, USA;
| |
Collapse
|
18
|
Haslacher H, Fallmann H, Waldhäusl C, Hartmann E, Wagner OF, Waldhäusl W. Type 2 diabetes care: Improvement by standardization at a diabetes rehabilitation clinic. An observational report. PLoS One 2019; 14:e0226132. [PMID: 31830073 PMCID: PMC6907777 DOI: 10.1371/journal.pone.0226132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/21/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Outcome of type 2 diabetes care depends on the acceptance of self-responsibility by informed patients, as treatment goals will otherwise be missed. AIMS AND METHODS This pre/post-observational report describes the clinical outcome of type 2 diabetes care in patients with type 2 diabetes (N =930) admitted consecutively to a diabetes rehabilitation clinic (DRC) between June 2013, and June 2016, where they were exposed to standardized lifestyle modification with meals low in salt and rich in vegetables and fruits, totaling 1,200 to 1,600 kcal/d, and an add-on exercise load equivalent to 400-600 kcal/d. RESULTS At admission, patients presented with multiple treatment modes, elevated HbA1c levels (7.6±1.5%, 60±16 mmol/mol), a high prevalence of co-morbidities dominated by obesity (79%), a low rate of influenza and pneumococcal immunization (<9%) and underuse of lipid-lowering drugs (-29%). Analysis of clinical and metabolic outcome after 3 weeks shows that simple standardization of and better adherence to treatment recommendations improved (p<0.0001) glucose (HbA1c -0.4±0.4%) and lipid metabolism (LDL/HDL ratio, -0.58±0.03), permitting a 39% reduction in insulin dosage, omission of insulin in 36/232 patients and omission of oral antidiabetic drugs (OADs) other than metformin and DPP4-inhibitors, while the use of GLP-1 analogs doubled to 5.2%. Improved outcome was independent of treatment strategy and more marked at initially high HbA1c at costs less than 25% of those encountered at a standard hospital. CONCLUSIONS Our observations support the clinical notion that adherence to basic treatment recommendations is indispensable in type 2 diabetes care if metabolic and clinical treatment goals are to be met, and if inappropriate add-on over-medicalization with OADs and/or insulin is to be avoided. To this end, 'imprinting' patients at a DRC could be of considerable help.
Collapse
Affiliation(s)
- Helmuth Haslacher
- Department for Laboratory Medicine, Medical University of Vienna, Waehringer Guertel, Vienna, Austria
| | - Hannelore Fallmann
- Rehabilitation Clinic for Diabetes and Metabolic Diseases, Moorbad Neydharting, Neydharting, Neydharting, Austria
| | - Claudia Waldhäusl
- Department of Radiotherapy, Medical University of Vienna, Waehringer Guertel, Vienna, Vienna, Austria
| | - Edith Hartmann
- Rehabilitation Clinic for Diabetes and Metabolic Diseases, Moorbad Neydharting, Neydharting, Neydharting, Austria
| | - Oswald F. Wagner
- Department for Laboratory Medicine, Medical University of Vienna, Waehringer Guertel, Vienna, Austria
| | - Werner Waldhäusl
- Rehabilitation Clinic for Diabetes and Metabolic Diseases, Moorbad Neydharting, Neydharting, Neydharting, Austria
- Department of Medicine III, Medical University of Vienna, Waehringer Guertel, Vienna, Vienna, Austria
- * E-mail:
| |
Collapse
|
19
|
Shi J, Hu H, Harnett J, Zheng X, Liang Z, Wang YT, Ung COL. An evaluation of randomized controlled trials on nutraceuticals containing traditional Chinese medicines for diabetes management: a systematic review. Chin Med 2019; 14:54. [PMID: 31798675 PMCID: PMC6884840 DOI: 10.1186/s13020-019-0276-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/07/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Nutraceuticals containing traditional Chinese medicine (TCM) are promoted for use in the management of diabetes. The evidence to support such use is largely unknown. This study aimed to summarise and evaluate the literature reporting the results of randomized controlled trials (RCTs) investigating the effects of nutraceuticals in people living with diabetes. METHODS Literature from four electronic databases (PubMed, Scopus, CINAHL and Web of Science) was searched following PRISMA guidelines to yield RCT publications on nutraceutical for diabetes management published since 2009. The quality of reporting was assessed using the CONSORT 2010 checklist statement. Risk-of-bias for each study was assessed using the Cochrane risk of bias tool. RESULTS Out of 1978 records identified in the initial search, 24 randomized, double/triple-blinded, controlled trials that investigated the effect of nutraceuticals covering 17 different TCM herbs for diabetes management were selected. Participants included people who were diabetic (n = 16), pre-diabetic (n = 3) or predisposed to diabetes (n = 5). Sample sizes ranged between 23 and 117 for 2 arms, or 99-165 for 3 arms. Comparisons were made against placebo (n = 22), conventional medicine (n = 1), or regular diet (n = 1) for a duration between 4 and 24 weeks. All but one study tested the effect on fasting blood glucose levels (n = 23) or glycated haemoglobin levels (n = 18), and/or postprandial 2-h blood glucose levels (n = 4) as the primary outcomes. Nineteen studies reported some statistically significant reductions in the respective measures while 5 studies showed no effect on primary or secondary outcomes. None of the included studies met all the criteria for the CONSORT guidelines. Incomplete reporting about randomization and blinding, and a lack of ancillary analyses to explore other influential factors and potential harms associated with the use were repeatedly noted. Based on the Cochrane risk-of-bias tool, 19 studies were deemed to have a high risk of bias mainly attributed to sponsor bias. CONCLUSIONS There is some evidence to suggest positive clinical outcomes in response to the administration of a range of nutraceuticals containing TCM in the management of diabetes. However, these results must be interpreted with caution due to the overall low quality of the trials.
Collapse
Affiliation(s)
- Junnan Shi
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao
| | - Hao Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao
| | - Joanna Harnett
- The University of Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Xiaoting Zheng
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao
| | - Zuanji Liang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao
| | - Yi-Tao Wang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao
| | - Carolina Oi Lam Ung
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao
- The University of Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| |
Collapse
|
20
|
Haslacher H, Fallmann H, Waldhäusl C, Hartmann E, Wagner OF, Waldhäusl WK. Obesity: outcome of standardized life-style change in a rehabilitation clinic. An observational study. Diabetes Metab Syndr Obes 2019; 12:813-820. [PMID: 31213867 PMCID: PMC6549422 DOI: 10.2147/dmso.s197495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 04/10/2019] [Indexed: 12/29/2022] Open
Abstract
Purpose: To explore differences in baseline characteristics following three weeks of semi-standardized in-patient care between patients with obesity without and with type 2 diabetes (T2D). Patients and methods: Patients without or with T2D were matched according to age, sex, and BMI. Food intake was restricted to 1,200-1,600 kcal/d to which a 400-600 kcal/d exercise load was added, and data were compared using Student's t-test, general linear models, and Spearman-rank correlations. Results: At baseline, patients with obesity and T2D displayed, besides elevated blood glucose and HbA1c values, higher serum liver enzymes (p<0.001-0.05), triglycerides, and CRP (p<0.01) and a greater prevalence of treated hyperlipidemia (p<0.001) than those with plain obesity who showed only higher LDL and HDL cholesterol levels (+9.0% and +16.0%). In response to three-weeks of standardized life-style change, both groups improved their vital variables and risk scores (p<0.001). While improvement in cholesterol slightly favored patients with plain obesity, the need for anti-hyperlipidemics (+25%) rose in both groups, albeit that for anti-hypertensives (+50%) increased only in patients with obesity and add-on T2D. Conclusion: Moderate changes in lifestyle improve the clinical condition, including coronary heart disease and premature mortality risk scores (HARD-CHD and ABSI) in patients with obesity both in the absence and presence of T2D, with the latter seemingly increasing the risk of hepatic steatosis and systemic inflammation.
Collapse
Affiliation(s)
- Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Hannelore Fallmann
- Rehabilitation Clinic for Diabetes and Metabolic Diseases, Moorbad Neydhartig, Neydharting, Upper Austria, Austria
| | - Claudia Waldhäusl
- Department of Radiotherapy, Medical University of Vienna, Vienna, Austria
| | - Edith Hartmann
- Rehabilitation Clinic for Diabetes and Metabolic Diseases, Moorbad Neydhartig, Neydharting, Upper Austria, Austria
| | - Oswald F Wagner
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Werner K Waldhäusl
- Rehabilitation Clinic for Diabetes and Metabolic Diseases, Moorbad Neydhartig, Neydharting, Upper Austria, Austria
- Department of Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
21
|
Effects of curcumin on glycemic control and lipid profile in prediabetes and type 2 diabetes mellitus: A systematic review and meta-analysis. PLoS One 2019; 14:e0215840. [PMID: 31013312 PMCID: PMC6478379 DOI: 10.1371/journal.pone.0215840] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 04/06/2019] [Indexed: 12/19/2022] Open
Abstract
Scope Studies have demonstrated inconsistent effects of curcumin on glycemic outcomes and lipid parameters in patients with prediabetes and type 2 diabetes mellitus (T2DM). This study aimed to assess the effect of curcumin on glycemic control and lipid profile in prediabetes and T2DM. Methods and results A systematic search of randomized controlled trials (RCTs) was conducted from inception to June 2018 in electronic sources including AMED, ANZCTR, BioMed Central, CENTRAL, CINAHL, ClinicalTrials.gov, Expanded Academic Index, Google Scholar, ISRCTN, LILACS, MEDLINE, NCCIH, Science Direct, Scopus, Web of Science, and WHO ICTRP. Hand search was also performed. Of the total 486 records, four trials (N = 508) and eight trials (N = 646) were eligible for the meta-analysis of individuals with prediabetes and T2DM, respectively. Curcumin significantly reduced glycosylated hemoglobin (HbA1c) in prediabetics (MD: -0.9%, 95% CI: -1.7 to -0.1%, p = 0.03). Furthermore, T2DM subjects gained favorable reduction in both HbA1c (MD: -0.5%, 95% CI: -1.0 to -0.0%, p = 0.04) and fasting plasma glucose (MD: -11.7 mg/dL, 95% CI: -22.1 to -1.3 mg/dL, p = 0.03). Tendency of lipid profile improvement was also observed. Conclusion Our findings may encourage curcumin supplementation based on its meaningful effect on glycemic control and positive trend on lipid outcomes in prediabetes and T2DM.
Collapse
|
22
|
Hirst JA, Farmer AJ, Smith MC, Stevens RJ. Timings for HbA 1c testing in people with diabetes are associated with incentive payments: an analysis of UK primary care data. Diabet Med 2019; 36:36-43. [PMID: 30175871 PMCID: PMC6519368 DOI: 10.1111/dme.13810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 11/29/2022]
Abstract
AIMS Guidelines recommend testing HbA1c every 3-6 months in people with diabetes. In the United Kingdom (UK), primary care clinics are financially incentivized to monitor HbA1c at least annually and report proportions of patients meeting targets on 31 March. We explored the hypothesis that this reporting deadline may be associated with over-frequent or delayed HbA1c testing. METHODS This analysis used HbA1c results from 100 000 people with diabetes during 2005-2014 in the Clinical Practice Research Datalink UK primary care database. Logistic regression was used to explore whether the four months prior to the deadline for quality reporting (December to March) or individual's previous HbA1c were aligned with retesting HbA1c within 60 days or > 1 year from the previous test, and identify other factors associated with the timing of HbA1c testing. RESULTS Retesting HbA1c within 60 days or > 1 year was more common in December to March compared with other months of the year (odds ratio 1.06, 95% confidence interval 1.04-1.08 for retesting within 60 days). Those with higher HbA1c were more likely to have a repeat test within 60 days and less likely to have a repeat test > 1 year from the previous test. CONCLUSIONS We have found that retesting HbA1c within 60 days and > 1 year from the previous test was more common in December to March compared with the other months of the year. This work suggests that both practice-centred administrative factors and patient-centred considerations may be influencing diabetes care in the UK.
Collapse
Affiliation(s)
- J. A. Hirst
- Nuffield Department of Primary Care Health ScienceUniversity of OxfordOxfordUK
| | - A. J. Farmer
- Nuffield Department of Primary Care Health ScienceUniversity of OxfordOxfordUK
| | - M. C. Smith
- Nuffield Department of Primary Care Health ScienceUniversity of OxfordOxfordUK
| | - R. J. Stevens
- Nuffield Department of Primary Care Health ScienceUniversity of OxfordOxfordUK
| |
Collapse
|
23
|
Haslacher H, Fallmann H, Waldhäusl C, Hartmann E, Wagner OF, Waldhäusl W. Type 1 diabetes care: Improvement by standardization in a diabetes rehabilitation clinic. An observational report. PLoS One 2018; 13:e0194135. [PMID: 29529063 PMCID: PMC5847233 DOI: 10.1371/journal.pone.0194135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 02/11/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND T1D treatment requires informed self-responsible patients, who, however, frequently miss their therapeutic goals, providing considerable potential for improvement. METHODS This observational report evaluates T1D patients [N = 109], aged ≥18 years (range 22-82), poorly controlled at home, at and 3 weeks after their admission to our diabetes rehabilitation clinic [DRC], where they were offered standardized, but unmonitored life-style modification. RESULTS At admission, patients displayed elevated HbA1c values (66 mmol/mol [57; 81]), a high prevalence of co-morbidities (88%), lipodystrophies due to monolocal insulin injections (42%), a low rate of influenza (16%) and pneumococcal (7%) immunization, and underuse of lipid-lowering drugs (-38%). Standardization of life-style improved glucose (p<0.0001) and lipid metabolism (LDL/HDL ratio p<0.01) permitting reduction of insulin dose and reduction of add-on glucose-lowering drugs (GLDs) other than metformin. Outcome was independent of the mode of insulin treatment strategy and more marked at initially high HbA1c, with DRC-costs/d less than 25% of those encountered at standard hospitals. CONCLUSION Type 1 diabetes care requires i) insulin treatment, food intake and life style to be handled in concert, ii) this need cannot be replaced by arbitrary addition of add-on GLDs, and iii) training to this end is 75% cheaper at a DRC than in standard hospitals.
Collapse
Affiliation(s)
- Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Waehringer Guertel 18–20, Vienna, Austria
| | - Hannelore Fallmann
- Rehabilitation Clinic for Diabetes and Metabolic Diseases, Moorbad Neydharting, Neydharting 4, Bad Wimsbach-Neydharting, Austria
| | - Claudia Waldhäusl
- Department of Radiotherapy, Medical University of Vienna, Waehringer Guertel 18–20, Vienna, Austria
| | - Edith Hartmann
- Rehabilitation Clinic for Diabetes and Metabolic Diseases, Moorbad Neydharting, Neydharting 4, Bad Wimsbach-Neydharting, Austria
| | - Oswald F. Wagner
- Department of Laboratory Medicine, Medical University of Vienna, Waehringer Guertel 18–20, Vienna, Austria
| | - Werner Waldhäusl
- Rehabilitation Clinic for Diabetes and Metabolic Diseases, Moorbad Neydharting, Neydharting 4, Bad Wimsbach-Neydharting, Austria
- Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18–20, Vienna, Austria
| |
Collapse
|
24
|
Hirst JA, Aronson JK, Feakins BG, Ma C, Farmer AJ, Stevens RJ. Short- and medium-term effects of light to moderate alcohol intake on glycaemic control in diabetes mellitus: a systematic review and meta-analysis of randomized trials. Diabet Med 2017; 34:604-611. [PMID: 27588354 DOI: 10.1111/dme.13259] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND People with diabetes are told that drinking alcohol may increase their risk of hypoglycaemia. AIMS To report the effects of alcohol consumption on glycaemic control in people with diabetes mellitus. METHODS Medline, EMBASE and the Cochrane Library databases were searched in 2015 to identify randomized trials that compared alcohol consumption with no alcohol use, reporting glycaemic control in people with diabetes. Data on blood glucose, HbA1c and numbers of hypoglycaemic episodes were pooled using random effects meta-analysis. RESULTS Pooled data from nine short-term studies showed no difference in blood glucose concentrations between those who drank alcohol in doses of 16-80 g (median 20 g, 2.5 units) compared with those who did not drink alcohol at 0.5, 2, 4 and 24 h after alcohol consumption. Pooled data from five medium-term studies showed that there was no difference in blood glucose or HbA1c concentrations at the end of the study between those who drank 11-18 g alcohol/day (median 13 g/day, 1.5 units/day) for 4-104 weeks and those who did not. We found no evidence of a difference in number of hypoglycaemic episodes or in withdrawal rates between randomized groups. CONCLUSIONS Studies to date have not provided evidence that drinking light to moderate amounts of alcohol, with or without a meal, affects any measure of glycaemic control in people with Type 2 diabetes. These results suggest that current advice that people with diabetes do not need to refrain from drinking moderate quantities of alcohol does not need to be changed; risks to those with Type 1 diabetes remain uncertain.
Collapse
Affiliation(s)
- J A Hirst
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - J K Aronson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - B G Feakins
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research, School for Primary Care Research, University of Oxford, Oxford, UK
| | - C Ma
- Department of Biomedical Sciences, University of Oxford, Oxford, UK
| | - A J Farmer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - R J Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
25
|
Dagliati A, Malovini A, Decata P, Cogni G, Teliti M, Sacchi L, Cerra C, Chiovato L, Bellazzi R. Hierarchical Bayesian Logistic Regression to forecast metabolic control in type 2 DM patients. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2017; 2016:470-479. [PMID: 28269842 PMCID: PMC5333278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In this work we present our efforts in building a model able to forecast patients' changes in clinical conditions when repeated measurements are available. In this case the available risk calculators are typically not applicable. We propose a Hierarchical Bayesian Logistic Regression model, which allows taking into account individual and population variability in model parameters estimate. The model is used to predict metabolic control and its variation in type 2 diabetes mellitus. In particular we have analyzed a population of more than 1000 Italian type 2 diabetic patients, collected within the European project Mosaic. The results obtained in terms of Matthews Correlation Coefficient are significantly better than the ones gathered with standard logistic regression model, based on data pooling.
Collapse
Affiliation(s)
| | | | | | - Giulia Cogni
- IRCCS Fondazione S. Maugeri, Pavia, Italy; University of Pavia, Pavia, Italy
| | | | | | | | - Luca Chiovato
- IRCCS Fondazione S. Maugeri, Pavia, Italy; University of Pavia, Pavia, Italy
| | - Riccardo Bellazzi
- University of Pavia, Pavia, Italy; IRCCS Fondazione S. Maugeri, Pavia, Italy
| |
Collapse
|
26
|
Jablonska E, Reszka E, Gromadzinska J, Wieczorek E, Krol MB, Raimondi S, Socha K, Borawska MH, Wasowicz W. The Effect of Selenium Supplementation on Glucose Homeostasis and the Expression of Genes Related to Glucose Metabolism. Nutrients 2016; 8:nu8120772. [PMID: 27983572 PMCID: PMC5188427 DOI: 10.3390/nu8120772] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 11/15/2016] [Accepted: 11/24/2016] [Indexed: 12/17/2022] Open
Abstract
The aim of the study was to evaluate the effect of selenium supplementation on the expression of genes associated with glucose metabolism in humans, in order to explain the unclear relationship between selenium and the risk of diabetes. For gene expression analysis we used archival samples of cDNA from 76 non-diabetic subjects supplemented with selenium in the previous study. The supplementation period was six weeks and the daily dose of selenium was 200 µg (as selenium yeast). Blood for mRNA isolation was collected at four time points: before supplementation, after two and four weeks of supplementation, and after four weeks of washout. The analysis included 15 genes encoding selected proteins involved in insulin signaling and glucose metabolism. In addition, HbA1c and fasting plasma glucose were measured at three and four time points, respectively. Selenium supplementation was associated with a significantly decreased level of HbA1c but not fasting plasma glucose (FPG) and significant down-regulation of seven genes: INSR, ADIPOR1, LDHA, PDHA, PDHB, MYC, and HIF1AN. These results suggest that selenium may affect glycemic control at different levels of regulation, linked to insulin signaling, glycolysis, and pyruvate metabolism. Further research is needed to investigate mechanisms of such transcriptional regulation and its potential implication in direct metabolic effects.
Collapse
Affiliation(s)
- Ewa Jablonska
- Nofer Institute of Occupational Medicine, Department of Toxicology and Carcinogenesis, Sw. Teresy 8 Street, 91-348 Lodz, Poland.
| | - Edyta Reszka
- Nofer Institute of Occupational Medicine, Department of Toxicology and Carcinogenesis, Sw. Teresy 8 Street, 91-348 Lodz, Poland.
| | - Jolanta Gromadzinska
- Nofer Institute of Occupational Medicine, Department of Biological and Environmental Monitoring, Sw. Teresy 8 Street, 91-348 Lodz, Poland.
| | - Edyta Wieczorek
- Nofer Institute of Occupational Medicine, Department of Toxicology and Carcinogenesis, Sw. Teresy 8 Street, 91-348 Lodz, Poland.
| | - Magdalena B Krol
- Nofer Institute of Occupational Medicine, Department of Biological and Environmental Monitoring, Sw. Teresy 8 Street, 91-348 Lodz, Poland.
| | - Sara Raimondi
- European Institute of Oncology, Division of Epidemiology and Biostatistics, via Ripamonti 435, Milan 20139, Italy.
| | - Katarzyna Socha
- The Medical University of Bialystok, Department of Bromatoloy, A. Mickiewicza 2D Street, 15-222 Bialystok, Poland.
| | - Maria H Borawska
- The Medical University of Bialystok, Department of Bromatoloy, A. Mickiewicza 2D Street, 15-222 Bialystok, Poland.
| | - Wojciech Wasowicz
- Nofer Institute of Occupational Medicine, Department of Biological and Environmental Monitoring, Sw. Teresy 8 Street, 91-348 Lodz, Poland.
| |
Collapse
|
27
|
Hirst JA, Farmer AJ, Feakins BG, Aronson JK, Stevens RJ. Quantifying the effects of diuretics and β-adrenoceptor blockers on glycaemic control in diabetes mellitus - a systematic review and meta-analysis. Br J Clin Pharmacol 2016; 79:733-43. [PMID: 25377481 DOI: 10.1111/bcp.12543] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/31/2014] [Indexed: 11/29/2022] Open
Abstract
AIMS Although there are reports that β-adrenoceptor antagonists (beta-blockers) and diuretics can affect glycaemic control in people with diabetes mellitus, there is no clear information on how blood glucose concentrations may change and by how much. We report results from a systematic review to quantify the effects of these antihypertensive drugs on glycaemic control in adults with established diabetes. METHODS We systematically reviewed the literature to identify randomized controlled trials in which glycaemic control was studied in adults with diabetes taking either beta-blockers or diuretics. We combined data on HbA1c and fasting blood glucose using fixed effects meta-analysis. RESULTS From 3864 papers retrieved, we found 10 studies of beta-blockers and 12 studies of diuretics to include in the meta-analysis. One study included both comparisons, totalling 21 included reports. Beta-blockers increased fasting blood glucose concentrations by 0.64 mmol l(-1) (95% CI 0.24, 1.03) and diuretics by 0.77 mmol l(-1) (95% CI 0.14, 1.39) compared with placebo. Effect sizes were largest in trials of non-selective beta-blockers (1.33, 95% CI 0.72, 1.95) and thiazide diuretics (1.69, 95% CI 0.60, 2.69). Beta-blockers increased HbA1c concentrations by 0.75% (95% CI 0.30, 1.20) and diuretics by 0.24% (95% CI -0.17, 0.65) compared with placebo. There was no significant difference in the number of hypoglycaemic events between beta-blockers and placebo in three trials. CONCLUSIONS Randomized trials suggest that thiazide diuretics and non-selective beta-blockers increase fasting blood glucose and HbA1c concentrations in patients with diabetes by moderate amounts. These data will inform prescribing and monitoring of beta-blockers and diuretics in patients with diabetes.
Collapse
Affiliation(s)
- Jennifer A Hirst
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom; National Institute for Health Research School for Primary Care Research, Oxford, United Kingdom
| | | | | | | | | |
Collapse
|
28
|
Magee MF, Nassar CM, Mete M, White K, Youssef GA, Dubin JS. THE SYNERGY TO ENABLE GLYCEMIC CONTROL FOLLOWING EMERGENCY DEPARTMENT DISCHARGE PROGRAM FOR ADULTS WITH TYPE 2 DIABETES: STEP-DIABETES. Endocr Pract 2015. [PMID: 26214111 DOI: 10.4158/ep15655.or] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate a diabetes (DM) care delivery model among hyperglycemic adults with type 2 DM being discharged from the emergency department (ED) to home. The primary hypothesis was that a focused education and medication management intervention would lead to a greater short-term improvement in glycemic control compared to controls. METHODS A 4-week, randomized controlled trial provided antihyperglycemic medications management using an evidence-based algorithm plus survival skills diabetes self-management education (DSME) for ED patients with blood glucose (BG) levels ≥200 mg/dL. The intervention was delivered by endocrinologist-supervised certified diabetes educators. Controls received usual ED care. RESULTS Among 101 participants (96% Black, 54% female, 62.3% Medicaid and/or Medicare insurance), 77% completed the week 4 visit. Glycated hemoglobin A1C (A1C) went from 11.8 ± 2.4 to 10.5 ± 1.9% (P<.001) and 11.5 ± 2.0 to 11.1 ± 2.1% in the intervention and control groups, respectively (P = .012). At 4 weeks, the difference in A1C reduction between groups was 0.9% (P = .01). Mean BG decreased for both groups (P<.001), with a higher percentage of intervention patients (65%) reaching a BG <180 mg/dL compared to 29% of controls (P = .002). Hypoglycemia rates did not differ by group, and no severe hypoglycemia was reported. Medication adherence (Modified Morisky Score(©)) improved from low to medium (P<.001) among intervention patients and did not improve among controls. CONCLUSIONS This study provides evidence that a focused diabetes care delivery intervention can be initiated in the ED among adults with type 2 diabetes and hyperglycemia and safely and effectively completed in the ambulatory setting. Improvement in short-term glycemic outcomes and medication adherence were observed.
Collapse
|
29
|
Two new species of the genus Mecyclothorax Sharp from New Guinea (Coleoptera: Carabidae: Psydrinae). TIJDSCHRIFT VOOR ENTOMOLOGIE 2008; 19:ijerph19158979. [PMID: 35897349 PMCID: PMC9332044 DOI: 10.3390/ijerph19158979] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/15/2022] [Accepted: 07/20/2022] [Indexed: 11/17/2022]
Abstract
Chronic diseases typically require long-term management through healthy lifestyle practices and pharmacological intervention. Although efficacious treatments exist, disease control is often sub-optimal leading to chronic disease-related sequela. Poor disease control can partially be explained by the ‘one size fits all’ pharmacological approach. Precision medicine aims to tailor treatments to the individual. CURATE.AI is a dosing optimisation platform that considers individual factors to improve the precision of drug therapies. CURATE.AI has been validated in other therapeutic areas, such as cancer, but has yet to be applied in chronic disease care. We will evaluate the CURATE.AI system through a single-arm feasibility study (n = 20 hypertensives and n = 20 type II diabetics). Dosing decisions will be based on CURATE.AI recommendations. We will prospectively collect clinical and qualitative data and report on the clinical effect, implementation challenges, and acceptability of using CURATE.AI. In addition, we will explore how to enhance the algorithm further using retrospective patient data. For example, the inclusion of other variables, the simultaneous optimisation of multiple drugs, and the incorporation of other artificial intelligence algorithms. Overall, this project aims to understand the feasibility of using CURATE.AI in clinical practice. Barriers and enablers to CURATE.AI will be identified to inform the system’s future development.
Collapse
|