Burden of Illness in Type 2 Diabetes Mellitus

Type 2 diabetes mellitus: A cross-sectional analysis of glycemic controls and brain health outcomes

In this cross-sectional analysis, we explored how fluctuations in glycemic levels impact executive functions and psychosocial outcomes in patients with type 2 diabetes mellitus (T2DM). The goal was to understand the relationship between glycemic control and both neuropsychological and psychosocial health. We stratified participants into well-controlled and poorly controlled groups based on glycated hemoglobin (HbA1c) levels and variability, including a healthy control group for comparison. The study consisted of neuropsychological tests and psychosocial assessments. Results indicated that the poorly controlled T2DM group experienced significant executive dysfunction and scored lower on the Tower of London, Wisconsin Card Sorting, and Digit Span Tests, reflecting a broader impact on quality of life and resilience. These findings support the importance of maintaining stable glycemic levels for better executive and psychosocial outcomes and highlight the need for regular neuropsychological and psychosocial assessments in diabetes care.

A patient choice-driven lifestyle intervention lowers HbA1c in type 2 diabetes: A feasibility study

Type 2 diabetes (T2D) is a common metabolic disorder in which only 25% of patients meet management targets. While the primary care setting is positioned to provide lifestyle management education, studies are lacking which integrate behavior interventions in this setting utilizing clinic staff. Thus, we evaluated a 90-day lifestyle intervention for management of glycemia at a family practice clinic administered by clinic medical assistants. Twenty patients with non-insulin-dependent T2D completed a 90-day intervention driven by patient choices of nutrition and physical activity. Medical assistants were trained by members of the study team and administered the intervention under nurse practitioner supervision. HbA1c trended toward significant reduction 8.59 ± 0.9% to 8.15 ± 1.2% (p = 0.051, 95% CI: -0.88 to 0.003). Modest reductions were observed for waist circumference (115.5 ± 12.6 vs. 112.5 ± 15.2 cm; p = 0.014, 95% CI: -5.66 to -0.26), body weight (97.7 ± 21.9 vs. 95.6 ± 23.9 kg; p = 0.016. 95% CI: -3.84 to -0.31), and BMI (33.7 ± 7.2 vs. 32.8 ± 7.5 kg/m2; p = 0.028, 95% CI: -1.29 to -0.12). This 90-day, patient choice-intervention was successful at lowering HbA1c in patients with T2D. Our study is limited by a lack of control group, and results should be interpreted as such. These data have implications for team-based care models in clinic settings to improve health outcomes in patients with T2D.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2025

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

Is avoidable diabetes-related hospitalization in older patients with type 2 diabetes mellitus associated with increased health expenditure?: A nationwide retrospective cohort study in South Korea

Objective

With South Korea's population aging rapidly, the number of patients with type 2 diabetes mellitus (T2DM) is expected to rise, leading to worsened health outcomes and potentially straining healthcare financing. This study aimed to investigate how avoidable diabetes-related hospitalizations affect short- and long-term health expenditures.

Methods

Data from the National Health Insurance Service-Senior cohort from 2008 to 2019 in South Korea. A total of 27,081 participants aged 60 years and older who were diagnosed with T2DM were included in the study. The independent variable in this study was avoidable diabetes-related hospitalization according to the ICD-10 criteria "E11". The outcome measures included one- and five-year health expenditures. Regression analysis was performed using the generalized estimating equation (GEE) with a gamma distribution and log-link function. Inverse Probability of Treatment Weighting (IPTW) analysis was conducted to enhance the robustness of the results.

Results

Out of the 27,081 participants, 685 patients (2.5 %) experienced avoidable diabetes-related hospitalizations. GEE analysis with IPTW weights revealed that participants who experienced avoidable hospitalizations had a higher risk of increased health expenditures (one-year: relative risk (RR) 1.83, 95 % CI 1.76-1.91; five-year: RR 1.63, 95 % CI 1.57-1.69). Consistent patterns were observed even without weighting (one-year: RR 1.85, 95 % CI 1.68-2.04; five-year: RR 1.60, 95 % CI 1.47-1.74).

Conclusions

Our findings highlight the importance of continuous health management to prevent avoidable hospitalization, thereby promoting health and ensuring the financial stability of older patients with T2DM within the healthcare insurance system.

Melatonin attenuates responses to angiotensin II in isolated aortic rings of STZ-induced type 1-like DM rats

BACKGROUND

In patients with diabetes mellitus (DM), vascular endothelial dysfunction (VED) is the main reason for impaired life expectancy. Melatonin (MEL) demonstrates wide-ranging effects across various organs and exhibits pleiotropic characteristics. The current study aims to investigate the modulatory roles of MEL vascular response to angiotensin II (Ang II) and its receptors including angiotensin type 1 receptor (AT-1 R) and angiotensin type 2 receptor (AT-2 R) in isolated thoracic aorta of non-diabetes (non-DM) and diabetes (DM) rats.

METHODS

The thoracic aortae were isolated in order to investigate the influence of MEL on AT-1 R, using valsartan (VAL) and MT-2Rusing luzindole (LUZ) via dose-response curve (DRC) measurement of Ang II reactivity. In addition, AT-1 R was involved in this study, under PD123319 with ADInstrument organ bath (Panlab apparatus, Harvard University, USA).

RESULTS

The maximum response of Ang II was increased significantly in DM condition. In addition, AT-1 R was completely blocked under VAL, while AT-2 R was upregulated in the DM group. The combination of VAL and PD123319 led to abolishing the Ang II effect dramatically as well. Melatonin alone reduced Ang II in the DM group dramatically. This effect was also observed with MEL, PD1213319, and VAL combination, as well as, with MEL, LUZ, and PD1213319 combination.

CONCLUSIONS

Melatonin has been demonstrated to modulate both AT-1 R and AT-2 R and has influenced the reactivity of Ang II in the aortas of diabetic rats through highly complex mechanisms.

Evidence of traditional Chinese medicine for treating type 2 diabetes mellitus: from molecular mechanisms to clinical efficacy

CONTEXT

The global prevalence of type 2 diabetes mellitus (T2DM) has increased significantly in recent decades. Despite numerous studies and systematic reviews, there is a gap in comprehensive and up-to-date evaluations in this rapidly evolving field.

OBJECTIVE

This review provides a comprehensive and current overview of the efficacy of Traditional Chinese Medicine (TCM) in treating T2DM.

METHODS

A systematic review was conducted using PubMed, Web of Science, Wanfang Data, CNKI, and Medline databases, with a search timeframe extending up to November 2023. The search strategy involved a combination of subject terms and free words in English, including 'Diabetes,' 'Traditional Chinese Medicine,' 'TCM,' 'Hypoglycemic Effect,' 'Clinical Trial,' and 'Randomized Controlled Trial.' The studies were rigorously screened by two investigators, with a third investigator reviewing and approving the final selection based on inclusion and exclusion criteria.

RESULTS

A total of 108 relevant papers were systematically reviewed. The findings suggest that TCMs not only demonstrate clinical efficacy comparable to existing Western medications in managing hypoglycemia but also offer fewer adverse effects and a multitarget therapeutic approach. Five main biological mechanisms through which TCM treats diabetes were identified: improving glucose transport and utilization, improving glycogen metabolism, promoting GLP-1 release, protecting pancreatic islets from damage, and improving intestinal flora.

CONCLUSIONS

TCM has demonstrated significant protective effects against diabetes and presents a viable option for the prevention and treatment of T2DM. These findings support the further exploration and integration of TCM into broader diabetes management strategies.

Dynamics trajectory of patient-reported quality of life and its associated risk factors among hepatocellular carcinoma patients receiving immune checkpoint inhibitors: a prospective cohort study

Objective

We aimed to characterize quality of life (QOL) trajectories among patients with intermediate and advanced hepatocellular carcinoma patients treated with immunotherapy.

Methods

Barcelona Clinic Liver Cancer (BCLC) stage B-C HCC patients receiving immunotherapy at Guangxi Medical University Cancer Hospital were included. Trajectories of QOL, assessed using the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) questionnaire, were identified through iterative estimations of group-based trajectory models. Associations with trajectory group membership were analyzed using multivariable multinomial logistic regression.

Results

Three trajectory groups were identified (n=156): excellent (35.3%), poor (43.6%), and deteriorating (21.1%) QOL. The deteriorating trajectory group reported a mean QOL score of 124.79 (95% CI, 116.58-133.00), but then declined significantly at month-2 (estimated QOL score 98.67 [95% CI, 84.33-113.00]), and the lowest mean score is reached at month-6 (estimated QOL score 16.58 [95% CI, 0-46.07]). Factors associated with membership to the deteriorating group included no drinking (odds ratio [OR] vs yes [95% CI], 3.70 [1.28-11.11]), no received radiotherapy (OR vs yes [95% CI], 8.33 [1.41-50.00]), diabetes (OR vs no [95% CI], 6.83 [1.57-29.73]), and extrahepatic metastasis (OR vs no [95% CI], 3.08 [1.07-8.87]). Factors associated with membership to the poor group also included body mass index ≤24.0 kg/m2 (OR vs no [95% CI], 4.49 [1.65-12.22]).

Conclusions

This latent-class analysis identified a high-risk cluster of patients with severe, persistent post-immunotherapy QOL deterioration. Screening relevant patient-level characteristics may inform tailored interventions to mitigate the detrimental impact of immunotherapy and preserve QOL.

The Burden of Food Insecurity on Quality of Life in Adults with Diabetes

Background: This study aimed to investigate the relationship between food insecurity and physical- and mental-health-related quality of life in adults with diabetes. Methods: Using two years of national Medical Expenditure Panel Survey data (2016-2017), we investigated the relationship between food insecurity and physical-health-related (PCS) and mental-health-related (MCS) quality of life in adults with diabetes. PCS and MCS were measured with the Short-Form 12 health survey and food insecurity was measured with the USDA 10-item adult scale. Analyses were weighted to represent the US adult population. Adjusted linear regression models, including covariates of age, gender, education, race/ethnicity, marital status, region, poverty level, employment status, health insurance, and comorbidities were used. Results: After adjustment, food-insecure adults with diabetes maintained significantly lower quality of life compared to food-secure adults with diabetes (PCS: -3.44, 95%CI -4.63, -2.25; MCS: -5.37, 95%CI -6.68, -4.06). This drop in PCS was larger than the drop for chronic conditions, including arthritis (-3.77, 95%CI -5.02, -2.52), emphysema (-2.82, 95%CI -5.12, -0.53), stroke (-2.63, 95%CI -4.11, -1.15), cancer (-2.59, 95%CI -4.00, -1.17), and heart attack (2.58, 95%CI 4.68, 0.48). Similarly, the drop for MCS was larger than for chronic pain (-2.37, 95%CI -3.24, -1.50) and arthritis (-1.31, 95%CI -2.28, -0.33). Conclusions: Food insecurity was associated with a significant reduction in both physical- and mental-health-related quality of life in adults with diabetes, with a magnitude of effect greater than adjusted estimates for the drop in quality of life for key chronic conditions. Addressing food insecurity through integration of social and medical care may lead to improvements in quality of life for adults with diabetes.

Cost-utility analysis of a flash continuous glucose monitoring system in the management of people with type 2 diabetes mellitus on basal insulin therapy-An Italian healthcare system perspective

AIMS

To assess the cost-utility of the FreeStyle Libre flash continuous glucose monitoring (CGM) system from an Italian healthcare system perspective, when compared with self-monitoring of blood glucose (SMBG) in people living with type 2 diabetes mellitus (T2DM) receiving basal insulin.

MATERIALS AND METHODS

A patient-level microsimulation model was run using Microsoft Excel for 10 000 patients over a lifetime horizon, with 3.0% discounting for costs and utilities. Inputs were based on clinical trials and real-world evidence, with patient characteristics reflecting Italian population data. The effect of flash CGM was modelled as a persistent 0.8% reduction in glycated haemoglobin versus SMBG. Costs (€ 2023) and disutilities were applied to glucose monitoring, diabetes complications, severe hypoglycaemia, and diabetic ketoacidosis. The health outcome was measured as quality-adjusted life-years (QALYs).

RESULTS

Direct costs were €5338 higher with flash CGM than with SMBG. Flash CGM was associated with 0.51 more QALYs than SMBG, giving an incremental cost-effectiveness ratio (ICER) of €10 556/QALY. Scenario analysis ICERs ranged from €3825/QALY to €26 737/QALY. In probabilistic analysis, flash CGM was 100% likely to be cost effective at willingness-to-pay thresholds > €20 000/QALY.

CONCLUSIONS

From an Italian healthcare system perspective, flash CGM is cost effective compared with SMBG for people living with T2DM on basal insulin.

Burden of Portal Hypertension Complications Is Greater in Liver Transplant Wait-Listed Registrants with End-Stage Liver Disease and Type 2 Diabetes

BACKGROUND AND AIMS

Impact of type 2 diabetes mellitus (T2DM) in patients with end-stage liver disease (ESLD) awaiting liver transplantation (LT) remains poorly defined. The objective of the present study is to evaluate the relationship between T2DM and clinical outcomes among patients with LT waitlist registrants. We hypothesize that the presence of T2DM will be associated with worse clinical outcomes.

METHODS

593 patients adult (age 18 years or older) who were registered for LT between 1/2010 and 1/2017 were included in this retrospective analysis. The impact of T2DM on liver-associated clinical events (LACE), survival, hospitalizations, need for renal replacement therapy, and likelihood of receiving LT were evaluated over a 12-month period. LACE was defined as variceal hemorrhage, hepatic encephalopathy, and ascites. Kaplan-Meier and Cox regression analysis were used to determine the association between T2DM and clinical outcomes.

RESULTS

The baseline prevalence of T2DM was 32% (n = 191) and patients with T2DM were more likely to have esophageal varices (61% vs. 47%, p = 0.002) and history of variceal hemorrhage (23% vs. 16%, p = 0.03). The presence of T2DM was associated with increased risk of incident ascites (HR 1.91, 95% CI 1.11, 3.28, p = 0.019). Patients with T2DM were more likely to require hospitalizations (56% vs. 49%, p = 0.06), hospitalized with portal hypertension-related complications (22% vs. 14%; p = 0.026), and require renal replacement therapy during their hospitalization. Patients with T2DM were less likely to receive a LT (37% vs. 45%; p = 0.03). Regarding MELD labs, patients with T2DM had significantly lower bilirubin at each follow-up; however, no differences in INR and creatinine were noted.

CONCLUSION

Patients with T2DM are at increased risk of clinical outcomes. This risk is not captured in MELD score, which may potentially negatively affect their likelihood of receiving LT.

Metformin monotherapy versus predominantly older non-metformin antidiabetic medications for cerebrovascular risk in early type 2 diabetes management

AIM

Choosing the initial treatment for type 2 diabetes (T2D) is pivotal, requiring consideration of solid clinical evidence and patient characteristics. Despite metformin's historical preference, its efficacy in preventing cerebrovascular events lacked empirical validation. This study aimed to evaluate the associations between first-line monotherapy (metformin or non-metformin antidiabetic medications) and cerebrovascular complications in patients with T2D without diabetic complications.

METHODS

We analysed 9090 patients with T2D without complications who were prescribed either metformin or non-metformin medications as initial therapy. Propensity score matching ensured group comparability. Cox regression analyses, stratified by initial metformin use, assessed cerebrovascular disease risk, adjusting for multiple covariates and using competing risk analysis. Metformin exposure was measured using cumulative defined daily doses.

RESULTS

Metformin users had a significantly lower crude incidence of cerebrovascular diseases compared with non-users (p < .0001). Adjusted hazard ratios (aHRs) consistently showed an association between metformin use and a lower risk of overall cerebrovascular diseases (aHRs: 0.67-0.69) and severe events (aHRs: 0.67-0.69). The association with reduced risk of mild cerebrovascular diseases was significant across all models (aHRs: 0.73-0.74). Higher cumulative defined daily doses of metformin correlated with reduced cerebrovascular risk (incidence rate ratio: 0.62-0.94, p < .0001), indicating a dose-dependent effect.

CONCLUSION

Metformin monotherapy is associated with a reduced risk of cerebrovascular diseases in early-stage T2D, highlighting its dose-dependent efficacy. However, the observed benefits might also be influenced by baseline differences and the increased risks associated with other medications, such as sulphonylureas. These findings emphasize the need for personalized diabetes management, particularly in mitigating cerebrovascular risk in early T2D stages.

Patient Out-of-Pocket Costs for Type 2 Diabetes Medications When Aging Into Medicare

Importance

For people with type 2 diabetes (T2D), out-of-pocket medication costs may influence medication choice, adherence, and overall diabetes management and progression. Little is known about how these costs change as insured people enter Medicare at age 65 years, when coinsurance in the coverage gap and catastrophic phases of Part D coverage can be increased greatly by use of insulin and newer, branded medications (eg, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 agonists, and sodium-glucose cotransporter 2 inhibitors).

Objective

To identify whether reaching age 65 years is associated with T2D medication out-of-pocket costs and utilization.

Design, Setting, and Participants

This retrospective cohort study (2012-2020) featuring 7 years of follow-up used prescription drug claims data from the TriNetX Diamond Network. Participants included people in the US with diagnosed T2D, and claims for T2D medications were observed both before and after age 65 years. Data analysis was performed from October 2022 to September 2023.

Exposure

Reaching age 65 years, according to participants' year of birth.

Main Outcomes and Measures

The primary outcome was patient out-of-pocket costs for T2D drugs per quarter (inflation adjusted to 2020 dollars). Utilization, measured as binary utilization of specific classes, and the number of claims for mutually exclusive classes and combinations of classes were also examined. All outcomes were examined using regression discontinuity design.

Results

In claims data for 129 997 individuals with T2D diagnosed at ages 58 to 72 years (mean [SD] age, 65.50 [2.95] years; 801 235 female [50.9%]), reaching age 65 years was associated with an increase of $23.04 (95% CI, $19.86-$26.22) in mean quarterly out-of-pocket costs for T2D drugs, and an increase of $56.36 (95% CI, $51.48-$61.23) at the 95th percentile of spending, after utilization adjustment. Utilization decreased by 5.3% at age 65 years, from 3.40 claims per quarter (95% CI, 3.38-3.42 claims per quarter) to 3.22 claims per quarter (95% CI, 3.21-3.24 claims per quarter), but a shift in composition of utilization, including increased insulin use, was associated with additional increases in patient costs.

Conclusions and Relevance

In this cohort study of individuals with T2D, the increase in spending upon reaching age 65 years (when most people enroll in Medicare) was associated with patient coinsurance in the coverage gap and catastrophic coverage phases of Medicare Part D. The increased patient cost burden at age 65 years and a modest reduction in overall T2D drug utilization suggest that as people with T2D age into Medicare, there is potentially an increase in nonadherence and diabetes complications.

The efficacy of self-monitoring of blood glucose (SMBG) intervention package through a subscription model among type-2 diabetes mellitus in Malaysia: a preliminary trial

BACKGROUND

The aim of this study was to determine the effect of a Self-Monitoring Blood Glucose (SMBG) intervention package through a subscription model in improving HbA1c and health parameters among type-2 diabetes mellitus (T2DM) individuals in Malaysia.

METHODS

This is a quasi-experimental study involving a total number of 111 individuals with T2DM (mean age 57.0 ± 11.7 years, 61% men) who were assigned to intervention (n = 51) and control (n = 60) groups. The intervention group participants were the subscribers of SugO365 program which provided a personalized care service based on self-recorded blood glucose values. Subscribers received a Contour® Plus One glucometer which can connect to Health2Sync mobile app to capture all blood glucose readings as well as physical and virtual follow up with dietitians, nutritionists, and pharmacists for 6 months. Outcome measures were body weight, body mass index (BMI), random blood glucose (RBG), glycated haemoglobin (HbA1c) and health-related quality of life (HRQoL, assessed by SF-36 questionnaire). Data were measured at baseline, third and sixth months.

RESULTS

Repeated-measure analysis of covariance showed significant improvement in HbA1c level (ƞp2 = 0.045, p = 0.008) in the intervention (baseline mean 7.7% ± 1.1%; end mean 7.3% ± 1.3%) as compared to control (baseline mean 7.7% ± 0.9%; end mean 8.1% ± 1.6%) group. Similar trend was observed for Role Emotional domain of the quality of life (ƞp2 = 0.047, p = 0.023) in the intervention (baseline mean 62.8 ± 35.1, end mean 86.3 ± 21.3) compared to control (baseline mean group 70.5 ± 33.8; end mean 78.4 ± 27.3) group. Negative association was found in HbA1c changes using Z-score and Physical Function domain (r = - 0.217, p = 0.022).

CONCLUSION

A 6 months SMBG intervention package through a subscription model improved blood glucose control as measured by HbA1c and health-related quality of life, particularly the Role Emotional domain. Elevated HbA1c levels are correlated with decreased physical function.There is a need to further examine the efficacy of SMBG intervention package using a larger sample and a longer period of intervention and to determine its cost efficacy.

Physical Activity Perceptions and Participation of People With Type II Diabetes Mellitus in the Dominican Republic

INTRODUCTION

Physical activity (PA) improves health outcomes for people with type II diabetes mellitus (diabetes), but little is known about PA among Dominicans. The purpose was to evaluate PA participation and perceptions among people with diabetes in the Dominican Republic (DR).

METHODS

Participants (N=29) were recruited from an urban diabetes clinic in DR. PA was assessed via accelerometry and Godin Leisure Time Exercise Questionnaire (GLTEQ).

RESULTS

Eighteen women and 11 men enrolled (age: 55 ± 13 years; BMI: 28.6 ± 4.5 kg·m-2). Twenty-seven participants reached acceptable wear time. Using a one-minute bout minimum, moderate- to vigorous-intensity PA (MVPA) was 152.2 ± 59.7 min·day-1; no vigorous PA was recorded. GLTEQ scores (103 ± 98) classified 25 participants as active. Around 93% reported that PA was "very important" for their health. There was no association between GLTEQ and MVPA (p>0.2). Participants who reported being "very active" (n=17) did more MVPA than those who were "rarely active" or "somewhat active" (n=10; p=0.02).

CONCLUSION

Dominicans with diabetes are highly physically active but do very little vigorous PA. The GLTEQ was not an accurate measure of PA. Future research should develop validated questionnaires and evaluate structured exercise and dietary interventions.

Real-world HbA1c changes and prescription characteristics among type 2 diabetes mellitus patients initiating treatment with once weekly semaglutide for diabetes

Purpose

The purpose of this study was to evaluate patient, prescriber, and dose characteristics and evaluate changes in glycated hemoglobin (HbA1c) for patients prescribed once weekly semaglutide for diabetes (OW sema T2D).

Methods

This study was a retrospective claims-based study using the Optum Research Database. The sample included adult patients who had at least one claim for OW sema T2D between Jan 1, 2018, and Dec 31, 2019, were continuously enrolled in the health plan and had a diagnosis of type 2 diabetes (T2DM) during the pre-index or post-index periods. Demographic and clinical characteristics of patients using OW sema T2D were collected, as were the dose and prescriber specialty and the change between pre-index and post-index HbA1c measures was calculated. Results were stratified by the latest pre-index HbA1c measurement (HbA1c greater than or equal to 9.0%, uncontrolled vs. HbA1c less than 9%, controlled). Statistical comparisons between HbA1c groups were conducted.

Results

Most patients, 76.3%, were prescribed a 0.25/0.50 mg dose of OW sema T2D. Patients had an overall decrease in HbA1c of 0.8% and patients with uncontrolled diabetes had a greater reduction in mean HbA1c compared to those with controlled diabetes (-2.1% vs. -0.3%, p < 0.001). Most patients had their index dose of OW sema T2D prescribed by endocrinologists (27.6%) primary care providers (24.6%) and internal medicine providers (21.6%).

Conclusions

OW sema T2D is an effective real-world T2DM treatment. Future research should further investigate real-world use patterns of this medication.

The Role of Alternative Medicine in Managing Type 2 Diabetes: A Comprehensive Review

Diabetes, a chronic metabolic disorder marked by elevated blood glucose levels, is increasingly prevalent globally, significantly impacting health-related quality of life. Type 2 diabetes (T2DM), characterized by insulin resistance and inadequate insulin production, presents a substantial public health challenge, necessitating comprehensive management strategies. Conventional treatments, including lifestyle modifications and pharmacotherapy, are essential for glycemic control and preventing complications. However, adherence to these treatments is often limited, highlighting the need for alternative strategies. Complementary and alternative medicine (CAM) offers potential cost-effective and accessible approaches for managing T2DM. Key herbal remedies like cinnamon, fenugreek, and bitter melon, along with dietary supplements like chromium, magnesium, and vanadium, have shown promise in glycemic control. Mind-body therapies, including yoga, tai chi, and meditation, contribute to improved hemoglobin A1c and fasting blood glucose levels. Research supports the integration of CAM with conventional therapies, demonstrating enhanced clinical efficacy and reduced economic burden. However, challenges such as standardization, quality control, and potential risks of herbal medicines need careful consideration. Regulatory frameworks and ethical considerations are essential to ensure patient safety and informed decision-making. Patient education and effective communication between healthcare providers and patients are crucial for integrating CAM into diabetes management. Empowerment-based interventions and collaborative approaches can enhance self-management skills and clinical outcomes. Overall, integrating CAM with conventional treatments offers a holistic approach to managing T2DM, potentially improving patient outcomes and reducing healthcare costs.

Person-Centred Diabetes Care: Examining Patient Empowerment and Diabetes-Specific Quality of Life in Slovenian Adults with Type 2 Diabetes

Patient empowerment is crucial for promoting and strengthening health. We aimed to assess patient empowerment and diabetes-specific health-related quality of life (HRQoL) in adults with type 2 diabetes (T2D). A multi-centre, cross-sectional survey was conducted among adults with T2D in urban and rural primary care settings in Slovenia between April and September 2023. The survey utilised convenience sampling and included sociodemographic and clinical data, the Diabetes Empowerment Scale (DES), and the Audit of Diabetes-Dependent QoL (ADDQoL). The study included 289 people with T2D and a mean age of 67.2 years (SD 9.2). The mean overall DES score was 3.9/5 (SD 0.4). In a multivariable linear regression model, higher empowerment was significantly associated with residing in a rural region (p = 0.034), higher education (p = 0.028), and a lack of comorbid AH (p = 0.016). The median overall ADDQoL score was -1.2 (IQR [-2.5, -0.6]). The greatest negative influence of diabetes on HRQoL was observed in the domain 'Freedom to eat', followed by 'Freedom to drink', 'Leisure activities', and 'Holidays'. Despite high empowerment among adults with T2D, the condition still imposes a personal burden. Integrated primary care models should prioritise the importance of implementing targeted interventions to enhance diabetes empowerment, address comorbidities, and improve specific aspects of QoL among individuals with T2D.

A systematic review of the economic burden of diabetes mellitus: contrasting perspectives from high and low middle-income countries

Introduction

Diabetes increases preventative sickness and costs healthcare and productivity. Type 2 diabetes and macrovascular disease consequences cause most diabetes-related costs. Type 2 diabetes greatly costs healthcare institutions, reducing economic productivity and efficiency. This cost of illness (COI) analysis examines the direct and indirect costs of treating and managing type 1 and type 2 diabetes mellitus.

Methodology

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, Cochrane, PubMed, Embase, CINAHL, Scopus, Medline Plus, and CENTRAL were searched for relevant articles on type 1 and type 2 diabetes illness costs. The inquiry returned 873 2011-2023 academic articles. The study included 42 papers after an abstract evaluation of 547 papers.

Results

Most articles originated in Asia and Europe, primarily on type 2 diabetes. The annual cost per patient ranged from USD87 to USD9,581. Prevalence-based cost estimates ranged from less than USD470 to more than USD3475, whereas annual pharmaceutical prices ranged from USD40 to more than USD450, with insulin exhibiting the greatest disparity. Care for complications was generally costly, although costs varied significantly by country and problem type.

Discussion

This study revealed substantial heterogeneity in diabetes treatment costs; some could be reduced by improving data collection, analysis, and reporting procedures. Diabetes is an expensive disease to treat in low- and middle-income countries, and attaining Universal Health Coverage should be a priority for the global health community.

Factors influencing hospitalization or emergency department visits and mortality in type 2 diabetes following the onset of new cardiovascular diagnoses in a population-based study

BACKGROUND

Individuals with type 2 diabetes (T2D) are at increased risk of developing cardiovascular disease (CVD) which necessitates monitoring of risk factors and appropriate pharmacotherapy. This study aimed to identify factors predicting emergency department visits, hospitalizations, and mortality among T2D patients after being newly diagnosed with CVD.

METHODS

In a retrospective observational study conducted in Region Halland, individuals aged > 40 years with T2D diagnosed between 2011 and 2019, and a new diagnosis of CVD between 2016 and 2019, were followed for one year from the date of CVD diagnosis. The first encounter for CVD diagnosis was categorized as inpatient-, outpatient-, primary-, or emergency department care. Follow-up included laboratory tests, blood pressure, pharmacotherapies, and healthcare utilization. Hazard ratios (HR) in two Cox regression analyses determined relative risks for emergency visits/hospitalization and mortality, adjusting for age, sex, glucose regulation, lipid levels, kidney function, blood pressure, pharmacotherapy, and healthcare utilization.

RESULTS

The study included a total of 1759 T2D individuals who received a new CVD diagnosis, with 67% diagnosed during inpatient care. The average hospitalization stay was 6.5 days, and primary care follow-up averaged 10.1 visits. Patients with CVD diagnosed in primary care had a HR 0.52 (confidence interval [CI] 0.35-0.77) for emergency department visits/hospitalization, but age had a HR 1.02 (CI 1.00-1.03). Pharmacotherapy with insulin, DPP4-inhibitors, aldosterone antagonists, and beta-blockers had a raised HR. Highest mortality risk was observed when CVD was diagnosed inpatient care, systolic blood pressure < 100 mm Hg and elevated HbA1c. Age had a HR 1.05 (CI 1.03-1.08), eGFR < 30 ml/min HR 1.46 (CI 1.01-2.11), and LDL-Cholesterol > 2,5 h 1.46 (CI 1.01-2.11) and associated with increased mortality risk. Pharmacotherapy with metformin had a HR 0.41 (CI 0.28-0.62), statins a HR 0.39 (CI 0.27-0.57), and a primary care follow-up < 30 days a HR 0.53 (CI 0.37-0.77) and associated with lower mortality risk.

CONCLUSIONS

T2D individuals who had a new diagnosis of CVD were predominantly diagnosed when hospitalized, while follow-up typically occurred in primary care. Identifying factors that predict risks of mortality and hospitalization should be a focus of follow-up care, underscoring the critical role of primary care in the effective management of T2D and CVD.

Nurse-led self-management education and support programme on self-management behaviour and quality of life among adults with type 2 diabetes: A pilot randomized controlled trial

AIM

This study examined the preliminary effects of a nurse-led self-management education and support programme on the self-management behaviours and quality of life among people with type 2 diabetes in Western Ethiopia.

METHODS

A pilot randomized controlled trial was conducted between January and August 2021. Participants were recruited in the hospital and randomly assigned to the control arm to continue usual care (n = 38) or the intervention arm to receive usual care and the diabetes self-management education and support programme (n = 38) in the community. Self-management behaviours and quality of life were assessed using a 10-item summary of diabetes self-care activity (expanded) scale and a 34-item diabetes quality of life measure, respectively, at baseline and 2 months after follow-up. Generalized estimating equation models were used to examine the preliminary effects of the programme on the outcomes.

RESULTS

Preliminary results indicated that the programme outperformed usual care in self-management practise, with large effect sizes immediately postintervention and at 2 months after the intervention, and quality of life at 2 months after the intervention.

CONCLUSION

A nurse-led diabetes self-management education and support intervention, including the families of people with diabetes, may be an option to boost the self-management practise and quality of life of patients with diabetes.

Exploring in-vivo infrared spectroscopy for nail-based diabetes screening

Diabetes screening is traditionally complex, inefficient, and reliant on invasive sampling. This study evaluates near-infrared spectroscopy for non-invasive detection of glycated keratin in nails in vivo. Glycation of keratin, prevalent in tissues like nails and skin, is a key indicator of T2DM risk. In this study involving 200 participants (100 with diabetes, 100 without), NIR's efficacy was compared against a point-of-care HbA1c analyzer. Results showed a specificity of 92.9% in diabetes risk assessment. This study highlights the proposed NIR system potential as a simple, reliable tool for early diabetes screening and risk management in various healthcare settings.

A Hybrid Model of In-Person and Telemedicine Diabetes Education and Care for Management of Patients with Uncontrolled Type 2 Diabetes Mellitus: Findings and Implications from a Multicenter Prospective Study

Background

Patients with uncontrolled type 2 diabetes mellitus (T2DM) require close follow-up, support, and education to achieve glycemic control, especially during the initiation or intensification of insulin therapy and self-care management. This study aimed to describe and evaluate the impact of implementing a hybrid model of in-person and telemedicine care and education on glycemic control for patients with uncontrolled T2DM (hemoglobin A1c [HbA1c] ≥9%) during the coronavirus disease pandemic.

Methods

This prospective multicenter-cohort pre-/post-intervention study was conducted on patients with uncontrolled T2DM. This study included three chronic illness centers affiliated with the Family and Community Medicine Department at Prince Sultan Military Medical City in Riyadh, Saudi Arabia. A hybrid model of in-person (onsite) and telemedicine care and education was developed. This involved implementing initial in-person care at the physicians' clinic and initial in-person education at the diabetes education clinic, followed by telemedicine services of tele-follow-ups, support, and education for an average 4-month follow-up period.

Results

Of the enrolled 181 patients, more than half of the participants were women (n = 103, 56.9%). The mean age of participants (standard deviation) was 58.64 ± 11.23 years and the mean duration of diabetes mellitus was 13.80 ± 8.55 years. The majority of the patients (n = 144; 79.6%) were on insulin therapy. Overall, in all three centers, the hybrid model had significantly reduced HbA1c from 10.47 ± 1.23% to 7.87 ± 1.59% (mean difference of reduction 2.59% [95% confidence interval (CI) = 2.34-2.85%], p < 0.001). At the level of each center, HbA1c was reduced significantly with mean differences of 3.17% (95% CI = 2.81-3.53%), 2.49% (95% CI = 1.92-3.06%), and 2.16% (95% CI = 1.76-2.57%) at centers A, B, and C, respectively (all p < 0.001).

Conclusion

The findings showed that the hybrid model of in-person and telemedicine care and education effectively managed uncontrolled T2DM. Consequently, the role of telemedicine in diabetes management could be further expanded as part of routine diabetes care in primary settings to achieve better glycemic control and minimize nonessential in-person visits when appropriate.

Nonlinear association of the systemic immune-inflammatory index with mortality in diabetic patients

Background

It has been demonstrated that in diabetic patients, an elevated neutrophil-lymphocyte ratio (NLR) is independently connected with higher cardiovascular and all-cause mortality. It is unclear, however, if the systemic immune-inflammatory index (SII) and the mortality rate among diabetic patients are related. Investigating the linkage between SII and diabetes patients' risk of cardiovascular and all-cause death was the aim of the study.

Methods

4972 diabetics who were chosen from six rounds of the National Health and Nutrition Examination Survey (NHANES) between 2005 and 2016 were the study's participants. The optimal SII threshold with the highest correlation with survival outcomes was identified by applying the Maximum Selection Ranking Statistical Method (MSRSM). To assess the relationship between SII and cardiovascular and all-cause mortality in diabetics, subgroup analysis and Cox regression modeling were employed. Furthermore, smoothed curve fitting was utilized to determine the nonlinear relationship of them.

Results

Over the course of a median follow-up of 69 months (interquartile range [IQR], 54-123 months), 1,172 (23.6%) of the 4,972 diabetic patients passed away. These deaths included 332 (6.7%) cardiovascular deaths and 840 (16.9%) non-cardiovascular deaths. Individuals were categorized into higher (>983.5714) and lower (≤983.5714) SII groups according to MSRSM. In multi-variable adjusted models, subjects with higher SII had a significantly increased chance of dying from cardiovascular disease (HR 2.05; 95% confidence interval (CI):1.42,2.97) and from all causes (HR 1.60; 95% CI:1.22,1.99). Kplan-Meier curves showed similar results. Subgroup studies based on age, sex, BMI, drinking, smoking, and hypertension revealed that the connection maintained intact. The previously stated variables and SII did not significantly interact (p interaction > 0.05). In diabetic patients, smooth curve fitting revealed a nonlinear correlation between SII and mortality.

Conclusion

In diabetic patients, elevated SII is linked to higher cardiovascular and all-cause mortality.

Budget impact analysis for three glucagon-like peptide-1 receptor agonist-based therapies for type 2 diabetes mellitus management in Saudi Arabia

BACKGROUND AND OBJECTIVES

This study presents a budget impact analysis (BIA) conducted in Saudi Arabia, evaluating the cost implications of adopting semaglutide, tirzepatide, or dulaglutide in the management of type 2 diabetes mellitus (T2DM) patients. The analysis aims to assess the individual budgetary impact of these treatment options on healthcare budgets and provide insights for decision-makers.

METHODS

A prevalence-based BIA was developed using real-world and clinical trials data. The model considered disease epidemiology, medication prices, diabetes management expenses, cardiovascular (CV) complications costs, and weight reduction savings over a 5-year time horizon. One-way and probabilistic sensitivity analyses (OWSA, PSA) were performed to assess the robustness of the results.

RESULTS

Over a 5-year period, the cumulative budget impact for semaglutide, tirzepatide, and dulaglutide were 85,923,089 USD, 169,790,195 USD, and 94,558,356 USD, respectively. Hypothetical scenarios considering price parity between semaglutide and tirzepatide are associated with financial impacts of 85,923,091 USD and 86,475,335 USD, respectively. In the public sector, semaglutide showed the lowest incidence of 3-point major adverse CV events (3P-MACE), with tirzepatide leading in weight loss and HbA1c reduction, and dulaglutide presenting the highest 3P-MACE rates and least improvements in HbA1c and weight. A breakeven analysis suggested that tirzepatide's list price would need to be $199.91 lower than its current list price to achieve budget impact parity with semaglutide based on currently available evidence. Results from the OWSA suggested that risk reductions for CV events were key drivers of budget impact. PSA results were confirmatory of base-case analyses.

CONCLUSIONS

CV cost-offsets and drug acquisition considerations may make semaglutide a favorable use of resources for Saudi budget planners and decision-makers. These results were robust to assumptions regarding the list price of tirzepatide.

Burden of disability in type 2 diabetes mellitus and the moderating effects of physical activity

The growing diabetic epidemic has created a substantial burden, not only on the people with diabetes but also on society at large. This mini-review discussed the limitations and patterns of disability in type 2 diabetes mellitus and put forward a case for the moderating effects of physical activity (PA) in the management of diabetes. The limitations and impairments associated with diabetes include vascular, neurological, cardiac, and renal impairments. Moreover, individuals participate less in their daily lives and in their instrumental activities of daily living, which negatively impacts the quality of life of individuals with diabetes. This often leads to a loss of quality of life due to disabilities, resulting in an increased rate of disability-adjusted life years among people with type 2 diabetes mellitus. Moreover, there are psychosocial sequelae of diabetes mellitus. This necessitates looking for moderating factors that may reduce the burden of the disease. PA has been shown to be one of the factors that can mitigate these burdens. PA does this in several ways, including through the benefits it confers, such as a reduction of hemoglobin A1c, a reduction of excess fat in the liver and pancreas, and the reduction of cardiovascular risk factors, all of which favorably affect glycemic parameters. Specifically, PA regulates or moderates diabetes disability through two mechanisms: The regulation of glucolipid metabolism disorders and the optimization of body mass index and systemic conditions. Therefore, efforts should be directed at PA uptake through identified strategies. This will not only prevent diabetes or diabetes complications but will reduce its burden.

Variation of butyrate production in the gut microbiome in type 2 diabetes patients

BACKGROUND

Diabetes mellitus type 2 is a common disease that poses a challenge to the healthcare system. The disease is very often diagnosed late. A better understanding of the relationship between the gut microbiome and type 2 diabetes can support early detection and form an approach for therapies. Microbiome analysis offers a potential opportunity to find markers for this disease. Next-generation sequencing methods can be used to identify the bacteria present in the stool sample and to generate a microbiome profile through an analysis pipeline. Statistical analysis, e.g., using Student's t-test, allows the identification of significant differences. The investigations are not only focused on single bacteria, but on the determination of a comprehensive profile. Also, the consideration of the functional microbiome is included in the analyses. The dataset is not from a clinical survey, but very extensive.

RESULTS

By examining 946 microbiome profiles of diabetes mellitus type 2 sufferers (272) and healthy control persons (674), a large number of significant genera (25) are revealed. It is possible to identify a large profile for type 2 diabetes disease. Furthermore, it is shown that the diversity of bacteria per taxonomic level in the group of persons with diabetes mellitus type 2 is significantly reduced compared to a healthy control group. In addition, six pathways are determined to be significant for type 2 diabetes describing the fermentation to butyrate. These parameters tend to have high potential for disease detection.

CONCLUSIONS

With this investigation of the gut microbiome of persons with diabetes type 2 disease, we present significant bacteria and pathways characteristic of this disease.

Barriers to Treatment Adherence Among Older Adults With Type 2 Diabetes: A Qualitative Study

The current qualitative study aimed to determine the barriers to treatment adherence among older adults with type 2 diabetes (T2D). This study was performed using a content analysis approach. Semi-structured interviews were conducted with 25 older adults with T2D between May and September 2021. Data were organized using MAXQDA-10 software and analyzed using the Elo and Kyngäs qualitative content analysis method. Three themes emerged from the analysis: Patient-Specific Barriers, Health Care Provider- and Heath Care System-Specific Barriers, and Social-Specific Barriers. Results of this study can be used to develop targeted interventions to promote and facilitate treatment adherence among older adults with T2D. [Journal of Gerontological Nursing, 49(1), 42-49.].

The relationship between patient empowerment and related constructs, affective symptoms and quality of life in patients with type 2 diabetes: a systematic review and meta-analysis

Introduction

The aim of this systematic review is to assess the relationship between patient empowerment and other empowerment-related constructs, and affective symptoms and quality of life in patients with type 2 diabetes.

Methods

A systematic review of the literature was conducted, according to the PRISMA guidelines. Studies addressing adult patients with type 2 diabetes and reporting the association between empowerment-related constructs and subjective measures of anxiety, depression and distress, as well as self-reported quality of life were included. The following electronic databases were consulted from inception to July 2022: Medline, Embase, PsycINFO, and Cochrane Library. The methodological quality of the included studies was analyzed using validated tools adapted to each study design. Meta-analyses of correlations were performed using an inverse variance restricted maximum likelihood random-effects.

Results

The initial search yielded 2463 references and seventy-one studies were finally included. We found a weak-to-moderate inverse association between patient empowerment-related constructs and both anxiety (r = -0.22) and depression (r = -0.29). Moreover, empowerment-related constructs were moderately negatively correlated with distress (r = -0.31) and moderately positively correlated with general quality of life (r = 0.32). Small associations between empowerment-related constructs and both mental (r = 0.23) and physical quality of life (r = 0.13) were also reported.

Discussion

This evidence is mostly from cross-sectional studies. High-quality prospective studies are needed not only to better understand the role of patient empowerment but to assess causal associations. The results of the study highlight the importance of patient empowerment and other empowerment-related constructs such as self-efficacy or perceived control in diabetes care. Thus, they should be considered in the design, development and implementation of effective interventions and policies aimed at improving psychosocial outcomes in patients with type 2 diabetes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020192429, identifier CRD42020192429.

[Malnutrition management of hospitalized patients with diabetes/hyperglycemia and concurrent pathologies]

Introduction

Type 2 diabetes mellitus is a highly prevalent disease worldwide, generating an increasing clinical and economic burden due to its micro- and macrovascular complications. Frequently, people with diabetes are hospitalized for various pathologies. These patients generally have higher risk of complications, prolonged hospitalizations and mortality. An additional factor that worsens the prognosis in these patients is the concurrence of malnutrition, especially in elderly people. All this makes the management of these patients challenging and requires a specific nutritional approach, whose purpose is to cover the nutritional requirements while always maintaining glycemic control. The purpose of this work is to provide, based on the evidence available in the literature and clinical experience, consensus recommendations by eighteen experts in Endocrinology and Nutrition on the nutritional approach of hospitalized patients with diabetes/ hyperglycemia and compare the optimal management, based on these recommendations with bedside usual care according to a panel of Spanish doctors surveyed about their daily clinical practice. This first article of this extraordinary issue of the journal Nutrición Hospitalaria describes the methodology of the study and the results obtained regarding common issues for all pathologies.

The efficacy and safety of dachaihu decoction in the treatment of type 2 diabetes mellitus: A systematic review and meta-analysis

Background: Type 2 diabetes mellitus (T2DM) is a clinical metabolic syndrome characterized by persistent hyperglycemia, which is caused by defective insulin secretion and decreased function in regulating glucose metabolism. Dachaihu Decoction (DCHD) is a traditional Chinese medicine formula that has been gradually used in T2DM treatment. A comprehensive analysis on the efficacy and safety of DCHD in T2DM treatment is necessary.

Objective: This meta-analysis aimed to systematically assess the clinical efficacy and safety of DCHD in the T2DM treatment and provide a reference for subsequent research and clinical practice.

Methods: Both Chinese and English databases were searched from their inceptions to November 2021. All retrieved studies were screened according to inclusion and exclusion criteria and randomized controlled trials about DCHD on T2DM were enrolled. The quality of the literature was assessed using the bias risk assessment tool in the Cochrane Handbook. Data extraction was performed on the selected studies. Review Manager 5.4 and Stata 16.0 were used for meta-analysis. Sources of heterogeneity were also explored by using meta-regression and subgroup analysis. Funnel plot and Egger’s test were used to assess publication bias and the evidence quality was assessed by GRADE.

Results: 17 eligible studies, involving 1,525 patients, were included in this study. Compared with conventional treatment, combined treatment with DCHD was significantly better in improving HbA1c (MD = −0.90%, 95%CI: −1.20 to −0.60, p &lt; 0.01), FBG (MD = −1.08 mmol/L, 95%CI: −1.28 to −0.87, p &lt; 0.01), 2hPG (MD = −1.25 mmol/L, 95%CI: −1.42 to −1.09, p &lt; 0.01), TC (MD = −0.50 mmol/L, 95%CI: −0.70 to −0.30, p &lt; 0.01), TG (MD = −0.44 mmol/L, 95%CI: −0.61 to −0.26, p &lt; 0.01), LDL-C (MD = −0.58 mmol/L, 95%CI: −0.85 to −0.31, p &lt; 0.01), HOMA-IR (SMD = −2.04, 95%CI: −3.09 to −0.99, p &lt; 0.01), HOMA-β (SMD = 2.48, 95%CI: 2.20 to 2.76, p &lt; 0.01) and BMI (MD = −1.52 kg/m2, 95%CI: −2.55 to −0.49, p &lt; 0.01). When DCHD used alone, it had a similar efficacy to conventional treatment in HbA1c (MD = −0.04%, 95%CI: −0.17 to 0.09, p = 0.57) and FBG (MD = 0.13 mmol/L, 95%CI: −0.09 to 0.36, p = 0.24). It can also reduce 2hPG, even if not as effective as conventional treatment (MD = 0.54 mmol/L, 95%CI: 0.19 to 0.89, p &lt; 0.01). Due to the small number of included studies, it is unclear whether DCHD used alone has an improving effect on lipid metabolism, BMI, HOMA-IR and HOMA-β. Analysis of adverse events showed DCHD was relatively safe. No obvious publication bias was detected by Funnel plot and Egger’s test.

Conclusion: Based on this meta-analysis, we found that the combination with DCHD in the T2DM treatment has more advantages than conventional treatment alone, which can further regulate the glucose and lipid metabolism, reduce insulin resistance, improve islet function and lower BMI. DCHD alone also plays a certain role in regulating glucose. Meanwhile, DCHD is relatively safe. However, limited by the quality and quantity of included studies, the efficacy and safety of DCHD remain uncertain. More high-quality studies are still needed to provide more reliable evidence for the clinical application of DCHD.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021296718, identifier CRD42021296718.

Ti2C-TiO2 MXene Nanocomposite-Based High-Efficiency Non-Enzymatic Glucose Sensing Platform for Diabetes Monitoring

Diabetes is a major health challenge, and it is linked to a number of serious health issues, including cardiovascular disease (heart attack and stroke), diabetic nephropathy (kidney damage or failure), and birth defects. The detection of glucose has a direct and significant clinical importance in the management of diabetes. Herein, we demonstrate the application of in-situ synthesized Ti₂C-TiO₂ MXene nanocomposite for high throughput non-enzymatic electrochemical sensing of glucose. The nanocomposite was synthesized by controlled oxidation of Ti₂C-MXene nanosheets using H₂O₂ at room temperature_. The oxidation results in the opening up of Ti₂C-MXene nanosheets and the formation of TiO₂ nanocrystals on their surfaces as revealed in microscopic and spectroscopic analysis. Nanocomposite exhibited considerably high electrochemical response than parent Ti₂C MXene, and hence utilized as a novel electrode material for enzyme-free sensitive and specific detection of glucose. Developed nanocomposite-based non-enzymatic glucose sensor (NEGS) displays a wide linearity range (0.1 µM-200 µM, R² = 0.992), high sensitivity of 75.32 μA mM^-1 cm^-2, a low limit of detection (0.12 μM) and a rapid response time (~3s). NEGS has further shown a high level of repeatability and selectivity for glucose in serum spiked samples. The unveiled excellent sensing performance of NEGS is credited to synergistically improved electrochemical response of Ti₂C MXene and TiO₂ nanoparticles. All of these attributes highlight the potential of MXene nanocomposite as a next-generation NEGS for on the spot mass screening of diabetic patients.

Promoting Physical Activity in Older Adults With Type 2 Diabetes via an Anthropomorphic Conversational Agent: Development of an Evidence and Theory-Based Multi-Behavior Intervention

Introduction

Anthropomorphic conversational agents (ACA) are a promising digital tool to support self-management of type 2 diabetes (T2D), albeit little explored. There is a dearth of literature on the detailed content of these interventions, which may limit effectiveness and replication. Our aim is to describe the development of an evidence and theory-based intervention to improve physical activity in older adults with T2D, subsumed in a multi-behavior intervention via a mobile application with an ACA.

Methods

Overall decisions on the multi-behavior intervention design, such as the use of standardized behavior change techniques (BCTTv1), guided the development of the physical activity component. Firstly, recommendations on ambulatory activity were used to select the target behavior (walking). Meta-research on effective behavior change techniques (BCTs) was then identified. One meta-analysis linked effective BCTs with the three basic psychological needs of the self-determination theory (SDT). This meta-analysis, taken together with additional evidence on SDT, led to the selection of this theory to inform the design. BCTs were extracted from meta-research; we selected the most appropriate to be operationalized via the conversational agent through multidisciplinary discussions. Rules governing the dialogue flow and BCTs tailoring, taking the form "if some conditions hold then execute some action," were derived based on the Basic Psychological in Exercise Scale (competence, autonomy, and relatedness scores), in conjunction with published evidence and multidisciplinary discussions.

Results

Thirteen BCTs were implemented in the prototype via the ACA (e.g., goal setting behavior 1.1). Six if-then rules were derived and depicted in the dialogue steps through process flow diagrams, which map how the system functions. An example of a rule is "If competence score ≤ 10 then, apply BCT 1.1 with 500 steps increments as options for the daily walking goal; If competence score > 10 then, apply BCT 1.1 with 1,000 steps increments as options for the daily walking goal."

Conclusion

Evidence and SDT were translated into a mobile application prototype using an ACA to promote physical activity in older adults with T2D. This approach, which includes 13 BCTs and six if-then rules for their tailoring, may leverage the efforts of others in developing similar interventions.

LitKDM2 study: the impact of health Literacy and knowledge about the disease on the metabolic control of type 2 diabetes mellitus

AIMS

Diabetes mellitus (DM) is a common chronic disease with serious individual and socioeconomic consequences. Low health literacy (HL) has been associated with higher morbimortality. Health knowledge about DM (HK-DM) may also influence individual health. We aimed to assess HL and HK-DM in patients with type 2 DM and their associations with metabolic control.

METHODS

Our sample comprised 194 diabetic patients from a primary care health centre. We collected clinical and demographic data and applied two validated questionnaires, the Newest Vital Sign (NST) and Diabetes Knowledge Test (DKT), to assess HL and HK-DM, respectively. Metabolic control was defined as HbA1c < 7.0%. Participants were classified according to the NST as having "high likelihood of limited HL" (HLL-HL), "possibility of limited HL" (PL-HL), or "adequate HL" (A-HL) and by the DKT as having "low", "average" and "good" HK. Statistical analysis included logistic regression models, using p < 0.05 as a cut-off for statistical significance.

RESULTS

Overall, 72.7 and 34.7% of participants had HLL-HL and low HK-DM, respectively. A-HL (OR = 6.02; 95% CI: 1.691-21.450) and PL-HL (OR = 4.78; 95% CI: 1.350-16.899) were significantly associated with better metabolic control than HLL-HL. We did not find a significant association between HK-DM and metabolic control.

CONCLUSIONS

HL seems to be associated with better metabolic control. We also found a high prevalence of illiteracy and scarce knowledge about DM. Primary care physicians should promote HL to help patients achieve better metabolic control.

Health Indicators as a Measure of Individual Health Status: Public Perspectives

Background

Disease status (eg, cancer stage) has been used in routine clinical practice to determine more accurate treatment plans. Health-related indicators, such as mortality, morbidity, and population group life expectancy, have also been used. However, few studies have specifically focused on the comprehensive and objective measures of individual health status.

Objective

The aim of this study was to analyze the perspectives of the public toward 29 health indicators obtained from a literature review to provide evidence for further prioritization of the indicators. The difference between health status and disease status should be considered.

Methods

This study used a cross-sectional design. Online surveys were administered through Ohio University, ResearchMatch, and Clemson University, resulting in three samples. Participants aged 18 years or older rated the importance of the 29 health indicators. The rating results were aggregated and analyzed as follows (in each case, the dependent variables were the individual survey responses): (1) to determine the agreement among the three samples regarding the importance of each indicator, where the independent variables (IVs) were the three samples; (2) to examine the mean differences between the retained indicators with agreement across the three samples, where the IVs were the identified indicators; and (3) to rank the groups of indicators into various levels after grouping the indicators with no mean differences, where the IVs were the groups of indicators.

Results

In total, 1153 valid responses were analyzed. Descriptive statistics revealed that the top five–rated indicators were drug or substance abuse, smoking or tobacco use, alcohol abuse, major depression, and diet and nutrition. Among the 29 health indicators, the three samples agreed upon the importance of 13 indicators. Inferential statistical analysis indicated that some of the 13 indicators held equal importance. Therefore, the 13 indicators were categorized by rank into seven levels: level 1 included blood sugar level and immunization and vaccination; level 2 included LDL cholesterol; level 3 included HDL cholesterol, blood triglycerides, cancer screening detection, and total cholesterol; level 4 included health literacy rate; level 5 included personal care needs and air quality index greater than 100; level 6 included self-rated health status and HIV testing; and level 7 included the supply of dentists. Levels 1 to 3 were rated significantly higher than levels 4 to 7.

Conclusions

This study provides a baseline for prioritizing 29 health indicators, which can be used by electronic health record or personal health record system designers or developers to determine what can be included in the systems to capture an individual’s health status. Currently, self-rated health status is the predominantly used health indicator. Additionally, this study provides a foundation for tracking and measuring preventive health care services more accurately and for developing an individual health status index.

Long-term effectiveness of a disease management program to prevent diabetic nephropathy: a propensity score matching analysis using administrative data in Japan

BACKGROUND

Existing reviews indicated that disease management for patients with diabetes may be effective in achieving better health outcomes with less resource utilization in the short term. However, the long-term results were inconsistent because of the heterogeneous nature of the study designs. In the present study, we evaluated the 5-year follow-up results of a local disease management program focused on diabetic nephropathy prevention under the universal public health insurance scheme in Japan.

METHODS

Patients diagnosed with type 2 diabetes who had stage 3 or 4 diabetic kidney disease and were aged between 20 and 75 years were invited to join a disease management program to support self-management and receive a recommended treatment protocol between 2011 and 2013. Follow-up data were collected from an electronic claims database for the public insurance scheme. Considering the non-random selection process, we prepared two control groups matched by estimated propensity scores to compare the incidence of diabetes-related complications, death, and resource utilization.

RESULTS

The treatment group was more likely to receive clinical management in accordance with the guideline-recommended medication. After propensity score matching, the treatment group had lower incidence of diabetic nephropathy and emergency care use than the control group selected from a beneficiary pool mainly under primary care. Comparisons between the treatment group and the control group with more selected clinical conditions did not show differences in the incidence rate and resource utilization.

CONCLUSIONS

The present results demonstrated limited effectiveness of the program for reducing complication incidence and resource utilization during the 5-year follow-up. Further research on the long-term effectiveness of co-management by primary care physicians, subspecialists in endocrinology and nephrology, and nurse educators is required for effective management of diabetes-related nephropathy.

Research for type 2 diabetes mellitus in endemic arsenism areas in central China: role of low level of arsenic exposure and KEAP1 rs11545829 polymorphism

Type 2 diabetes mellitus (T2DM) is one of the major public health problems worldwide; both genetic and environmental factors are its risk factors. Arsenic, an environmental pollutant, might be a risk factor for T2DM, but the association of low-to-moderate level arsenic exposure with the risk of T2DM is still inconsistent. Single nucleotide polymorphisms (SNPs) can affect the development of T2DM, but the study on KEAP1 rs11545829 (G>A) SNP is few. In this paper, we explored the effect of KEAP1 rs11545829 (G>A) SNP and low-to-moderate level arsenic exposure on risk of T2DM in a cross-sectional case-control study conducted in Shanxi, China. Total of 938 participants, including 318 T2DM cases and 618 controls, were enrolled. Blood glycosylated haemoglobin (HbA1c) was detected by Automatic Biochemical Analyzer, and participants with HbA1c≧6.5% were diagnosed as T2DM. Urinary total arsenic (tAs, mg/L), as the indicator of arsenic exposure, was detected by liquid chromatography-atomic fluorescence spectrometry (LC-AFS). Genomic DNA was extracted and the genotypes of KEAP1 rs11545829 SNP were examined by multiplex polymerase chain reaction (PCR). The urinary tAs concentration in recruited participants was 0.075 (0.03-0.15) mg/L, and was associated with an increased risk of T2DM (OR = 8.45, 95% CI 2.63-27.17); rs11545829 mutation homozygote AA genotype had a protective effect on risk of T2DM (OR = 0.42, 95 % CI 0.25-0.73). Although this protective effect of AA genotype was found in participants with higher urinary tAs level (>0.032 mg/L) (OR = 0.48, 95% CI 0.26-0.86), there was no interaction effect for arsenic exposure and rs11545829 SNP on risk of T2DM. In addition, BMI modified the association between rs11545829 SNP and the risk of T2DM (RERI = -1.11, 95% CI -2.18-0.04). The present study suggest that low-to-moderate level arsenic exposure may be a risk factor, while KEAP1 rs11545829 SNP mutation homozygote AA genotype may be a protective factor for risk of T2DM, especially for T2DM patients with urinary tAs level>0.032 mg/L.

The Cost-Effectiveness of Subcutaneous Semaglutide Versus Empagliflozin in Type 2 Diabetes Uncontrolled on Metformin Alone in Denmark

INTRODUCTION

International and Danish guidelines recommend the use of glucagon-like peptide 1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter 2 (SGLT-2) inhibitors already in second line in the management of type 2 diabetes (T2D). The objective of this study was to evaluate the long-term cost-effectiveness (CE) of subcutaneous (SC) semaglutide (GLP-1 RA) versus empagliflozin (SGLT-2 inhibitor) in individuals with T2D uncontrolled on metformin alone from a Danish payer's perspective.

METHODS

Cost-effectiveness analyses (CEA) were conducted from a Danish payer's perspective, using the IQVIA Core Diabetes model (CDM 9.5), with a time horizon of 50 years and an annual discount of 4% on costs and effects. Patients received either SC semaglutide or empagliflozin, in addition to metformin, until HbA1c threshold of 7.5% (58 mmol/mol) was reached, following which treatment intensification with insulin glargine in addition to empagliflozin or SC semaglutide plus metformin was considered. Baseline cohort characteristics and treatment effects were sourced from a published CEA. Utilities and cost of diabetes-related complications were also obtained from published sources. Treatment costs were derived from Danish official sources. Scenario analyses were also performed to test the accuracy of the base case results.

RESULTS

Individuals with T2D on SC semaglutide plus metformin gained 0.065 life-years (LYs) and 0.130 quality-adjusted LYs (QALYs), respectively, at an incremental cost of DKK 96,923 (€ 13,031) compared to empagliflozin plus metformin, resulting in an incremental cost-effectiveness ratio (ICER) of DKK 745,561(€ 100,239) per QALY gained. The probabilistic sensitivity analysis (PSA) results showed that the SC semaglutide plus metformin was cost-effective in 19% of simulations assuming a willingness-to-pay (WTP) threshold of DKK 357,100 (€ 48,011)/QALY gained. Duration of therapy with SC semaglutide seems the key driver of results.

CONCLUSION

The current analyses suggest that SC semaglutide plus metformin is not cost-effective compared to empagliflozin plus metformin from a Danish payer's perspective.

Predicting Real-world Hypoglycemia Risk in American Adults With Type 1 or 2 Diabetes Mellitus Prescribed Insulin and/or Secretagogues: Protocol for a Prospective, 12-Wave Internet-Based Panel Survey With Email Support (the iNPHORM [Investigating Novel Predictions of Hypoglycemia Occurrence Using Real-world Models] Study)

BACKGROUND

Hypoglycemia prognostic models contingent on prospective, self-reported survey data offer a powerful avenue for determining real-world event susceptibility and interventional targets.

OBJECTIVE

This protocol describes the design and implementation of the 1-year iNPHORM (Investigating Novel Predictions of Hypoglycemia Occurrence Using Real-world Models) study, which aims to measure real-world self-reported severe and nonsevere hypoglycemia incidence (daytime and nocturnal) in American adults with type 1 or 2 diabetes mellitus prescribed insulin and/or secretagogues, and develop and internally validate prognostic models for severe, nonsevere daytime, and nonsevere nocturnal hypoglycemia. As a secondary objective, iNPHORM aims to quantify the effects of different antihyperglycemics on hypoglycemia rates.

METHODS

iNPHORM is a prospective, 12-wave internet-based panel survey that was conducted across the United States. Americans (aged 18-90 years) with self-reported type 1 or 2 diabetes mellitus prescribed insulin and/or secretagogues were conveniently sampled via the web from a pre-existing, closed, probability-based internet panel (sample frame). A sample size of 521 baseline responders was calculated for this study. Prospective data on hypoglycemia and potential prognostic factors were self-assessed across 14 closed, fully automated questionnaires (screening, baseline, and 12 monthly follow-ups) that were piloted using semistructured interviews (n=3) before fielding; no face-to-face contact was required as part of the data collection. Participant responses will be analyzed using multivariable count regression and machine learning techniques to develop and internally validate prognostic models for 1-year severe and 30-day nonsevere daytime and nocturnal hypoglycemia. The causal effects of different antihyperglycemics on hypoglycemia rates will also be investigated.

RESULTS

Recruitment and data collection occurred between February 2020 and March 2021 (ethics approval was obtained on December 17, 2019). A total of 1694 participants completed the baseline questionnaire, of whom 1206 (71.19%) were followed up for 12 months. Most follow-up waves (10,470/14,472, 72.35%) were completed, translating to a participation rate of 179% relative to our target sample size. Over 70.98% (856/1206) completed wave 12. Analyses of sample characteristics, quality metrics, and hypoglycemia incidence and prognostication are currently underway with published results anticipated by fall 2022.

CONCLUSIONS

iNPHORM is the first hypoglycemia prognostic study in the United States to leverage prospective, longitudinal self-reports. The results will contribute to improved real-world hypoglycemia risk estimation and potentially safer, more effective clinical diabetes management.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04219514; https://clinicaltrials.gov/ct2/show/NCT04219514.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/33726.

Adipose-Derived Stem Cells from Type 2 Diabetic Rats Retain Positive Effects in a Rat Model of Erectile Dysfunction

Erectile dysfunction is a common complication associated with type 2 diabetes mellitus (T2DM) and after prostatectomy in relation to cancer. The regenerative effect of cultured adipose-derived stem cells (ASCs) for ED therapy has been documented in multiple preclinical trials as well as in recent Pase 1 trials in humans. However, some studies indicate that diabetes negatively affects the mesenchymal stem cell pool, implying that ASCs from T2DM patients could have impaired regenerative capacity. Here, we directly compared ASCs from age-matched diabetic Goto–Kakizaki (ASC_GK) and non-diabetic wild type rats (ASC_WT) with regard to their phenotypes, proteomes and ability to rescue ED in normal rats. Despite ASC_GK exhibiting a slightly lower proliferation rate, ASC_GK and ASC_WT proteomes were more or less identical, and after injections to corpus cavernosum they were equally efficient in restoring erectile function in a rat ED model entailing bilateral nerve crush injury. Moreover, molecular analysis of the corpus cavernosum tissue revealed that both ASC_GK and ASC_WT treated rats had increased induction of genes involved in recovering endothelial function. Thus, our finding argues that T2DM does not appear to be a limiting factor for autologous adipose stem cell therapy when correcting for ED.

Macroalgal protein hydrolysates from Palmaria palmata influence the 'incretin effect' in vitro via DPP-4 inhibition and upregulation of insulin, GLP-1 and GIP secretion

PURPOSE

This study investigated metabolic benefits of protein hydrolysates from the macroalgae Palmaria palmata, previously shown to inhibit dipeptidylpeptidase-4 (DPP-4) activity in vitro.

METHODS

Previously, Alcalase/Flavourzyme-produced P. palmata protein hydrolysate (PPPH) improved glycaemia and insulin production in streptozotocin-induced diabetic mice. Here the PPPH, was compared to alternative Alcalase, bromelain and Promod-derived hydrolysates and an unhydrolysed control. All PPPH's underwent simulated gastrointestinal digestion (SGID) to establish oral bioavailability. PPPH's and their SGID counterparts were tested in pancreatic, clonal BRIN-BD11 cells to assess their insulinotropic effect and associated intracellular mechanisms. PPPH actions on the incretin effect were assessed via measurement of DPP-4 activity, coupled with GLP-1 and GIP release from GLUTag and STC-1 cells, respectively. Acute in vivo effects of Alcalase/Flavourzyme PPPH administration on glucose tolerance and satiety were assessed in overnight-fasted mice.

RESULTS

PPPH's (0.02-2.5 mg/ml) elicited varying insulinotropic effects (p < 0.05-0.001). SGID of the unhydrolysed protein control, bromelain and Promod PPPH's retained, or improved, bioactivity regarding insulin secretion, DPP-4 inhibition and GIP release. Insulinotropic effects were retained for all SGID-hydrolysates at higher PPPH concentrations. DPP-4 inhibitory effects were confirmed for all PPPH's and SGID counterparts (p < 0.05-0.001). PPPH's were shown to directly influence the incretin effect via upregulated GLP-1 and GIP (p < 0.01-0.001) secretion in vitro, largely retained after SGID. Alcalase/Flavourzyme PPPH produced the greatest elevation in cAMP (p < 0.001, 1.7-fold), which was fully retained post-SGID. This hydrolysate elicited elevations in intracellular calcium (p < 0.01) and membrane potential (p < 0.001). In acute in vivo settings, Alcalase/Flavourzyme PPPH improved glucose tolerance (p < 0.01-0.001) and satiety (p < 0.05-0.001).

CONCLUSION

Bioavailable PPPH peptides may be useful for the management of T2DM and obesity.

Exploring protective factors through positive psychology and salutogenesis in Danish families with type 2 diabetes

People with type 2 diabetes (T2D) live with several challenges, which may enhance the risk of poor mental and physical health. However, despite living with a chronic illness, some individuals manage to achieve a life with positivity and well-being. The objective of this study is to explore the potential of Positive Psychology and Salutogenesis when analyzing how families with one or more members with T2D experience having resources leading to thriving. Data consist of 18 semi-structured family interviews with 38 participants. Data were analyzed using systematic text condensation with the concepts of sense of coherence and upward/downward spirals as the analytical framework. The analysis revealed three overall findings: (i) T2D is perceived as manageable due to general optimism despite living with a chronic illness; (ii) establishing supportive social relations means having the opportunity to share the burden of diabetes; and (iii) achieving an open dialogue and communicating the difficulties of diabetes without straining surroundings with negative illness communication. The three overall findings may reinforce each other in an upward spiral and enhance the sense of coherence. These findings have implications for diabetes management research and our understanding of psychological health in chronic illness. The overall goal is to help people with diabetes create meaning with their illness and make use of their social environment through dialogue and communication in order to increase positivity, optimism and mental health.

Qingre Yiqi Method along with Oral Hypoglycemic Drugs in Treating Adults with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

Objective

To evaluate the efficacy of the Qingre Yiqi method in the treatment of type 2 diabetes mellitus (T2DM) with meta-analysis.

Method

The randomized controlled trials (RCTs) of the Qingre Yiqi method in the treatment of T2DM in the PubMed, Medline, EMBase, Cochrane Library, Web of Science, Weipu Journal, China Knowledge Network (CNKI), and Wanfang database were conducted. Three reviewers independently conducted the screening, extracted the data, and assessed methodological quality. Data analysis was performed using Rev Man 5.3 software for statistical analysis.

Results

A total of 15 RCTs, including 1440 patients, were included. The results showed that compared with oral hypoglycemic drugs alone, the add-on treatment of the Qingre Yiqi method could significantly improve Chinese medicine syndrome (OR (95%CI) = 3.66 [2.47,5.42], P < 0.00001) and lower the level of HbA1c (MD (95%CI) = −0.68 [0.91, −0.45], P < 0.00001), triglyceride (TG) (MD (95%CI) = −0.38 [−0.58,-0.17], P=0.0004), low-density lipoprotein cholesterol (LDL-C) (MD (95%CI) = −0.25 [−0.37, −0.13], P < 0.0001), and total cholesterol(TC) (MD(95%CI) = −0.40[−0.67, −0.13], P=0.003). In terms of fasting blood glucose (FBG) and postprandial blood sugar (PBG), subgroup analysis showed that the baseline of FBG and the number of combined oral hypoglycemic drugs of PBG were the major sources of heterogeneity.

Conclusion

Compared with the standard treatment, the Qingre Yiqi method along with oral hypoglycemic drugs showed the more beneficial effects for T2DM on improving TCM syndromes and reducing the blood glucose and partial lipid parameter.

Adaptation and psychometric validation of Diabetes Health Profile (DHP-18) in patients with type 2 diabetes in Quito, Ecuador: a cross-sectional study

Introduction

The Diabetes Health Profile (DHP‐18), structured in three dimensions (psychological distress (PD), barriers to activity (BA) and disinhibited eating (DE)), assesses the psychological and behavioural burden of living with type 2 diabetes. The objectives were to adapt the DHP‐18 linguistically and culturally for use with patients with type 2 DM in Ecuador, and to evaluate its psychometric properties.

Methods

Participants were recruited using purposive sampling through patient clubs at primary health centres in Quito, Ecuador. The DHP-18 validation consisted in the linguistic validation made by two Ecuadorian doctors and eight patient interviews. And in the psychometric validation, where participants provided clinical and sociodemographic data and responded to the SF-12v2 health survey and the linguistically and culturally adapted version of the DHP-18. The original measurement model was evaluated with confirmatory factor analysis (CFA). Reliability was assessed through internal consistency using Cronbach’s alpha and test–retest reproducibility by administering DHP-18 in a random subgroup of the participants two weeks after (n = 75) using intraclass correlation coefficient (ICC). Convergent validity was assessed by establishing previous hypotheses of the expected correlations with the SF12v2 using Spearman’s coefficient.

Results

Firstly, the DHP-18 was linguistically and culturally adapted. Secondly, in the psychometric validation, we included 146 participants, 58.2% female, the mean age was 56.8 and 31% had diabetes complications. The CFA indicated a good fit to the original three factor model (χ2 (132) = 162.738, p < 0.001; CFI = 0.990; TLI = 0.989; SRMR = 0.086 and RMSEA = 0.040. The BA dimension showed the lowest standardized factorial loads (λ) (ranging from 0.21 to 0.77), while λ ranged from 0.57 to 0.89 and from 0.46 to 0.73, for the PD and DE dimensions respectively. Cronbach’s alphas were 0.81, 0.63 and 0.74 and ICCs 0.70, 0.57 and 0.62 for PD, BA and DE, respectively. Regarding convergent validity, we observed weaker correlations than expected between DHP-18 dimensions and SF-12v2 dimensions (r > −0.40 in two of three hypotheses).

Conclusions

The original three factor model showed good fit to the data. Although reliability parameters were adequate for PD and DE dimensions, the BA presented lower internal consistency and future analysis should verify the applicability and cultural equivalence of some of the items of this dimension to Ecuador.

Altered Jagged1-Notch1 Signaling in Enhanced Dysfunctional Neovascularization and Delayed Angiogenesis After Ischemic Stroke in HFD/STZ Induced Type 2 Diabetes Rats

Diabetes exacerbates brain damage in cerebral ischemic stroke. Our previous study has demonstrated that after cerebral ischemia, type 2 diabetes rats displayed worse neurological outcomes, larger cerebral infarction and severer blood-brain barrier disruption. However, our knowledge of the mechanisms of how diabetes impacts the cerebrovascular repair process is limited. This study was aimed to characterize structural alterations and potential mechanisms in brain microvessels before and after ischemic stroke in type 2 diabetic rats treated with high-fat diet and streptozotocin (HFD/STZ). Furtherly, we tested our hypothesis that dysregulated intercellular Jagged1-Notch1 signaling was involved in the dysfunctional cerebral neovascularization both before and after ischemic stroke in HFD/STZ rats. In our study, we found increased yet dysfunctional neovascularization with activated Jagged1-Notch1 signaling in the cerebrovasculature before cerebral ischemia in HFD/STZ rats compared with non-diabetic rats. Furthermore, we observed delayed angiogenesis as well as suppressed Jagged1-Notch1 signaling after ischemic stroke. Our results elucidate the potential mechanisms underlying diabetes-related cerebral microvasculature dysfunction after ischemic stroke.

The Burden of Type 2 Diabetes and the Value of Achieving Near Normoglycemia from the Patient Perspective

INTRODUCTION

Type 2 diabetes (T2D) is extremely burdensome to people with T2D and associated with impaired health-related quality of life. This study explores the impact of T2D and potentially relevant outcomes for new therapies using a unique approach to in-depth qualitative interviews where people with T2D are asked to think about their future with T2D.

METHODS

A cross-sectional qualitative interview study among people with T2D from the USA and UK. Interviews explored their treatment journey, perceptions of their future with T2D, and the value of achieving normoglycemia (explored through presentation of two vignettes with hypothetical medications that reduced hemoglobin A1c [HbA1c] levels < 7% and < 5.7%).

RESULTS

Patients with T2D (N = 50; US n = 25; UK n = 25) were 66.0% male, had a mean body mass index (BMI) of 30.8 ± 6.3 kg/m², and had a mean of 13.0 ± 10.0 years since diagnosis. Current diabetes treatments included diet and exercise only (8.0%), oral medications only (62.0%), oral plus injections (24.0%), and insulin only (6.0%). Despite being treated, participants reported over 25 different unmet needs related to their T2D across a broad range of domains. The most common concerns were diet, diabetes-related complications, weight changes, and psychological and emotional issues. A large majority of participants indicated that achieving lower HbA1c values would change their life. When reflecting on the value of improved glycemic control, patients primarily anticipated physical improvements and improved psychological well-being. When presented with two hypothetical treatments, about 70% of participants preferred the < 5.7% treatment option over the < 7% HbA1c treatment option.

CONCLUSIONS

People with T2D have a high disease burden, a broad range of unmet needs, and extremely varied experiences and expectations on the impacts of T2D on their lives and future. Many patients indicated that achieving near normoglycemia would substantially change their lives primarily in terms of their physical and emotional health.

The Influence of Baseline Hemoglobin A1c on Digital Health Coaching Outcomes in Adults With Type 2 Diabetes: Real-World Retrospective Cohort Study

BACKGROUND

Digital health coaching is an increasingly common diabetes self-management support strategy for individuals with type 2 diabetes and has been linked to positive mental and physical health outcomes. However, the relationship between baseline risk and outcomes is yet to be evaluated in a real-world setting.

OBJECTIVE

The purpose of this real-world study was to evaluate trends in digital health coaching outcomes by baseline hemoglobin A1c (HbA1c) to better understand which populations may experience the greatest clinical and psychosocial benefit.

METHODS

A retrospective cohort study design was used to evaluate program effect in a convenience sample of participants in a 12-week digital health coaching program administered by Pack Health. Participants were referred through their health care provider, payer, or employer. The program included patient-centered lifestyle counseling and psychosocial support delivered via telephone, text, and/or email. Self-reported HbA1c and weight were collected at baseline and completion. Physical and mental health were assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Short Form and the Diabetes Distress Scale-2. Changes in HbA1c, weight, BMI, and physical and mental health were analyzed within three participant cohorts stratified by baseline HbA1c level.

RESULTS

Participants with complete HbA1c data sets (n=226) were included in the analysis. The sample population was 71.7% (162/226) female, with 61.5% (139/226) identifying as white and 34.1% (77/226) as black. Most participants (184/226, 81.4%) reported a baseline HbA1c ≥7%, and 20.3% (46/226) were classified as high risk (HbA1c >9%). Across HbA1c cohorts, the mean baseline BMI was 35.83 (SD 7.79), and the moderate-risk cohort (7% ≤ HbA1c ≤ 9%) reported the highest mean value (36.6, SD 7.79). At 12 weeks, patients reported a significant decrease in HbAlc, and high-risk participants reduced their levels by the greatest margin (2.28 points; P<.001). Across cohorts, BMI improved by 0.82 (P<.001), with the moderate-risk cohort showing the greatest reduction (-0.88; P<.001). Overall, participants reported significant improvements for PROMIS scores, with the greatest change occurring in the high-risk cohort for whom physical health improved 3.84 points (P<.001) and mental health improved 3.3 points (P<.001). However, the lowest-risk cohort showed the greatest improvements in diabetes distress (-0.76; P=.005).

CONCLUSIONS

Acknowledging the limitations in this real-world study design, the results reported here suggest that adults with type 2 diabetes with a high baseline HbA1c or high BMI may benefit the most from patient-centered digital health coaching programs when compared to their lower risk counterparts. While all participants improved in physical and mental health categories, participants with high HbA1c experienced the greatest HbA1c reduction and individuals with the highest baseline BMI lost the most weight. These results may be used to inform referrals for patients who are more likely to benefit from digital health coaching.

Dietary exposures in childhood and adulthood and cardiometabolic outcomes: a systematic scoping review

Associations between diet and cardiometabolic outcomes are often based on a single measurement of diet in adulthood. Dietary exposures in childhood are thought to influence cardiometabolic disease development and individuals' diets can change over time, therefore dietary exposure in childhood and over long periods are both important to consider. This scoping review aimed to identify and characterise the literature on associations between diet measured in both childhood and adulthood and cardiometabolic outcomes. Seven databases were searched; eligible evidence sources were original analyses published as a journal article in English. Exposures included measures of dietary intake, diet quality and eating behaviours measured in both childhood and adulthood with at least five years between first and last measurements. Cardiometabolic outcomes included measures of anthropometry, biochemistry, vascular structure/function and disease states/scores. We identified 37 eligible articles from nine cohort studies. Dietary exposures were measured between two and eight times and most often assessed by food frequency questionnaire or diet history. The dietary exposures most frequently examined were protein, fat, carbohydrate, fruit, vegetables, sugar-sweetened beverages and breakfast. Cardiometabolic outcomes were predominantly based on risk markers. Authors utilised a variety of analytical approaches to transform and analyse repeated measures of diet, providing insights relevant to different lifespan nutrition concepts. The literature on associations between diet in childhood and adulthood and cardiometabolic outcomes is limited, but such studies have great potential to extend our knowledge in ways only possible with repeated measures of diet over time. Further research is needed to develop the evidence base for diet-disease relationships from a life course perspective, accounting for diet in both childhood and adulthood.

Asymptomatic urinary tract infections and associated risk factors in Pakistani Muslim type 2 diabetic patients

Background

One of the leading long-term complications of type 2 diabetes mellitus (T2DM) includes renal dysfunction and urinary tract infections (UTI) which are considered to be prevalent in uncontrolled diabetes. Moreover, physiological factors like age, gender, duration of diabetes, other diabetic complications like neuropathy, autonomic neuropathy and glycosuria are also considered as predisposing factors for increased prevalence of UTI in diabetes which can be symptomatic or asymptomatic.

Methods

This was a cross-sectional, multi-centre study including diabetic patients from 12 clinical sites spread across major cities of Pakistan. The inclusion criteria were adult Pakistani population of age between 18 to 75 years both genders and suffering from T2DM irrespective of duration. A detailed clinical history of the past 3 months was recorded and, biochemical investigations of blood samples were conducted. Urine culture analysis performed identified the type of pathogen present and was done only for asymptomatic patients.

Results

A total of 745 type 2 diabetic patients were initially screened, out of 545 patients considered for final analysis 501 (91.92%) were negative and the rest 44 (8.08%) had positive urine culture. Female gender had a significantly higher proportion of positive urine culture (77.27%, p-value< 0.001). Body mass index and mean age had insignificant distribution among the two groups of positive and negative urine culture, with age 40–59 years having higher proportion (70.45%) in the positive group. Escherichia coli was detected in most of the positive samples (52.3%). All bacterial samples were found resistant to Ciprofloxacin.

Conclusion

Diabetic Pakistani muslim female patients are identified to be at high risk of suffering from asymptomatic UTI and age more than 40 years is an important risk factor. Escherichia coli was the most common causative organism among people living in this geographical area.

Healthcare Costs Associated with Complications in Patients with Type 2 Diabetes among 1.85 Million Adults in Beijing, China

We aimed to provide reliable regression estimates of expenditures associated with various complications in type 2 diabetics in China. In total, 1,859,039 type 2 diabetes patients with complications were obtained from the Beijing Medical Claim Data for Employees database from 2008 to 2016. We estimated costs for complications using a generalized estimating equation model adjusted for age, sex, and the incidence of various complications. The average total cost for diabetic patients with complications was 17.12 thousand RMB. Prescribed drugs accounted for 63.4% of costs. We observed a significant increase in costs in the first year after the onset of complications. Compared with costs before the incidence of complications, the additional costs per person in the first year and >1 year after the event would be 10,631.16 RMB and 1150.71 RMB for cardiovascular disease, 1017.62 RMB and 653.82 RMB for cerebrovascular disease, and 301.14 RMB and 624.00 RMB for kidney disease, respectively. The estimated coefficients for outpatient visits were relatively lower than those of inpatient visits. Complications in diabetics exert a significant impact on total healthcare costs in the first year of their onset and in subsequent years. Our estimates may assist policymakers in quantifying the economic burden of diabetes complications.

Professional continuous glucose monitoring and endocrinology eConsult for adults with type 2 diabetes in primary care: Results of a clinical pilot program

Background

Limitations in access to specialty diabetes care exist. Endocrinology eConsult that integrates professional continuous glucose monitoring (CGM-enhanced eConsult) may improve healthcare delivery, but has yet to be evaluated. We implemented a pilot program for patients with type 2 diabetes (T2DM) managed by primary care clinical pharmacists using CGM-enhanced eConsult and evaluated the acceptability and clinical outcomes in comparison to routine in-person endocrinology consultation.

Methods

Seventy-four adult patients with established T2DM (age 18-65) were included. Twenty-nine were seen in-person by endocrinology and 45 were seen by pharmacists in primary care. Thirteen patients were referred for CGM-enhanced eConsult. Acceptability was assessed with pre/post clinician acceptability questionnaires and patient assessment of perceived burden. Clinical outcomes included time to first specialty appointment, baseline and 3-month follow-up HbA1c, and antihyperglycemic medication use.

Results

There were no differences in patient acceptability of the CGM-enhanced eConsult as compared to endocrinology referral or pharmacy care. At baseline, all patients referred for eConsult were prescribed insulin. Three-month glycemic outcomes were comparable, with HbA1c reduction 1% + 2% in endocrinology, 1.5% + 1.1% with CGM-enhanced eConsult, and 1.6% + 1.8% in clinical pharmacy (p = 0.19). Time to an initial diabetes visit with a pharmacist was significantly shorter than with endocrinology, 20 days (IQR 26) for pharmacy vs. 45 days (IQR 54) for endocrinology, (p = 0.0001).

Conclusions

CGM-enhanced eConsult resulted in more timely access to endocrinology expertise, was acceptable to patients, and resulted in similar short-term glycemic outcomes compared to in-person consultation. Effectiveness of CGM-enhanced eConsults should be further explored.