Glycemic Variability and Diabetes Complications: Does It Matter? Of Course It Does!

DDLA: a double deep latent autoencoder for diabetic retinopathy diagnose based on continuous glucose sensors

The current diagnosis of diabetic retinopathy is based on fundus images and clinical experience. However, considering the ineffectiveness and non-portability of medical devices, we aimed to develop a diagnostic model for diabetic retinopathy based on glucose series data from the wearable continuous glucose monitoring system. Therefore, this study developed a novel method, i.e., double deep latent autoencoder, for exploring glycemic variability influence from multi-day glucose data for diabetic retinopathy. Specifically, the model proposed in this research could encode continuous glucose sensor data with non-continuous and variable length via the integration of a data reorganization module and a novel encoding module with fragmented-missing-wise objective function. Additionally, the model implements a double deep autoencoder, which integrated convolutional neural network, long short-term memory, to jointly capturing the inter-day and intra-day glucose latent features from glucose series. The effectiveness of the proposed model is evaluated through a cross-validation method to clinical datasets of 765 type 2 diabetes patients. The proposed method achieves the highest accuracy value (0.89), precision value (0.88), and F1 score (0.73). The results suggest that our model can be used to remotely diagnose and screen for diabetic retinopathy by learning potential features of glucose series data collected by wearable continuous glucose monitoring systems.

Yoga as an alternative to cycling in type 1 diabetes: A preliminary study of acute effects on glucose levels

We evaluated the acute effects of yoga compared to cycling on glucose change and variability, and the occurrence of hypoglycemia in adults with type 1 diabetes. Fifteen participants performed 50 min of cycling or yoga. Glucose values were collected before and after exercise. Coefficient of variation (CV) and hypoglycemic episodes were evaluated from the start up to 12 h after exercise. Cycling and yoga significantly reduced glucose values during exercise, and CV was lower after yoga. One hypoglycemic episode occurred with yoga and seven with cycling. Yoga is a safe exercise that acutely reduces glucose values, but with lower risk of hypoglycemia compared to cycling.

Personal and Social-Built Environmental Factors of Glucose Variability Among Multiethnic Groups of Adults With Type 2 Diabetes: Research Protocol Using Ecological Momentary Assessment, Continuous Glucose Monitoring, and Actigraphy

Glucose variability (GV)-the degree of fluctuation in glucose levels over a certain period of time-is emerging as an important parameter of dynamic glycemic control. Repeated glycemic oscillations have been reported to be the link to diabetes complications. This prospective observational study aims to: (1) identify multilevel risk factors (personal and social-built environmental factors) associated with high GV; (2) identify "within-person predictors" of high GV leveraging the intra-person data to inform future personalized diabetes interventions; and (3) examine which lifestyle factors either mediate or moderate the relationship between emotional well-being and GV among diverse adults with type 2 diabetes (T2D). We will recruit 200 adults with T2D from the community. All participants will complete baseline surveys assessing demographics, lifestyle, social-built environmental, and clinical factors. Real-time dynamic glucose levels will be measured using continuous glucose monitoring (CGM). Sleep, physical activity, diet/eating, and emotional well-being will be measured with an actigraphy device and a real-time self-report tool (ecological momentary assessment [EMA]) across 14 days. Two 24-h dietary recall data will be collected by online video calls. Generalized linear models, multilevel models, and structural equation models will be developed to achieve the study aims. The findings from the study will identify high-risk groups of high GV who would benefit from CGM to improve diabetes outcomes and inform the future development of personalized just-in-time interventions targeting lifestyle behaviors with an increased understanding of GV and by supporting healthcare providers' clinical decisions.

Evaluation of folliculogenesis and oxidative stress parameters in type 1 diabetes mellitus women with different glycemic profiles

BACKGROUND

Despite enormous advances in diabetes treatment, women with type 1 diabetes mellitus (DM) still experience delayed menarche, menstrual irregularities, fewer pregnancies, and a higher rate of stillbirths compared to women without the disease. Due to the fact that type 1 DM occurs at a young age, the preservation of reproductive health is one of the most important goals of treatment.

AIMS

The aim of this study was to evaluate the relationship between different glycemic profiles and changes in the pro-oxidant-antioxidant balance and ovarian follicular apparatus in reproductive-age patients with type 1 DM.

METHODS

We examined 50 reproductive-age (19-38 years) women with type 1 DM with a disease duration of at least ten years. Carbohydrate metabolism was assessed with the continuous glucose monitoring (CGM) system and glycated hemoglobin (HbA1c) concentration measurement. CGM was performed using the FreeStyle Libre flash glucose monitoring system (Abbott Diabetes Care, Witney, UK). In each patient, malondialdehyde level, catalase activity and 3-nitrotyrosine level in the blood serum were determined. To assess the ovarian function, we measured the ovarian volume, the antral follicle count, and the serum levels of anti-Müllerian hormone and follicle-stimulating hormone. All patients were divided into four groups (glucotypes) based on the CGM results. Group 1 included type 1 DM patients with satisfactory compensation of carbohydrate metabolism; group 2 consisted of patients with frequent hypoglycemic conditions and pathological glucose variability; group 3 included individuals with prolonged hyperglycemic conditions and maximum HbA1c levels; and group 4 comprised patients with the glycemic profile characterized by all the presented types of dysglycemia (intermittent glycemia).

RESULTS

We revealed a negative correlation between serum catalase activity and time of hypoglycemic conditions in patients with type 1 DM based on the CGM results (rs = -0.47, p < 0.01). In group 4 (intermittent glycemia), patients demonstrated the lowest serum catalase activity and increased serum 3-nitrotyrosine level, while in group 3, women with chronic hyperglycemia (HbA1c 8.4 [8.1; 9.9]%; 68 [65; 85] mmol/mol) had a moderate change in antioxidant defense and oxidative stress parameters. Correlation analysis of ovarian volume, the antral follicle count, and the serum anti-Müllerian hormone level in type 1 DM women with different glycemic profiles established a negative relationship (rs = -0.82, p < 0.05) between the antral follicle count and glucose variability in group 1, a positive relationship (rs = 0.68, p < 0.05) between ovarian volume and glucose variability in group 2, and a positive relationship (rs = 0.88, p < 0.05) between ovarian volume and time of hypoglycemic conditions, which, according to the CGM results, amounted to a critical value of 57.5 [40.0; 82.0]%.

CONCLUSIONS

The data obtained indicate the relationship between the ovarian volume, serum anti-Müllerian hormone level, the antral follicle count and oxidative stress parameters not only in patients with hyperglycemia, but also in those with hypoglycemic conditions, as well as with pathological glucose variability.

Observational study on stability of within-day glycemic variability of type 2 diabetes inpatients treated with decoctions of traditional Chinese medicine

Background

Within-day glycemic variability (GV), characterized by frequent and significant fluctuations in blood glucose levels, is a growing concern in hospitalized patients with type 2 diabetes mellitus (T2DM). It is associated with an increased risk of hypoglycemia and potentially higher long-term mortality rates. Robust clinical evidence is needed to determine whether traditional Chinese medicine (TCM) decoctions can be a beneficial addition to the management of within-day GV in this patient population.

Methods

This retrospective cohort study utilized data from adult inpatients diagnosed with T2DM admitted to the Traditional Chinese Medicine Hospital of Kaifeng. The primary outcome investigated was the association between the use of TCM decoctions and improved stability of within-day GV. Blood glucose variability was assessed using the standard deviation of blood glucose values (SDBG). For each patient, the total number of hospitalization days with SDBG below 2 mmol/L was calculated to represent within-day GV stability. Hospitalization duration served as the secondary outcome, compared between patients receiving TCM decoctions and those who did not. The primary analysis employed a multivariable logistic regression model, with propensity score matching to account for potential confounding variables.

Results

A total of 1,360 patients were included in the final analysis. The use of TCM decoctions was significantly associated with enhanced stability of within-day GV (OR = 1.77, 95% CI: 1.34-2.33, P < 0.01). This association was most prominent in patients with a diagnosis of deficiency syndrome (predominantly qi-yin deficiency, accounting for 74.8% of cases) and a disease duration of less than 5 years (OR = 2.28, 95% CI: 1.21-4.29, P = 0.03). However, TCM decoctions did not exert a statistically significant effect on hospitalization duration among patients with T2DM (OR = 0.96, 95% CI: 0.91-1.01, P = 0.22).

Conclusion

This study suggests that TCM decoctions may be effective in improving within-day GV stability in hospitalized patients with T2DM. This effect appears to be most pronounced in patients diagnosed with deficiency syndrome, particularly those with qi-yin deficiency and a shorter disease course. Further investigation is warranted to confirm these findings and elucidate the underlying mechanisms.

Pre-hospital glycemia as a biomarker for in-hospital all-cause mortality in diabetic patients - a pilot study

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) presents a significant healthcare challenge, with considerable economic ramifications. While blood glucose management and long-term metabolic target setting for home care and outpatient treatment follow established procedures, the approach for short-term targets during hospitalization varies due to a lack of clinical consensus. Our study aims to elucidate the impact of pre-hospitalization and intra-hospitalization glycemic indexes on in-hospital survival rates in individuals with T2DM, addressing this notable gap in the current literature.

METHODS

In this pilot study involving 120 hospitalized diabetic patients, we used advanced machine learning and classical statistical methods to identify variables for predicting hospitalization outcomes. We first developed a 30-day mortality risk classifier leveraging AdaBoost-FAS, a state-of-the-art ensemble machine learning method for tabular data. We then analyzed the feature relevance to identify the key predictive variables among the glycemic and routine clinical variables the model bases its predictions on. Next, we conducted detailed statistical analyses to shed light on the relationship between such variables and mortality risk. Finally, based on such analyses, we introduced a novel index, the ratio of intra-hospital glycemic variability to pre-hospitalization glycemic mean, to better characterize and stratify the diabetic population.

RESULTS

Our findings underscore the importance of personalized approaches to glycemic management during hospitalization. The introduced index, alongside advanced predictive modeling, provides valuable insights for optimizing patient care. In particular, together with in-hospital glycemic variability, it is able to discriminate between patients with higher and lower mortality rates, highlighting the importance of tightly controlling not only pre-hospital but also in-hospital glycemic levels.

CONCLUSIONS

Despite the pilot nature and modest sample size, this study marks the beginning of exploration into personalized glycemic control for hospitalized patients with T2DM. Pre-hospital blood glucose levels and related variables derived from it can serve as biomarkers for all-cause mortality during hospitalization.

Glucocorticoid-Induced Hyperglycemia: A Neglected Problem

Glucocorticoids provide a potent therapeutic response and are widely used to treat a variety of diseases, including coronavirus disease 2019 (COVID-19) infection. However, the issue of glucocorticoid-induced hyperglycemia (GIH), which is observed in over one-third of patients treated with glucocorticoids, is often neglected. To improve the clinical course and prognosis of diseases that necessitate glucocorticoid therapy, proper management of GIH is essential. The key pathophysiology of GIH includes systemic insulin resistance, which exacerbates hepatic steatosis and visceral obesity, as well as proteolysis and lipolysis of muscle and adipose tissue, coupled with β-cell dysfunction. For patients on glucocorticoid therapy, risk stratification should be conducted through a detailed baseline evaluation, and frequent glucose monitoring is recommended to detect the onset of GIH, particularly in high-risk individuals. Patients with confirmed GIH who require treatment should follow an insulin-centered regimen that varies depending on whether they are inpatients or outpatients, as well as the type and dosage of glucocorticoid used. The ideal strategy to maintain normoglycemia while preventing hypoglycemia is to combine basal-bolus insulin and correction doses with a continuous glucose monitoring system. This review focuses on the current understanding and latest evidence concerning GIH, incorporating insights gained from the COVID-19 pandemic.

A genetic mouse model of lean-NAFLD unveils sexual dimorphism in the liver-heart axis

Lean patients with NAFLD may develop cardiac complications independently of pre-existent metabolic disruptions and comorbidities. To address the underlying mechanisms independent of the development of obesity, we used a murine model of hepatic mitochondrial deficiency. The liver-heart axis was studied as these mice develop microvesicular steatosis without obesity. Our results unveil a sex-dependent phenotypic remodeling beyond liver damage. Males, more than females, show fasting hypoglycemia and increased insulin sensitivity. They exhibit diastolic dysfunction, remodeling of the circulating lipoproteins and cardiac lipidome. Conversely, females do not manifest cardiac dysfunction but exhibit cardiometabolic impairments supported by impaired mitochondrial integrity and β-oxidation, remodeling of circulating lipoproteins and intracardiac accumulation of deleterious triglycerides. This study underscores metabolic defects in the liver resulting in significant sex-dependent cardiac abnormalities independent of obesity. This experimental model may prove useful to better understand the sex-related variability, notably in the heart, involved in the progression of lean-NAFLD.

Serum betaine and dimethylglycine in mid-pregnancy and the risk of gestational diabetes mellitus: a case-control study

PURPOSE

To investigate the associations of choline, betaine, dimethylglycine (DMG), L-carnitine, and Trimethylamine-N-oxide (TMAO) with the risk of Gestational diabetes mellitus (GDM) as well as the markers of glucose homeostasis.

METHODS

We performed a case-control study including 200 diagnosed GDM cases and 200 controls matched by maternal age (±2 years) and gestational age (±2 weeks). Concentrations of serum metabolites were measured by the high-performance liquid chromatography - tandem mass spectrometry (HPLC-MS/MS).

RESULTS

Compared to the control group, GDM group had significantly lower serum betaine concentration and betaine/choline ratio, and higher DMG concentration. Furthermore, decreased betaine concentration and betaine/choline ratio, increased DMG concentration showed significant association with the risk of GDM. In addition, serum betaine concentrations were negatively associated with blood glucose levels at 1-h post-glucose load (OGTT-1h), and both betaine and L-carnitine concentrations were positively associated with 1,5-anhydroglucitol levels. Betaine/choline ratio was negatively associated with OGTT-1h and blood glucose levels at 2-h post-glucose load (OGTT-2h) and serum choline concentrations were negatively associated with fasting blood glucose and positively associated with OGTT-2h.

CONCLUSION

Decreased serum betaine concentrations and betaine/choline ratio, and elevated DMG concentrations could be significant risk factors for GDM. Furthermore, betaine may be associated with blood glucose regulation and short-term glycemic fluctuations.

Short-term glucose variability as a determinant of the healing rate of diabetic foot ulcer: A retrospective study

BACKGROUND

The aim of this study was to describe the clinical characteristics of people with diabetic foot ulcer (DFU) according to glucose variability (GV) and to investigate the relationship between GV and DFU outcome in a population with type 2 diabetes (T2D) and DFU.

METHODS

This is a retrospective study of 300 individuals aged 64.3 years (181 males) treated for DFU in a tertiary-care center with a regular follow-up for 6 months. Laboratory measurements and clinical assessments were collected at baseline. According to the coefficient of variation (CV) cut-off (≥36%), people were divided into two groups (low and high GV).

RESULTS

Compared with low GV group (n = 245), high GV group (n = 55) had significant longer duration of diabetes [low vs high GV, mean ± Standard Deviation (SD), 17.8 ± 11.8 vs 22.4 ± 10.8, P = 0.012], higher levels of glycated haemoglobin [median (IQR), 7.4 (6.6, 8.8) vs 8.2 (7.0, 9.6), P = 0.010] and urinary albumin excretion [25.2 (11.9, 77.0) vs 48.0 (23.2, 106.0), P = 0.031]. Moreover, 10 days self-monitoring of blood glucose-derived glycemic metrics were significantly different between groups. No differences among clinical features were found. The multiple logistic regression analysis identified CV and SD as negative predictors of healing.

CONCLUSIONS

In a population of people with T2D and DFU treated in a tertiary-care center, individuals with high GV had a 3-fold higher risk of healing failure, as compared with those with low GV. CV and SD were related to poor healing within 6 months follow-up.

Enhancement of Ambulatory Glucose Profile for Decision Assistance and Treatment Adjustments

The ambulatory glucose profile (AGP) lacks sufficient statistical metrics and insightful graphs; indeed, it is missing important information on the temporal patterns of glucose variations. The AGP graph is difficult to interpret due to the overlapping metrics and fluctuations in glucose levels over 14 days. The objective of this proposed work is to overcome these challenges, specifically the lack of insightful information and difficulty in interpreting AGP graphs, to create a platform for decision assistance. The present work proposes 20 findings built from decision rules that were developed from a combination of AGP metrics and additional statistical metrics, which have the potential to identify patterns and insightful information on hyperglycemia and hypoglycemia. The "CGM Trace" webpage was developed, in which insightful metrics and graphical representations can be used to make inferences regarding the glucose data of any user. However, doctors (endocrinologists) can access the "Findings" tab for a summarized presentation of their patients' glycemic control. The findings were implemented for 67 patients' data, in which the data of 15 patients were collected from a clinical study and the data of 52 patients were gathered from a public dataset. The findings were validated by means of MANOVA (multivariate analysis of variance), wherein a p value of < 0.05 was obtained, depicting a strong significant correlation between the findings and the metrics. The proposed work from "CGM Trace" offers a deeper understanding of the CGM data, enhancing AGP reports for doctors to make treatment adjustments based on insightful information and hidden patterns for better diabetic management.

Washed microbiota transplantation reduces glycemic variability in unstable diabetes

BACKGROUND

Dysbiosis of gut microbiota is causally linked to impaired host glucose metabolism. We aimed to study effects of the new method of fecal microbiota transplantation, washed microbiota transplantation (WMT), on reducing glycemic variability (GV) in unstable diabetes.

METHODS

Fourteen eligible patients received three allogenic WMTs and were followed up at 1 week, 1 month, and 3 months. Primary outcomes were daily insulin dose, glucose excursions during meal tests, and GV indices calculated from continuous monitoring or self-monitoring glucose values. Secondary outcomes were multiomics data, including 16S rRNA gene sequencing, metagenomics, and metabolomics to explore underlying mechanisms.

RESULTS

Daily insulin dose and glucose excursions markedly dropped, whereas GV indices significantly improved up to 1 month. WMT increased gut microbial alpha diversity, beta diversity, and network complexity. Taxonomic changes featured lower abundance of genera Bacteroides and Escherichia-Shigella, and higher abundance of genus Prevotella. Metagenomics functional annotations revealed enrichment of distinct microbial metabolic pathways, including methane biosynthesis, citrate cycle, amino acid degradation, and butyrate production. Derived metabolites correlated significantly with improved GV indices. WMT did not change circulating inflammatory cytokines, enteroendocrine hormones, or C-peptide.

CONCLUSIONS

WMT showed strong ameliorating effect on GV, raising the possibility of targeting gut microbiota as an effective regimen to reduce GV in diabetes.

Glycemic variability: Measurement, target, impact on complications of diabetes and does it really matter?

Over the past two decades, there has been continuous advancement in the accuracy and complexity of continuous glucose monitoring devices. Continuous glucose monitoring provides valuable insights into blood glucose dynamics, and can record glucose fluctuations accurately and completely. Glycemic variability (GV) is a straightforward measure of the extent to which a patient's blood glucose levels fluctuate between high peaks and low nadirs. Many studies have investigated the relationship between GV and complications, primarily in the context of type 2 diabetes. Nevertheless, the exact contribution of GV to the development of diabetes complications remains unclear. In this literature review, we aimed to summarize the existing evidence regarding the measurement, target level, pathophysiological mechanisms relating GV and tissue damage, and population-based studies of GV and diabetes complications. Additionally, we introduce novel methods for measuring GV, and discuss several unresolved issues of GV. In the future, more longitudinal studies and trials are required to confirm the exact role of GV in the development of diabetes complications.

Injectable systems for long-lasting insulin therapy

Insulin therapy is the mainstay to treat diabetes characterizedd by hyperglycemia. However, its short half-life of only 4-6 min limits its effectiveness in treating chronic diabetes. Advances in recombinant DNA technology and protein engineering have led to several insulin analogue products that have up to 42 h of glycemic control. However, these insulin analogues still require once- or twice-daily injections for optimal glycemic control and have poor patient compliance and adherence issues. To achieve insulin release for more than one day, different injectable delivery systems including microspheres, in situ forming depots, nanoparticles and composite systems have been developed. Several of these delivery systems have advanced to clinical trials for once-weekly insulin injection. This review comprehensively summarizes the developments of injectable insulin analogs and delivery systems covering the whole field of injectable long-lasting insulin technologies from prototype design, preclinical studies, clinical trials to marketed products for the treatment of diabetes.

Association of glycemic variability with death and severe consciousness disturbance among critically ill patients with cerebrovascular disease: analysis of the MIMIC-IV database

BACKGROUND

The association of glycemic variability with severe consciousness disturbance and in-hospital all-cause mortality in critically ill patients with cerebrovascular disease (CVD) remains unclear, This study aimed to investigate the association of glycemic variability with cognitive impairment and in-hospital death.

METHOD

We extracted all blood glucose measurements of patients diagnosed with CVD from the Medical Information Mart for Intensive Care IV (MIMIC-IV). Glycemic variability was defined as the coefficient of variation (CV), which was determined using the ratio of standard deviation and the mean blood glucose levels. Cox hazard regression models were applied to analyze the link between glycemic variability and outcomes. We also analyzed non-linear relationship between outcome indicators and glycemic variability using restricted cubic spline curves.

RESULTS

The present study included 2967 patients diagnosed with cerebral infarction and 1842 patients diagnosed with non-traumatic cerebral hemorrhage. Log-transformed CV was significantly related to cognitive impairment and in-hospital mortality, as determined by Cox regression. Increasing log-transformed CV was approximately linearly with the risk of cognitive impairment and in-hospital mortality.

CONCLUSION

High glycemic variability was found to be an independent risk factor for severe cognitive decline and in-hospital mortality in critically ill patients with CVD. Our study indicated that enhancing stability of glycemic variability may reduced adverse outcomes in patients with severe CVD.

Not so fast: Paradoxically increased variability in the glucose tolerance test due to food withdrawal in continuous glucose-monitored mice

OBJECTIVE

This study was performed to determine the effect of fasting on reproducibility of the glucose tolerance test. Due to individual variation in animal feeding behaviors, fasting animals prior to metabolic and behavioral experiments is widely held to reduce inter-subject variation in glucose and metabolic parameters of preclinical rodent models. Reducing variability is especially important for studies where initial metabolite levels can influence the magnitude of experimental interventions, but fasting also imposes stress that may distort the variables of interest. One such intervention is the glucose tolerance test (GTT) which measures the maximum response and recovery following a bolus of exogenous glucose. We sought to investigate how fasting affects the response of individual mice to a GTT.

METHODS

Using simultaneous continuous glucose monitoring (CGM) and indirect calorimetry, we quantified blood glucose, physical activity, body temperature, metabolic rates, and food consumption levels on a minute-to-minute basis in adult male mice for 4 weeks. We tested the effects of a 4-h or 18-h fast on the GTT to examine the effect of food withdrawal in light or dark photoperiods. Studies were also performed with 4-h fasting in additional mice without implanted CGM probes.

RESULTS

Contrary to our expectations, a 4-h fast during the light photoperiod promotes a paradoxical increase in inter-animal variation in metabolic rate, physical activity, body temperature, glycemia, and glucose tolerance. This hyperglycemic and hyper-metabolic phenotype promotes increased corticosterone levels and is consistent with a behavioral stress response to food deprivation, even in well-fed mice. We find that mice undergoing an 18-h fast entered torpor, a hibernation-like state. In addition to low body temperature and metabolic rate, torpor is also associated with glucose levels 56 mg/dl lower than those seen in mice with ad libitum access to food. Moreover, the time spent in torpor affects the response to a GTT.

CONCLUSION

Our results suggest fasting mice before glucose tolerance testing, and perhaps other experiments, can have the opposite of the intended effect where fasting can increase, rather than decrease, experimental variability.

Analysis of Risk Factors for Revitrectomy in Eyes with Diabetic Vitreous Hemorrhage

Purpose

We aimed to investigate the risk factors associated with revitrectomy in eyes with diabetic vitreous hemorrhage and to determine the prognosis of these patients at least one year postoperatively.

Patients and Methods

This retrospective case-control study had a minimum follow-up period of one year. Patients were divided into single vitrectomy group (control group, n=202) and revitrectomy group (case group, n=36) for analysis. The indications, number, and timing of revitrectomies were documented. And the revitrectomy group was further divided into two vitrectomies group (n=30) and three or more vitrectomies group (n=6). The best-corrected visual acuity (BCVA) at the last follow-up and the occurrence of neovascular glaucoma (NVG) were compared among the single vitrectomy, two vitrectomies and three or more vitrectomies groups. We conducted a thorough collection of patient data and used univariate and binary logistic regression analyses to identify the risk factors associated with revitrectomy.

Results

A total of 197 patients (238 eyes) were included. Thirty-six eyes (15.1%) required revitrectomy with six eyes (2.5%) undergoing three or more vitrectomies during the follow-up period. The median duration of the second vitrectomy was 3 (2-6) months. The indications for a second vitrectomy included 28 eyes (77.8%) of postoperative vitreous hemorrhage and 7 eyes (22.2%) combined with tractional retinal detachment. Patients undergoing three or more vitrectomies had significantly worse postoperative BCVA and a higher incidence of NVG (P<0.01). Fibrinogen> 4 g/L (P<0.001) and preoperative anti-vascular endothelial growth factor intravitreal injection (P=0.015) were independent risk factors for revitrectomy, and glycated hemoglobin A1c (HbA1c)>10% (P=0.049) showed significant difference only in univariate analysis.

Conclusion

Patients requiring revitrectomy tended to have higher fibrinogen levels, tightly adhered fibrovascular membranes, higher HbA1c levels, and worse prognoses.

A deep learning nomogram of continuous glucose monitoring data for the risk prediction of diabetic retinopathy in type 2 diabetes

Continuous glucose monitoring (CGM) data analysis will provide a new perspective to analyze factors related to diabetic retinopathy (DR). However, the problem of visualizing CGM data and automatically predicting the incidence of DR from CGM is still controversial. Here, we explored the feasibility of using CGM profiles to predict DR in type 2 diabetes (T2D) by deep learning approach. This study fused deep learning with a regularized nomogram to construct a novel deep learning nomogram from CGM profiles to identify patients at high risk of DR. Specifically, a deep learning network was employed to mine the nonlinear relationship between CGM profiles and DR. Moreover, a novel nomogram combining CGM deep factors with basic information was established to score the patients' DR risk. This dataset consists of 788 patients belonging to two cohorts: 494 in the training cohort and 294 in the testing cohort. The area under the curve (AUC) values of our deep learning nomogram were 0.82 and 0.80 in the training cohort and testing cohort, respectively. By incorporating basic clinical factors, the deep learning nomogram achieved an AUC of 0.86 in the training cohort and 0.85 in the testing cohort. The calibration plot and decision curve showed that the deep learning nomogram had the potential for clinical application. This analysis method of CGM profiles can be extended to other diabetic complications by further investigation.

Role of glucose variability on linear growth in children with type 1 diabetes

OBJECTIVE

Linear growth is impaired in children with type 1 diabetes (T1D) and poor metabolic control. A good metabolic control is a key therapeutic goal to prevent vascular complications and also to ensure appropriate anthropometric development during childhood. In this study, we aimed to identify and characterize the effects of glycemic variability on linear growth in children with T1D.

METHODS

Data from 144 prepubertal children with T1D were evaluated. Anthropometric measurements (weight, weight-SDS, height, height-SDS, BMI, BMI-SDS) were collected and glycosylated hemoglobin (HbA1c) was measured at admission and every 4 months over a 2-year period. Glycemic variability indexes (glycemic coefficient of variation (CV), glycemic CV percentage (CV%), and the product between HbA1c-mean and HbA1c-SDS/100 (M*SDS-HbA1c/100)) were calculated. According to height-SDS changes after 2 years of follow-up, the study population was divided into three tertile groups and differences across groups were investigated for variables of interest.

RESULTS

The three groups were similar in terms of age, gender, and follow-up period. After 2 years, all prepubertal children showed a significant positive trend of anthropometric data. Across the three tertile groups, HbA1c-SDS, CV, CV%, and M*SDS-HbA1c significantly decreased from the first to the third tertile of height-SDS. During follow-up, children with lower Δheight-SDS values reported higher values of HbA1c-SDS, CV, CV%, and M*SDS-HbA1c than subjects with higher linear growth.

CONCLUSIONS

Glycemic variability correlates with linear growth in children with T1D. Low glycemic variability indexes were reported in higher height-SDS tertiles. Δheight-SDS is inversely correlated with glycemic CV, CV%, and M*SDS-HbA1c.

Effect of calorie restriction in comparison to usual diet or usual care on remission of type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Limited evidence is available about the dose-dependent effects of calorie restriction in patients with type 2 diabetes.

OBJECTIVE

To gather available evidence on the effect of calorie restriction on management of type 2 diabetes.

METHODS

We systematically searched PubMed, Scopus, CENTRAL, Web of Science, and gray literature to November 2022 for randomized trials longer than 12 weeks looking at the effect of a pre-specified calorie-restricted diet on remission of type 2 diabetes. We performed random-effects meta-analyses to estimate the absolute effect (risk difference) at 6-month (6±3 months) and 12-month (12±3 months) follow-ups. We performed dose-response meta-analyses to estimate mean difference (MD) for the effects of calorie restriction on cardiometabolic outcomes. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to judge the certainty of evidence.

RESULTS

28 randomized trials with 6281 participants were included. Using a remission definition of glycated hemoglobin (HbA_1c) <6.5% without antidiabetic medication use, calorie-restricted diets increased remission by 38 more per 100 patients (95%CI: 9 more, 67 more; n=5 trials, GRADE=moderate) at 6-month, and by 13 more per 100 patients (95%CI: 10 more, 18 more; n=4, GRADE=moderate) at 12-month in comparison to usual diet or usual care. Using a definition of HbA_1c<6.5% after at least two months cessation of antidiabetic medications, remission increased by 34 more per 100 patients (95%CI: 15 more, 53 more; n=1, GRADE=very low) at 6-month and by 16 more per 100 patients (95%CI: 4 more, 49 more; n=2, GRADE=low) at 12-month. At 6-month, each 500 kcal/day decrease in energy intake resulted in clinically meaningful reductions in body weight (MD: -6.33 kg, 95%CI: -7.76, -4.90; n=22; GRADE=high) and HbA_1c (MD: -0.82%, 95%CI: -1.05, -0.59; n=18, GRADE=high), which attenuated remarkably at 12-month.

CONCLUSIONS

Calorie-restricted diets may be effective interventions for type 2 diabetes remission, especially when coupled with an intensive lifestyle modification program.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42022300875).

Effects of hypoxic exercise on 24-hour glucose profile and substrate metabolism in overweight and obese men with impaired glucose metabolism

Hypoxic exercise (HE) may have more pronounced effects on glucose homeostasis than exercise under normoxic conditions (NE), but effects on 24-h glucose profile and substrate utilization remain unclear. We investigated the effects of moderate-intensity HE compared with NE on 24-h glucose profile and substrate metabolism in overweight/obese individuals. Ten overweight/obese men with impaired glucose homeostasis participated in a randomized, single-blind, crossover trial. Participants performed moderate-intensity cycling exercise for 4 consecutive days under mild normobaric hypoxic ([Formula: see text]: 15%) or normoxic ([Formula: see text]: 21%) conditions at similar relative exercise intensity (2 × 30 min/day at 50% of maximal heart rate, with a ∼4-wk washout period. Twenty-four-hour glucose levels and systemic oxygen saturation ([Formula: see text]) were monitored throughout the study. At day 5, plasma metabolites and substrate oxidation were determined during a mixed-meal test under normoxic conditions. [Formula: see text] and absolute workload were lower (both P < 0.001), whereas heart rate was comparable during HE compared with NE. HE did not alter mean 24-h, daytime, and nighttime glucose concentrations, and measures of glycemic variability. However, the HE-induced decrease in [Formula: see text] was positively correlated with HE-induced improvements in mean 24-h (r_s = 0.683, P = 0.042) and daytime (r_s = 0.783, P = 0.013) glucose concentrations. HE at similar relative exercise intensity reduces [Formula: see text] and has comparable effects on mean 24-h glucose concentration and glycemic variability than NE in overweight/obese men with impaired glucose metabolism. Nevertheless, a more pronounced reduction in [Formula: see text] during HE was associated with lower 24-h glucose concentrations, suggesting that a marked hypoxic stimulus is needed to improve glucose homeostasis.NEW & NOTEWORTHY We demonstrate that hypoxic exercise at similar relative exercise intensity (i.e. lower absolute workload) reduces systemic oxygen saturation ([Formula: see text]) and has comparable effects on mean 24-h glucose concentrations and glycemic variability than normoxic exercise in men with overweight/obesity and impaired glucose metabolism. A more pronounced reduction in [Formula: see text] during hypoxic exercise, however, was associated with lower 24-h and daytime glucose concentrations. Our findings suggest that a marked hypoxic stimulus may improve glucose homeostasis.

Continuous Glucose Monitoring Time Series Data Analysis: A Time Series Analysis Package for Continuous Glucose Monitoring Data

The R package Continuous Glucose Monitoring Time Series Data Analysis (CGMTSA) was developed to facilitate investigations that examine the continuous glucose monitoring (CGM) data as a time series. Accordingly, novel time series functions were introduced to (1) enable more accurate missing data imputation and outlier identification; (2) calculate recommended CGM metrics as well as key time series parameters; (3) plot interactive and three-dimensional graphs that allow direct visualizations of temporal CGM data and time series model optimization. The software was designed to accommodate all popular CGM devices and support all common data processing steps. The program is available for Linux, Windows, and Mac at GitHub.

Flash glucose monitoring system in special situations

The management of diabetes mellitus (DM) requires maintaining glycemic control, and patients must keep their blood glucose levels close to the normal range to reduce the risk of microvascular complications and cardiovascular events. While glycated hemoglobin (A1C) is currently the primary measure for glucose management and a key marker for long-term complications, it does not provide information on acute glycemic excursions and overall glycemic variability. These limitations may even be higher in some special situations, thereby compromising A1C accuracy, especially when wider glycemic variability is expected and/or when the glycemic goal is more stringent. To attain adequate glycemic control, continuous glucose monitoring (CGM) is more useful than self-monitoring of blood glucose (SMBG), as it is more convenient and provides a greater amount of data. Flash Glucose Monitoring (isCGM /FGM) is a widely accepted option of CGM for measuring interstitial glucose levels in individuals with DM. However, its application under special conditions, such as pregnancy, patients on hemodialysis, patients with cirrhosis, during hospitalization in the intensive care unit and during physical exercise has not yet been fully validated. This review addresses some of these specific situations in which hypoglycemia should be avoided, or in pregnancy, where strict glycemic control is essential, and the application of isCGM/FGM could alleviate the shortcomings associated with poor glucose control or high glycemic variability, thereby contributing to high-quality care.

Long-term glycemic variability and risk of adverse health outcomes in patients with diabetes: A systematic review and meta-analysis of cohort studies

AIMS

To quantify associations of different metrics of long-term glycemic variability (GV) with multiple adverse diabetes-related outcomes.

METHODS

We searched PubMed and Embase from database inception to 23 August 2021. GV was based on measurements of HbA1c or fasting plasma glucose (FPG) and calculated by standard deviation (SD), coefficient of variance (CV) or other metrics. Outcomes included mortality, cardiovascular disease (CVD), renal disease, peripheral neuropathy, retinopathy, dementia and cancer. Random-effects meta-analyses were adopted to pool the relative risks (RRs).

RESULTS

Seventy-five articles with 2,051,701 participants were included. When comparing top with bottom quartiles, HbA1c variabilities were associated with all-cause mortality (RR_CV = 1.63, 95 % CI 1.37-1.92; RR_SD = 1.87, 1.55-2.26), CVD (RR_CV = 1.38, 1.07-1.78; RR_SD = 1.34, 1.12-1.59), renal disease (RR_CV = 1.43, 1.18-1.74; RR_SD = 1.44, 1.24-1.67), and peripheral neuropathy (RR_CV = 1.84, 1.40-2.43; RR_SD = 1.98, 1.51-2.61), but not retinopathy. FPG variabilities were associated with all-cause mortality (RR_CV = 1.59, 1.43-1.78; RR_SD = 1.67, 1.26-2.20), renal disease (RR_CV = 1.77, 1.32-2.38), and retinopathy (RR_CV = 1.92, 1.10-3.35), but not CVD and peripheral neuropathy. Associations of GV with Alzheimer's disease (RR_HbA1c-CV = 1.38, 1.13-1.70; RR_FPG-CV = 1.32, 1.07-1.63) and cancer (RR_HbA1c-SD = 2.19, 1.52-3.17; RR_FPG-CV = 3.64, 2.21-5.98) were each found significant in one study.

CONCLUSIONS

Long-term GV was associated with multiple adverse diabetes-related outcomes, while the strength of associations varied. The findings support the use of long-term GV for diabetes management in clinical practice.

Thirty-Year Time Trends in Diabetic Retinopathy and Macular Edema in Youth With Type 1 Diabetes

OBJECTIVE

To examine trends in diabetic retinopathy (DR) and diabetic macular edema (DME) in adolescents with type 1 diabetes between 1990 and 2019.

RESEARCH DESIGN AND METHODS

We analyzed 5,487 complication assessments for 2,404 adolescents (52.7% female, aged 12-20 years, diabetes duration >5 years), stratified by three decades (1990-1999, 2000-2009, 2010-2019). DR and DME were graded according to the modified Airlie House classification from seven-field stereoscopic fundal photography.

RESULTS

Over three decades, the prevalence of DR was 40, 21, and 20% (P < 0.001) and DME 1.4, 0.5, and 0.9% (P = 0.13), respectively, for 1990-1999, 2000-2009, and 2010-2019. Continuous subcutaneous insulin infusion (CSII) use increased (0, 12, and 55%; P < 0.001); mean HbA1c was bimodal (8.7, 8.5, and 8.7%; P < 0.001), and the proportion of adolescents meeting target HbA1c <7% did not change significantly (8.3, 7.7, and 7.1%; P = 0.63). In multivariable generalized estimating equation analysis, DR was associated with 1-2 daily injections (odds ratio 1.88, 95% CI 1.42-2.48) and multiple injections in comparison with CSII (1.38, 1.09-1.74); older age (1.11, 1.07-1.15), higher HbA1c (1.19, 1.05-1.15), longer diabetes duration (1.15, 1.12-1.18), overweight/obesity (1.27, 1.08-1.49) and higher diastolic blood pressure SDS (1.11, 1.01-1.21). DME was associated with 1-2 daily injections (3.26, 1.72-6.19), longer diabetes duration (1.26, 1.12-1.41), higher diastolic blood pressure SDS (1.66, 1.22-2.27), higher HbA1c (1.28, 1.03-1.59), and elevated cholesterol (3.78, 1.84-7.76).

CONCLUSIONS

One in five adolescents with type 1 diabetes had DR in the last decade. These findings support contemporary guidelines for lower glycemic targets, increasing CSII use, and targeting modifiable risk factors including blood pressure, cholesterol, and overweight/obesity.

Acute Flaxseed Intake Reduces Postprandial Glycemia in Subjects with Type 2 Diabetes: A Randomized Crossover Clinical Trial

Background: Postprandial glycemic excursions are associated with impairment control of diabetes mellitus. Long-term consumption of flaxseed can lower blood glucose levels; however, its effects on the postprandial glycemic response remain unknown. Therefore, this study aimed to evaluate the acute effects of raw flaxseed consumption on the 2 h postprandial glycemic curve in men with type 2 diabetes mellitus (T2DM). Methods: This was a randomized crossover clinical trial. Nineteen men with T2DM were randomly assigned a standardized breakfast without (control) or with a previous intake of 15 g of ground raw golden flaxseed (flax). Glycemia was measured at fasting and postprandial at 15, 30, 45, 60, 90, and 120 min. Palatability markers (visual appeal, smell, and pleasantness of taste) and taste intensity (sweetness, saltiness, bitterness, sourness, and creaminess) were evaluated. Results: The peak glucose rise and the 2 h AUC glycemic response reduced in the flax group by 17% (p = 0.001) and 24% (p < 0.001), respectively. The glucose peak time, palatability, and taste parameters did not differ between the two groups. Conclusions: Ingestion of 15 g of ground raw golden flaxseed before breakfast decreases the 2 h postprandial glycemic response in men with T2DM.

Patient-Tailored Decision Support System Improves Short- and Long-Term Glycemic Control in Type 2 Diabetes

BACKGROUND

The increasing prevalence of type 2 diabetes mellitus (T2D) and specialist shortage has caused a healthcare gap that can be bridged by a decision support system (DSS). We investigated whether a diabetes DSS can improve long- and/or short-term glycemic control.

METHODS

This is a retrospective observational cohort study of the Diabetiva program, which offered a patient-tailored DSS using Karlsburger Diabetes-Management System (KADIS) once a year. Glycemic control was analyzed at baseline and after 12 months in 452 individuals with T2D. Time in range (TIR; glucose 3.9-10 mmol/L) and Q-Score, a composite metric developed for analysis of continuous glucose profiles, were short-term and HbA1c long-term measures of glycemic control. Glucose variability (GV) was also measured.

RESULTS

At baseline, one-third of patients had good short- and long-term glycemic control. Q-Score identified insufficient short-term glycemic control in 17.9% of patients with HbA1c <6.5%, mainly due to hypoglycemia. GV and hyperglycemia were responsible in patients with HbA1c >7.5% and >8%, respectively. Application of DSS at baseline improved short- and long-term glycemic control, as shown by the reduced Q-Score, GV, and HbA1c after 12 months. Multiple regression demonstrated that the total effect on GV resulted from the single effects of all influential parameters.

CONCLUSIONS

DSS can improve short- and long-term glycemic control in individuals with T2D without increasing hypoglycemia. The Q-Score allows identification of individuals with insufficient glycemic control. An effective strategy for therapy optimization could be the selection of individuals with T2D most at need using the Q-Score, followed by offering patient-tailored DSS.

Dose-Dependent Effect of Supervised Aerobic Exercise on HbA1c in Patients with Type 2 Diabetes: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Previous meta-analyses indicated that aerobic exercise can improve glycemic control. However, the optimum dose of exercise is still being discussed.

OBJECTIVE

The aim of this study was to examine the dose-dependent effect of supervised aerobic training (SAT) on glycated hemoglobin (HbA_1c).

METHODS

We searched PubMed, Scopus, and Web of Science to May 2021 for randomized trials with an intervention period of 12 weeks or longer evaluating the effect of SAT on HbA_1c in adults with type 2 diabetes mellitus. Secondary outcomes included quality of life, change in hypoglycemic medications, and adverse events. A random-effects dose-response meta-analysis was conducted.

RESULTS

The analysis of 26 trials with 1253 participants indicated that each 30-min/week SAT reduced HbA_1c by - 0.22 percentage point (95% CI - 0.29 to - 0.15; GRADE = strong). Levels of HbA_1c decreased proportionally with the increase in the duration of moderate to vigorous-intensity SAT to 100 min/week (mean difference_{100 min/week}: - 0.96 percentage point, 95% CI - 1.25 to - 0.67), with flattening of the curve at higher duration. Aerobic exercise decreased antidiabetic medications by 13 per 100 patients (risk difference 0.13, 95% CI 0.02-0.23; 7 trials, n = 375; GRADE = moderate), and increased hypoglycemic reactions by 10 per 100 patients (risk difference: 0.10, 95% CI 0.03-0.17; 4 trials, n = 263; GRADE = low) and adverse events by 4 per 100 patients (risk difference: 0.04, 95% CI - 0.02 to 0.11; 2 trials, n = 236; GRADE = low). Limited evidence is available for quality of life.

CONCLUSIONS

Every 30 min/week of moderate to vigorous aerobic exercise can exert a significant effect on HbA_1c, with the highest effect observed from 100 min/week and above. However, exercise durations above 100 min/week seem ineffective for further reductions.

PROTOCOL REGISTRATION

PROSPERO (CRD42021257251).

Mitigation of Rebound Hyperglycemia With Real-Time Continuous Glucose Monitoring Data and Predictive Alerts

BACKGROUND

Excess carbohydrate intake during hypoglycemia can lead to rebound hyperglycemia (RH). We investigated associations between RH and use of real-time continuous glucose monitoring (rtCGM) and an rtCGM system's predictive alert.

METHODS

RH events were series of sensor glucose values (SGVs) >180 mg/dL starting within two hours of an antecedent SGV <70 mg/dL. Events were characterized by their frequency, duration (consecutive SGVs >180 mg/dL × five minutes), and severity (area under the glucose concentration-time curve). To assess the impact of rtCGM, data gathered during the four-week baseline phase (without rtCGM) and four-week follow-up phase (with rtCGM) from 75 participants in the HypoDE clinical trial (NCT02671968) of hypoglycemia-unaware individuals were compared. To assess the impact of predictive alerts, we identified a convenience sample of 24 518 users of an rtCGM system without predictive alerts who transitioned to a system whose predictive alert signals an SGV ≤55 mg/dL within 20 minutes (Dexcom G5 and G6, respectively). RH events from periods of blinded versus unblinded rtCGM wear and from periods of G5 and G6 wear were compared with paired t tests.

RESULTS

Compared to RH events in the HypoDE baseline phase, the mean frequency, duration, and severity of events fell by 14%, 12%, and 23%, respectively, in the follow-up phase (all P < .05). Compared to RH events during G5 use, the mean frequency, duration, and severity of events fell by 7%, 8%, and 13%, respectively, during G6 use (all P < .001).

CONCLUSIONS

Rebound hypreglycemia can be objectively quantified and mitigated with rtCGM and rtCGM-based predictive alerts.

Assessment of glycemia in chronic kidney disease

Reliable assessment of glycemia is central to the management of diabetes. The kidneys play a vital role in maintaining glucose homeostasis through glucose filtration, reabsorption, consumption, and generation. This review article highlights the role of the kidneys in glucose metabolism and discusses the benefits, pitfalls, and evidence behind the glycemic markers in patients with chronic kidney disease. We specifically highlight the role of continuous glucose monitoring as an emerging minimally invasive technique for glycemic assessment.

Efficacy of Flash Glucose Monitoring in Type 1 and Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Objective

Flash glucose monitoring (FlashGM) is a sensor-based technology that displays glucose readings and trends to people with diabetes. In this meta-analysis, we assessed the effect of FlashGM on glycaemic outcomes including HbA1c, time in range, frequency of hypoglycaemic episodes and time in hypo/hyperglycaemia compared to self-monitoring of blood glucose, using data from randomised controlled trials.

Methods

A systematic search was conducted on MEDLINE, EMBASE and CENTRAL for articles published between 2014 and 2021. We selected randomised controlled trials comparing flash glucose monitoring to self-monitoring of blood glucose that reported change in HbA1c and at least one other glycaemic outcome in adults with type 1 or type 2 diabetes. Two independent reviewers extracted data from each study using a piloted form. Meta-analyses using a random-effects model was conducted to obtain a pooled estimate of the treatment effect. Heterogeneity was assessed using forest plots and the I2 statistic.

Results

We identified 5 randomised controlled trials lasting 10 – 24 weeks and involving 719 participants. Flash glucose monitoring did not lead to a significant reduction in HbA1c. However, it resulted in increased time in range (mean difference 1.16 hr, 95% CI 0.13 to 2.19, I2 = 71.7%) and decreased frequency of hypoglycaemic episodes (mean difference -0.28 episodes per 24 hours, 95% CI -0.53 to -0.04, I2 = 71.4%).

Conclusions

Flash glucose monitoring did not lead to a significant reduction in HbA1c compared to self-monitoring of blood glucose, however, it improved glycaemic management through increased time in range and decreased frequency of hypoglycaemic episodes.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier PROSPERO (CRD42020165688).

Variations in Sleep Characteristics and Glucose Regulation in Young Adults With Type 1 Diabetes

CONTEXT

Short sleep duration and sleep disruptions are associated with impaired glucoregulation in type 1 diabetes (T1D). However, the mechanistic pathways between sleep and glucose variability remain unclear.

OBJECTIVE

To determine within- and between-person associations between objective sleep-wake characteristics and glucose variability indices.

METHODS

Multilevel models were used to analyze concurrent sleep and glucose patterns over 7 days in 42 young adults with T1D in their natural home environment. Young adults with T1D (mean age 22.2 ± 3.0 years, HbA1c 7.2%, 32.6% male) for at least 6 months with no other medical or major psychiatric comorbidity were included. Sleep-wake characteristics were measured via wrist actigraphy and glucose variability indices via a continuous glucose monitor (CGM).

RESULTS

Lower sleep efficiency predicted higher glucose variability (less time in range β = 0.011 and more time in hyperglycemia β = -0.011) within-person. A longer wake after sleep onset and more sleep disruptions were associated with higher glucose variability between persons (β = 0.28 and 0.31). Higher glucose variability predicted poorer sleep within-person (delayed bedtime, waketime, mid-sleep time, and lower sleep efficiency), while higher glucose variability was associated with poorer sleep and more sleep disruptions between persons (lower sleep efficiency, longer wake after sleep onset, and a higher sleep fragmentation index).

CONCLUSION

Clinicians can address the reciprocal nature of the sleep-glucose relationship by optimizing sleep and targeting efforts toward a euglycemic range overnight. Sleep habits are a modifiable personal target in diabetes care.

Analysis of Severe Hypoglycemia Among Adults With Type 2 Diabetes and Nonalcoholic Fatty Liver Disease

IMPORTANCE

Previous studies have indicated that liver cirrhosis is associated with hypoglycemia, but there have been no studies investigating the association between nonalcoholic fatty liver disease (NAFLD) and hypoglycemia in noncirrhotic populations with type 2 diabetes.

OBJECTIVE

To explore the association of NAFLD with severe hypoglycemia among patients with type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide population-based retrospective cohort study using the National Health Insurance System of South Korea included individuals aged 20 years or older who had undergone a medical health examination between January 1, 2009, and December 31, 2012, and were diagnosed with type 2 diabetes. Participants were followed up until December 31, 2015. Data analyses were performed between January 1, 2019, and February 2, 2021.

EXPOSURES

The baseline fatty liver index (FLI) was used as a surrogate marker for NAFLD.

MAIN OUTCOMES AND MEASURES

The outcome of interest, severe hypoglycemia, was measured using hospital admission and emergency department visit records with a primary diagnosis of hypoglycemia.

RESULTS

Among 1 946 581 individuals with type 2 diabetes, 1 125 187 (57.8%) were male. During a median (IQR) follow-up of 5.2 (4.1-6.1) years, 45 135 (2.3%) experienced 1 or more severe hypoglycemia events. Participants with severe hypoglycemia, vs those without severe hypoglycemia, were older (mean [SD] age, 67.9 [9.9] years vs 57.2 [12.3] years; P < .001) and had lower mean (SD) body mass index (24.2 [3.43] vs 25.1 [3.4]; P < .001). Patients with NAFLD tended to have less severe hypoglycemia without consideration of obesity status. However, after adjustment of multiple clinical covariates, including body mass index, there was a J-shaped association between FLI and severe hypoglycemia (5th decile: adjusted hazard ratio [aHR], 0.86; 95% CI, 0.83-0.90; 9th decile: aHR, 1.02; 95% CI, 0.96-1.08; 10th decile: aHR, 1.29; 95% CI, 1.22-1.37), and the estimated risk of hypoglycemia was higher in participants with NAFLD (aHR, 1.26; 95% CI, 1.22-1.30). The association was more prominent in female participants (aHR, 1.29; 95% CI, 1.23-1.36) and those with underweight (aHR, 1.71; 95% CI, 1.02-2.88).

CONCLUSIONS AND RELEVANCE

In this study, NAFLD was associated with a higher risk of severe hypoglycemia in patients with type 2 diabetes independent of obesity status. Presence of NAFLD should be considered when evaluating vulnerability to hypoglycemia in patients with type 2 diabetes.

The impact of perioperative glucose variability on outcomes after hip fracture

Diabetes is considered an independent risk factor for hip fracture. In the present study, we evaluated whether perioperative glucose variability (GV) was a significant predictor of the outcomes of patients with diabetes after hip fracture.We analyzed the characteristics and outcomes of all patients with hip fractures admitted to our hospital between September 2008 and December 2012. Patients with diabetes were grouped into tertiles for GV, and multivariate survival analysis included age, sex, fracture type, mean fasting plasma glucose, and GV.Among the 1099 patients included in this study, 239 (21.7%) had diabetes. Patients with diabetes were more likely to develop infectious complications (5.4% vs 2.8%, P = .045), and experience mortality postoperatively (1 month: 5.5% vs 2.7%, P = .052; 12 months: 15.1% vs 8.7%, P = .006). The postoperative mortality rate was increased across the GV tertiles, and GV was an independent predictor of 1- and 12-month mortality after surgery.Patients with diabetes had poor prognoses after hip fracture. Perioperative GV is an independent predictor of mortality in patients with diabetes. Therefore, GV might be considered a valid additional parameter to consider in the management of these patients.

Preoperative Carbohydrate Drink Intake Increases Glycemic Variability in Patients with Type 2 Diabetes Mellitus in Total Joint Arthroplasty: A Prospective Randomized Trial

BACKGROUND

Preoperative carbohydrate treatment attenuates insulin resistance and improves metabolism to an anabolic state. Despite these benefits, impaired glycemic control and aspiration risk related to gastroparesis represent concerns for patients with diabetes undergoing surgery. This randomized controlled trial investigated the effects of oral carbohydrate therapy on perioperative glucose variability, metabolic responses, and gastric volume in diabetic patients undergoing elective total hip or knee arthroplasty.

METHODS

Fifty diabetic patients scheduled to undergo elective total knee or hip arthroplasty during August 2019-October 2020 were randomly assigned to a control or carbohydrate therapy (CHO) group. CHO group of patients received a 400-mL carbohydrate drink 2-3 h before anesthesia; control group of patients underwent overnight fasting from midnight, one night before surgery. Blood glucose levels were measured before intake of the carbohydrate drink, before spinal anesthesia, preoperatively, immediately postoperatively, and 1 h postoperatively. Insulin level and gastric volume were measured before spinal anesthesia.

RESULTS

The glucose variability of patients in the CHO group was significantly higher than that of those in the control group (16.5 vs. 10.1%, P = 0.008). Similarly, insulin resistance was higher in the CHO group than in the control group (8.5 vs. 2.7, P < 0.001). The gastric volume did not differ significantly between the groups (61.3 vs. 15.2 ml, P = 0.082).

CONCLUSIONS

Preoperative oral carbohydrate therapy increases glucose variability and insulin resistance in diabetic patients. Therefore, carbohydrate beverages should be cautiously administered to diabetic patients, considering metabolic and safety aspects. Trial registration number ClinicalTrials.gov (No. NCT04013594).

Glycemic Metrics Derived From Intermittently Scanned Continuous Glucose Monitoring

BACKGROUND

Glucose data from intermittently scanned continuous glucose monitoring (isCGM) is a combination of scanned and imported glucose values. The present knowledge of glycemic metrics originate mostly from glucose data from real-time CGM sampled every five minutes with a lack of information derived from isCGM.

METHODS

Glucose data obtained with isCGM and hemoglobin A1c (HbA1c) were obtained from 169 patients with type 1 diabetes. Sixty-one patients had two observations with an interval of more than three months.

RESULTS

The best regression line of HbA1c against mean glucose was observed from 60 days prior to HbA_1c measurement as compared to 14, 30, and 90 days. The difference between HbA1c and estimated HbA1c (=glucose management indicator [GMI]) first observed correlated with the second observation (R2 0.61, P < .001). Time in range (TIR, glucose between 3.9 and 10 mmol/L) was significantly related to GMI (R2 0.87, P < .001). A TIR of 70% corresponded to a GMI of 6.8% (95% confidence interval, 6.3-7.4). The fraction of patients with the optimal combination of TIR >70% and time below range (TBR) <4% was 3.6%. The fraction of patients with TBR>4% was four times higher for those with high glycemic variability (coefficient of variation [CV] >36%) than for those with lower CV.

CONCLUSION

The individual difference between HbA1c and GMI was reproducible. High glycemic variability was related to increased TBR. A combination of TIR and TBR is suggested as a new composite quality indicator.

Insulin Degludec Versus Insulin Glargine on Glycemic Variability in Diabetic Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND/AIMS

Currently, glycemic variability has more deleterious effects than sustained hyperglycemia and is closely associated with acute and chronic complications of diabetes. Reducing glycemic excursion is becoming another vital goal of glycemic control in clinical practice. This study aimed to determine whether insulin degludec (IDeg) or insulin glargine (IGla) was more beneficial for reducing glycemic fluctuations.

MATERIALS AND METHODS

This research was constructed according to the PRISMA guidelines. We searched eight databases and ClinicalTrials.gov from their inception to 30 November 2021. All randomized controlled trials comparing the efficacy of glucose variability between IDeg and IGla in diabetic patients were included.

RESULTS

Fourteen trials with 8,683 participants were included. In patients with T1DM, IDeg was associated with a lower mean (MD: -16.25, 95% CI -29.02 to -3.07, P = 0.01) and standard deviation (P = 0.03) compared to IGla in fasting blood glucose (FBG); in people with T2DM, IDeg was related to a lower mean of FBG versus insulin glargine 100 U/ml (IGla100) (P <0.001) and had a more extended time in the range (TIR) than IGla100 (SMD: 0.15, 95% CI 0.02 to 0.27, P = 0.02) but not longer than insulin glargine 300 U/ml (IGla300). Moreover, IDeg had a lower coefficient of variation of FBG than IGla (P = 0.0254). For other indicators of glycemic variability, namely, standard deviation of blood glucose for 24 h, the mean of 24-h blood glucose, mean amplitude of glycemic excursion, the coefficient of variation for 24 h, the mean of daily differences, area under the glucose curve, and M-value, no significant differences were identified between IDeg and IGla, regardless of T1DM or T2DM.

CONCLUSIONS

Based on the current studies, there was comparable efficacy between IDeg and IGla from multiple aspects of glycemic variability, regardless of T1DM or T2DM. However, IDeg may be superior to IGla in reducing FBG variability in T1DM and T2DM. Nonetheless, due to the limitations of the original studies, it is still unclear whether IDeg is superior to both IGla100 and IGla300. In T2DM, IDeg had more extended TIR than IGla100 but not longer than IGla300. Additionally, more well-designed randomized controlled trials comparing IDeg with IGla300 for different indicators of glycemic variability are still warranted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021283203.

High-dose Vitamin D Supplementation on Type 1 Diabetes Mellitus Patients: Is there an Improvement in Glycemic Control?

BACKGROUND

Some authors evaluated the effect of VD on hyperglycemia in T1DM, but the results remain controversial. This study aims to analyze the effects of high-dose VD supplementation on T1DM patients' glycemic levels, maintaining stable doses of insulin.

METHODS

Prospective, 12-week clinical trial including 67 T1DM patients, supplemented with high doses of cholecalciferol according to participants' VD value. Patients with VD levels below 30 ng/mL received 10,000 IU/day; those with levels between 30-60 ng/mL received 4,000 IU/day. Patients who had not achieved 25(OH)D levels > 30 ng/ml or presented insulin dose variation during the study were not analyzed.

RESULTS

Only 46 out of 67 patients accomplished the criteria at the end of the study. There was no general improvement in the glycemic control evaluated by HbA1c (9.4 ± 2.4 vs 9.4 ± 2.6, p=NS) after VD supplementation. However, a post-hoc analysis, based on HbA1c variation, identified patients who had HbA1c reduced at least 0.6% (group 1, N = 13 (28%)). In addition, a correlation between 25(OH)D levels with HbA1c and total insulin dose at the end of the study was observed (r = -0.3, p<0.05; r=-0.4, p<0.05, respectively), and a regression model demonstrated that 25(OH)D was independent of BMI, duration of T1DM and final total insulin dose, being capable of determining 9.2% of HbA1c final levels (Unstandardized B coefficient = -0.033 (CI 95%: -0.064 to -0.002), r2 = 0.1, p <0.05).

CONCLUSION

Our data suggest that VD is not widely recommended for glycemic control. Nevertheless, specific patients might benefit from this approach.

Perspectives of glycemic variability in diabetic neuropathy: a comprehensive review

Diabetic neuropathy is one of the most prevalent chronic complications of diabetes, and up to half of diabetic patients will develop diabetic neuropathy during their disease course. Notably, emerging evidence suggests that glycemic variability is associated with the pathogenesis of diabetic complications and has emerged as a possible independent risk factor for diabetic neuropathy. In this review, we describe the commonly used metrics for evaluating glycemic variability in clinical practice and summarize the role and related mechanisms of glycemic variability in diabetic neuropathy, including cardiovascular autonomic neuropathy, diabetic peripheral neuropathy and cognitive impairment. In addition, we also address the potential pharmacological and non-pharmacological treatment methods for diabetic neuropathy, aiming to provide ideas for the treatment of diabetic neuropathy.

Zhang et al. describe metrics for evaluating glycaemic variability (GV) in clinical practice and summarize the role and related mechanisms of GV in diabetic neuropathy, including cardiovascular autonomic neuropathy, diabetic peripheral neuropathy and cognitive impairment. They aim to stimulate ideas for the treatment of diabetic neuropathy.

Renal Complications and Duration of Diabetes: An International Comparison in Persons with Type 1 Diabetes

INTRODUCTION

Renal complications are both a marker of previous suboptimal glycaemic control and a major risk factor for cardiovascular disease in persons with type 1 diabetes (T1D). The aim of the study was to evaluate the prevalence of renal complications in persons with T1D in four geographical regions.

METHODS

Nationwide registry data from Austria/Germany, Sweden and the US were used to estimate the prevalence of renal complications from January 2016 until September 2018. Chronic kidney disease (CKD) and albuminuria in the study population and each registry were analysed by diabetes duration. Risk factors for renal complications were described by registry.

RESULTS

In the total cohort of 78.926 adults with T1D, mean age was 44.4 ± 18.43 years and mean diabetes duration was 21.6 ± 22 years. Mean estimated glomerular filtration rate (eGFR) was 94.0 ± 31.45 ml/min, 13.0% had microalbuminuria and 3.9% had macroalbuminuria. Mean age, diabetes duration, use of insulin pumps and continuous glucose monitoring, as well as presence of albuminuria, varied between registries. Albuminuria was present in approximately 10% of persons with diabetes duration < 20 years and impaired renal function (eGFR < 60 ml/min) was present in 17%. In persons with diabetes duration > 40 years, approximately one-third had albuminuria and 25% had impaired renal function.

CONCLUSIONS

This analysis used three nationwide registries of persons with T1D. Despite recent use of more effective diabetes therapies, a substantial proportion of persons with T1D have renal complications at < 20 years after diagnosis. Efficient glucose-lowering and renal-protective strategies are needed in persons with T1D.

Maternal glucose variability during pregnancy & birthweight percentile in women with pre-gestational diabetes

INTRODUCTION

Pre-gestational diabetes mellitus (PGDM) is a major risk factor for fetal overgrowth. Interestingly, even in relatively well controlled PGDM women, as determined by average glucose indices such HbA1c, there is an increased rate of LGA (large for gestational age). Glucose variability (GV) has emerged as an important independent risk factor for several diabetes complications. The aim of this study was to determine the relationship between maternal GV indices and neonatal birth percentile.

METHODS

This was a historical cohort study that included all consecutive PGDM women monitored in a single tertiary care center. Clinical and demographic variables, as well as data regarding glucose control, were prospectively recorded. Mean, standard deviation (SD) and coefficient of variance (CV) of glucose values were calculated. Pearson correlations coefficient was used to determine the correlation between glucose indices and birth percentile. The analysis was repeated after adjustment for several confounders.

RESULTS

Mean birthweight and birthweight percentile were 3212 ± 532 g and 66.9%, respectively. There was a statistically significant correlation between birthweight percentile and maternal glucose SD (β = 0.28, p = .002) and maternal glucose CV (β = 0.21, p = .019). There was no significant correlation between birthweight percentile and mean glucose values. The association between the maternal glucose SD and birthweight percentile remained statistically significant after adjustment for maternal age, pre-pregnancy BMI and duration of diabetes.

CONCLUSION

There is an association between maternal glucose variability indices (SD and CV) during pregnancy and neonatal birth percentile. Larger studies are needed to confirm these results.

Glucose variability predicts 6-month mortality in patients hospitalized with acute heart failure

In diabetes mellitus (DM), glycaemic fluctuations associate with higher oxidative stress than sustained chronic hyperglycaemia and glucose variability increases the risk of chronic diabetic complications. Our hypothesis was that higher glucose variability would associate with mortality after an acute heart failure (HF) episode. We retrospectively analysed patients with DM hospitalized with acute HF between 2009 and 2010. Patients with < 2 point-of-care glucose values/day were excluded. Glucose coefficient of variation (GCV) was defined as (glucose standard deviation/mean glucose) × 100. Patients were categorized according GCV ≤ 30.0 and > 30.0%. Follow-up: 6-months. Endpoint: all-cause mortality. A Cox-regression analysis was used to study the association of glucose variability with 6-month mortality. We studied 214 diabetic patients with acute HF, 49.1% male, mean age 76 years. Mean glycaemia during hospitalization was 187 ± 50 mg/dL, hypoglycaemia (< 70 mg/dL) was reported in 21 patients and mean GCV was 28.3 ± 7.6%. Patients with GCV > 30.0% had higher mean glycaemia, more hypoglycaemic episodes and higher HbA1c; they were also more often treated with insulin. Patients were similar concerning age, gender, comorbidities, left ventricular systolic dysfunction and ischemic heart disease. During the 6-month follow-up, 38 (17.8%) patients died. Patients with GCV > 30.0% had a HR of 6-month mortality of 2.21 (95% CI: 1.16-4.21), p = 0.02. This association with more than twofold higher short-term mortality was independent of main confounders. Elevated glycaemic variability in acute HF admissions of patients with DM predicts short-term mortality. Patients with GCV > 30.0% have an independent more than twofold higher risk of 6-month death after an acute HF hospitalization.

Ultra Rapid Lispro (URLi) Accelerates Insulin Lispro Absorption and Insulin Action vs Humalog® Consistently Across Study Populations: A Pooled Analysis of Pharmacokinetic and Glucodynamic Data

BACKGROUND AND OBJECTIVE

Ultra rapid lispro (URLi) is a novel insulin lispro formulation developed to more closely match physiological insulin secretion and improve postprandial glucose control. This pooled analysis compared the pharmacokinetics and glucodynamics between URLi and Humalog® in healthy subjects and patients with type 1 or type 2 diabetes mellitus.

METHODS

The analysis included four randomized, double-blind, crossover, single-dose studies (healthy subjects [n = 74], patients with type 1 diabetes [n = 78], and type 2 diabetes [n = 38]) evaluating subcutaneous doses of 7, 15, or 30 U of URLi and Humalog during an 8- to 10-h euglycemic clamp procedure.

RESULTS

The pooled analysis showed an ~ 5-min faster onset of appearance, an ~8-fold greater exposure in the first 15 min, a 43% reduction in exposure beyond 3 h, and a 68-min shorter exposure duration with URLi vs Humalog across all study populations and dose range. Compared with Humalog, URLi had a 10-min faster onset of action, a 3-fold greater insulin action in the first 30 min, a 35% reduction in insulin action beyond 4 h, and a 44-min shorter duration of action across all populations and dose range. Overall exposure and insulin action were similar between URLi and Humalog for each dose level and study population.

CONCLUSIONS

Across the studied populations and dose range, URLi consistently demonstrated a faster absorption, reduced late exposure, and overall shorter exposure duration compared with Humalog. Similarly, URLi demonstrated earlier insulin action while reducing late insulin action and shorter insulin action compared with Humalog across the study populations and dose range.

CLINICAL TRIAL REGISTRATION

NCT02942654 (registered: 21 October, 2016), NCT03286751 (registered: 15 September, 2017), NCT03166124 (registered: 23 May, 2017), and NCT03305822 (registered: 5 October, 2017).

Continuous glucose monitoring in persons with type 2 diabetes not using insulin

INTRODUCTION

CGM is an evidence-based intervention to improve glycemic control in persons with T1D and T2D using insulin. Use of CGM in persons with T2D not using insulin is not well studied.

AREAS COVERED

Existing clinical evidence for the use of CGM in persons with T2D is reviewed with a focus on persons with T2D not using insulin. Additional perspective and consideration are provided on the role and rationale for using CGM in persons with T2D not using insulin.

EXPERT OPINION

On the basis of available evidence, persons with T2D not using insulin benefit clinically through reduction in HbA1c, and improvement in time in range. Additional benefits include improvement in behavior modification, satisfaction, quality of life, empowerment, and diabetes distress. Drivers of these benefits are independent of insulin use in persons with T2D and may include an improved understanding of how diet, lifestyle, and exercise impact diabetes through CGM use. Clinical benefits from CGM independent of medication use include ability to modify health behavior and subsequently improve self-management.

Pharmacokinetics and Glucodynamics of Ultra Rapid Lispro (URLi) versus Humalog® (Lispro) in Patients with Type 2 Diabetes Mellitus: A Phase I Randomised, Crossover Study

Background and objective

Ultra rapid lispro (URLi) is a novel insulin lispro formulation developed to more closely match physiological insulin secretion and improve postprandial glucose control. This study compared the insulin lispro pharmacokinetics and glucodynamics, safety and tolerability of URLi and Humalog^® after a single subcutaneous dose in patients with type 2 diabetes mellitus (T2DM).

Methods

This was a phase I, randomised, two-period, two-treatment, double-blind, crossover study in 38 patients with T2DM. At each dosing visit, patients received either 15 units of URLi or Humalog, followed by a 10 h automated euglycaemic clamp procedure. Serum insulin lispro and blood glucose were measured.

Results

Insulin lispro appeared in the serum 5 min faster (p < 0.0001) and exposure was 6.4-fold greater in the first 15 min (p < 0.0001) with URLi versus Humalog. Exposure beyond 3 h postdose was 26% lower and the duration of exposure was 51 min shorter with URLi versus Humalog. Onset of insulin action was 13 min faster (p < 0.0001) and insulin action was 4.2-fold greater within the first 30 min (p < 0.0001) with URLi versus Humalog. Insulin action beyond 4 h postdose was 20% lower (p = 0.0099) with URLi versus Humalog. Overall insulin lispro exposure and total glucose infused were similar for URLi and Humalog. Both treatments were well tolerated.

Conclusions

This is the first study to investigate URLi in patients with T2DM using a euglycaemic clamp procedure. URLi demonstrated ultra-rapid pharmacokinetics and glucodynamics in patients with T2DM.

ClinicalTrials.gov identifier:

NCT03305822.

Electronic supplementary material

The online version of this article (10.1007/s40262-020-00901-2) contains supplementary material, which is available to authorized users.

Time in Specific Glucose Ranges, Glucose Management Indicator, and Glycemic Variability: Impact of Continuous Glucose Monitoring (CGM) System Model and Sensor on CGM Metrics

BACKGROUND

International consensus recommends a set of continuous glucose monitoring (CGM) metrics to assess quality of diabetes therapy. The impact of individual CGM sensors on these metrics has not been thoroughly studied yet. This post hoc analysis aimed at comparing time in specific glucose ranges, coefficient of variation (CV) of glucose concentrations, and glucose management indicator (GMI) between different CGM systems and different sensors of the same system.

METHOD

A total of 20 subjects each wore two Dexcom G5 (G5) sensors and two FreeStyle Libre (FL) sensors for 14 days in parallel. Times in ranges, GMI, and CV were calculated for each 14-day sensor experiment, with up to four sensor experiments per subject. Pairwise differences between different sensors of the same CGM system as well as between sensors of different CGM system were calculated for these metrics.

RESULTS

Pairwise differences between sensors of the same model showed larger differences and larger variability for FL than for G5, with some subjects showing considerable differences between the two sensors. When pairwise differences between sensors of different CGM models were calculated, substantial differences were found in some subjects (75th percentiles of differences of time spent <70 mg/dL: 5.0%, time spent >180 mg/dL: 9.2%, and GMI: 0.42%).

CONCLUSION

Relevant differences in CGM metrics between different models of CGM systems, and between different sensors of the same model, worn by the same study subjects were found. Such differences should be taken into consideration when these metrics are used in the treatment of diabetes.