Diabetes Advocacy: Standards of Medical Care in Diabetes-2018

Suppressed Renin Status is a Risk Factor for Cardiocerebrovascular Events in Bilateral Primary Aldosteronism Treated with Mineralocorticoid Receptor Antagonists

BACKGROUND

Mineralocorticoid receptor antagonists (MRAs) are the recommended medical therapy for bilateral primary aldosteronism (BPA). Compared with essential hypertension (EH), patients with BPA have higher cardiocerebrovascular disease (CCVD). There is no consensus on the criteria to assess the effectiveness of medical therapy for BPA.

OBJECTIVE

To investigate the incidence and the risk factors for CCVD after medical therapy of BPA.

METHODS

We conducted a retrospective cohort study including 240 BPA patients treated with MRA. The post-treatment plasma renin activity (PRA) was defined as unsuppressed (PRA≥1ng/ml/h) otherwise, it was defined as suppressed. We analyzed the association of post-treatment PRA status with CCVD outcomes.

RESULTS

7.1% (17/240) of patients with BPA developed CCVD at a median follow-up of 5.0 (2.96,7.66) years. 57.1% of patients had PRA ≥ 1ng/ml/h after treatment. Patients with PRA <1ng/ml/h have a higher incidence of CCVD (12.6% vs. 2.9%, P < 0.05) and they are at greater risk than those with PRA ≥1ng/ml/h (HR=4.50, 95% CI: 1.47-13.83, P<0.05; adjusted HR=3.98, 95% CI: 1.22-13.02, P<0.05).

CONCLUSION

Patients with BPA treated with pharmacological have a high incidence of CCVD. PRA may be an indicator that mineralocorticoids are being adequately antagonized.

Effect of a self-care promoting program on engagement in self-care behaviors and health-related outcomes among persons with type 2 diabetes and diabetic retinopathy: A single-blind randomized controlled trial

Background

Diabetic retinopathy (DR) is the most common microvascular complication of diabetes, leading to visual impairment and eventual blindness. Promoting self-care behaviors is crucial in controlling DR progression and preventing blindness.

Objective

This study aimed to investigate the effects of a Self-Care Promoting Program (SCPP) on engagement in self-care behaviors, HbA1c levels, visual acuity (VA), severity of DR, and vision-related quality of life (VRQoL) among individuals with type 2 diabetes and DR.

Methods

This study employed a single-blind randomized controlled trial design to compare SCPP with conventional diabetic care interventions (standard care). The SCPP was based on the Self-Care of Chronic Illness Theory, Self-efficacy theory, and the Association of Diabetic Care and Education Specialist (ADCES) guidelines incorporating health education, self-care maintenance, monitoring, and management skills training over 12 weeks. Ninety-eight participants were randomly allocated to the experimental or control group (n = 49 per group). While the experimental group received SCPP alongside standard care, the control group received standard care alone. Data collection occurred between May 2022 and March 2023 and included demographic information, the Self-Care of Diabetes Index questionnaire (SCODI), the self-care for diabetes eye care questionnaire (SCFDE), the impact of visual impairment questionnaire (IVI-Thai version), and retinal images for DR severity grading. Data analysis utilized descriptive statistics, Chi-Square tests, t-tests, and MANOVA.

Results

Following 8 and 16 weeks of SCPP, the experimental group had significantly higher mean scores in engagement with self-care and eye-care behaviors compared to the control group (p <0.001). The highest scores were observed in self-care and eye-care confidence behaviors, followed by maintenance, monitoring, and management. Furthermore, HbA1c levels and VRQoL significantly decreased and were lower than those of the control group at week 16 (p <0.001 and p <0.05, respectively). However, there were no significant differences in VA, and DR severity increased in both groups by week 16.

Conclusion

SCPP benefits individuals with DR, enhancing their confidence and ability to perform, monitor, and manage self-care behaviors. These strategies contribute to improved diabetes management, enhanced quality of life, and reduced DR-related blindness. Integrating SCPP into routine DR management is recommended, with nurses playing a pivotal role in overseeing and driving this integration, highlighting the critical role of nurses in managing this widespread global disease.

Trial Registry Number

Thai Clinical Trials Registration (TCTR20230302002).

Interaction of circulating TGFβ regulatory miRNAs in different severity of diabetic kidney disease

AIMS

To explore the interaction of TGFβ regulatory microRNAs (miRNAs) with different severities of diabetic kidney disease (DKD).

METHODS

According to different UACR (30 and 300 mg/g), 436 subjects were included, and high glucose induced RMCs were cultured. Real-time PCR, ELISA, and automatic biochemical analysis were used to measure miRNAs, TGFβ1, and other biochemical indicators in serum and RMCs. Target genes of miRNA were predicted and visualised by bioinformatics.

RESULTS

HbA1c, TGFβ1, miR-217, and miR-224 in T2DM patients increased with UACR, while miR-192 and miR-216a decreased. Ln UACR was positively correlated with HbA1c, TGFβ1, miR-217, and miR-224, and negatively correlated with miR-192 and miR-216a. High glucose and TGFβ1 affected miRNAs and these miRNAs affected each other. The miRNA target genes mainly revolve around PTEN, PI3K/Akt, and MAPK signalling pathways.

CONCLUSION

TGFβ regulatory miRNAs and different severity of DKD have a potential interaction regulating fibrosis through PTEN, PI3K/Akt, and MAPK pathways.

Metalloestrogens exposure and risk of gestational diabetes mellitus: Evidence emerging from the systematic review and meta-analysis

BACKGROUND

Metalloestrogens are metals and metalloid elements with estrogenic activity found everywhere. Their impact on human health is becoming more apparent as human activities increase.

OBJECTIVE

Our aim is to conduct a comprehensive systematic review and meta-analysis of observational studies exploring the correlation between metalloestrogens (specifically As, Sb, Cr, Cd, Cu, Se, Hg) and Gestational Diabetes Mellitus (GDM).

METHODS

PubMed, Web of Science, and Embase were searched to examine the link between metalloestrogens (As, Sb, Cr, Cd, Cu, Se, and Hg) and GDM until December 2023. Risk estimates were derived using random effects models. Subgroup analyses were conducted based on study countries, exposure sample, exposure assessment method, and detection methods. Sensitivity analyses and adjustments for publication bias were carried out to assess the strength of the findings.

RESULTS

Out of the 389 articles identified initially, 350 met our criteria and 33 were included in the meta-analysis, involving 141,175 subjects (9450 cases, 131,725 controls). Arsenic, antimony, and copper exposure exhibited a potential increase in GDM risk to some extent (As: OR = 1.28, 95 % CI [1.08, 1.52]; Sb: OR = 1.73, 95 % CI [1.13, 2.65]; Cu: OR = 1.29, 95 % CI [1.02, 1.63]), although there is a high degree of heterogeneity (As: Q = 52.93, p < 0.05, I2 = 64.1 %; Sb: Q = 31.40, p < 0.05, I2 = 80.9 %; Cu: Q = 21.14, p < 0.05, I2 = 71.6 %). Conversely, selenium, cadmium, chromium, and mercury exposure did not exhibit any association with the risk of GDM in our study.

DISCUSSION

Our research indicates that the existence of harmful metalloestrogens in the surroundings has a notable effect on the likelihood of GDM. Hence, we stress the significance of environmental elements in the development of GDM and the pressing need for relevant policies and measures.

Overview of Ethnobotanical-Pharmacological Studies Carried Out on Medicinal Plants from the Serra da Estrela Natural Park: Focus on Their Antidiabetic Potential

The Serra da Estrela Natural Park (NPSE) in Portugal stands out as a well-preserved region abundant in medicinal plants, particularly known for their pharmaceutical applications in diabetes prevention and treatment. This comprehensive review explores these plants' botanical diversity, traditional uses, pharmacological applications, and chemical composition. The NPSE boast a rich diversity with 138 medicinal plants across 55 families identified as traditionally and pharmacologically used against diabetes globally. Notably, the Asteraceae and Lamiaceae families are prevalent in antidiabetic applications. In vitro studies have revealed their significant inhibition of carbohydrate-metabolizing enzymes, and certain plant co-products regulate genes involved in carbohydrate metabolism and insulin secretion. In vivo trials have demonstrated antidiabetic effects, including glycaemia regulation, insulin secretion, antioxidant activity, and lipid profile modulation. Medicinal plants in NPSE exhibit various activities beyond antidiabetic, such as antioxidant, anti-inflammatory, antibacterial, anti-cancer, and more. Chemical analyses have identified over fifty compounds like phenolic acids, flavonoids, terpenoids, and polysaccharides responsible for their efficacy against diabetes. These findings underscore the potential of NPSE medicinal plants as antidiabetic candidates, urging further research to develop effective plant-based antidiabetic drugs, beverages, and supplements.

Incretin effect determines glucose trajectory and insulin sensitivity in youths with obesity

In youths with obesity, the gut hormone potentiation of insulin secretion - the incretin effect - is blunted. We explored the longitudinal impact of the incretin effect during pubertal transition on β cell function and insulin sensitivity. Youths with obesity and 2-hour glucose level ≥ 120 mg/dL underwent a 3-hour oral glucose-tolerance test (OGTT) and an isoglycemic i.v. glucose infusion to quantify the incretin effect. After 2 years, 30 of 39 participants had a repeated OGTT and were stratified into 3 tertiles according to the baseline incretin effect. The high-incretin effect group demonstrated a longitudinal increase in β cell function (disposition index, minimal model [DIMM]), with greater insulin sensitivity at follow-up and stable insulin secretion (φtotal). A lower incretin effect at baseline was associated with higher 1-hour and 2-hour glucose level at follow-up. The high-incretin effect group displayed a greater increase of GLP-17-36 than the moderate- and low-incretin group at baseline, while such a difference did not persist after 2 years. Glucagon suppression was reduced at follow-up in those with low-baseline incretin in respect to the high-incretin group. The incretin effect during pubertal transition affected the longitudinal trajectory of β cell function and weight in youths with obesity.

Glycemia is associated with subclinical atherosclerosis through renal function in nondiabetic apparently healthy adults: a mediation analysis

The causative associations between glycemia and early alterations in renal and vascular function remain unclear. To examine the interplay among glycemia, renal function, and markers of subclinical atherosclerosis in apparently healthy subjects. Nondiabetic (30-60 years old) individuals (n = 205) without chronic kidney disease or cardiovascular disease were consecutively recruited from a cardiovascular prevention clinic. All subjects underwent arterial stiffness assessment by measuring the carotid-femoral pulse wave velocity (cfPWV). Glomerular filtration rate (GFR) was estimated by CKD-EPI equation. Study procedures were identical in the two visits (median follow-up 66 months). We employed structural equation modeling (SEM) analysis to investigate the directionality of associations. Baseline fasting plasma glucose (FPG) was independently and inversely associated with GFR (p = 0.008). GFR was significantly associated with cfPWV (p < 0.001) at baseline. By SEM analysis decreasing baseline GFR directly correlated with increasing cfPWV (p = 0.003) whereas FPG correlated with cfPWV indirectly through GFR (mediation) (P = 0.032). FPG did not mediate the effect of GFR on cfPWV (P = 0.768). SEM analysis of longitudinal data revealed bidirectional correlations between changes in FPG and GFR (P < 0.001). Alterations in GFR were directly related to changes in cfPWV (p < 0.001) whereas FPG only indirectly correlated with cfPWV through GFR changes (P = 0.002). In apparently healthy nondiabetic subjects, the association between baseline or longitudinal glycemia levels and arterial stiffening was indirect, consistently mediated by renal function status. These findings provide the first clinical evidence supporting the directionality between kidney function and glycemia in nondiabetic subjects leading to vascular dysfunction. In apparently healthy nondiabetic subjects, without cardiovascular disease or chronic kidney disease, the association between baseline or longitudinal glycemia levels and arterial stiffening was indirect, consistently mediated by renal function status.

Identification of human placenta-derived circular RNAs and autophagy related circRNA-miRNA-mRNA regulatory network in gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is a metabolic and reproductive disease with serious risks and adverse health effects. However, the pathophysiological mechanism of GDM, especially the roles of circRNAs in its pathogenesis, is largely unknown. The objective of this study was to identify and investigate the roles of circRNAs in GDM. In the current study, placental circRNA expression profiles of normal controls and GDM patients were analyzed using high-throughput sequencing. Bioinformatics analysis identified a total of 4,955 circRNAs, of which 37 circRNAs were significantly deregulated in GDM placentas compared with NC placentas. GO and KEGG enrichment analyses demonstrated that metabolic process-associated terms and metabolic pathways that may be related to GDM were significantly enriched. The biological characteristics of placenta-derived circRNAs, such as their stability and RNase R resistance, were also validated Bioinformatics prediction. Moreover, we constructed the autophagy related circRNA-miRNA-mRNA regulatory network and further functional analysis revealed that the circCDH2-miR-33b-3p-ULK1 axis may be associated with autophagy in the placentas of GDM patients. Our study indicates that aberrant expression of circRNAs may play roles in autophagy in GDM placentas, providing new insights into GDM.

Mechanistic Insights Into the Heterogeneity of Glucose Response Classes in Youths With Obesity: A Latent Class Trajectory Approach

OBJECTIVE

In a large, multiethnic cohort of youths with obesity, we analyzed pathophysiological and genetic mechanisms underlying variations in plasma glucose responses to a 180 min oral glucose tolerance test (OGTT).

RESEARCH DESIGN AND METHODS

Latent class trajectory analysis was used to identify various glucose response profiles to a nine-point OGTT in 2,378 participants in the Yale Pathogenesis of Youth-Onset T2D study, of whom 1,190 had available TCF7L2 genotyping and 358 had multiple OGTTs over a 5 year follow-up. Insulin sensitivity, clearance, and β-cell function were estimated by glucose, insulin, and C-peptide modeling.

RESULTS

Four latent classes (1 to 4) were identified based on increasing areas under the curve for glucose. Participants in class 3 and 4 had the worst metabolic and genetic risk profiles, featuring impaired insulin sensitivity, clearance, and β-cell function. Model-predicted probability to be classified as class 1 and 4 increased across ages, while insulin sensitivity and clearance showed transient reductions and β-cell function progressively declined. Insulin sensitivity was the strongest determinant of class assignment at enrollment and of the longitudinal change from class 1 and 2 to higher classes. Transitions between classes 3 and 4 were explained only by changes in β-cell glucose sensitivity.

CONCLUSIONS

We identified four glucose response classes in youths with obesity with different genetic risk profiles and progressive impairment in insulin kinetics and action. Insulin sensitivity was the main determinant in the transition between lower and higher glucose classes across ages. In contrast, transitions between the two worst glucose classes were driven only by β-cell glucose sensitivity.

miR-154-5p Affects the TGFβ1/Smad3 Pathway on the Fibrosis of Diabetic Kidney Disease via Binding E3 Ubiquitin Ligase Smurf1

Aim

The study is aimed at verifying miR-154-5p and Smurf1 combination in glomerular mesangial cells regulating TGFβ1/Smad3 pathway-related protein ubiquitination in the model of diabetic rats renal tissues, primary mesangial cells, and cell lines.

Methods

The diabetic SD rat model and high-glucose-cultured primary mesangial cells and cell lines were established. miR-154-5p mimic and inhibitor, Smurf1 siRNA, and TGF β 1/Smad3 inhibitor (SB431542) were pretreated to make the TGFβ1/Smad3 pathway and ubiquitin changes. Fluorescence in situ hybridization was used for the miR-154-5p renal localization; molecular biological detection was adopted for cell proliferation, renal function, urine protein, and pathway proteins. After bioinformatics predicted binding sites, luciferase and Co-IP were used to detect miRNA and protein binding.

Results

miR-154-5p was significantly increased and mainly concentrated in the glomerular of renal cortex in well-established diabetic rat renal tissues. Rno-miR-154-5p combined Rno-Smurf1 3′ UTR, while Smurf1 combined Smad3 directly. Meanwhile, miR-154-5p regulates TGFβ1/Smad3-mediated cell proliferation via Smurf1 ubiquitination.

Conclusion

miR-154-5p regulates the TGFβ1/Smads pathway through Smurf1 ubiquitination and promotes the fibrosis process of diabetic kidney disease.

Association between self-monitoring of blood glucose and hepatitis B virus infection among people with diabetes mellitus: a cross-sectional study in Gansu Province, China

OBJECTIVE

The purpose was to explore the association between self-monitoring of blood glucose (SMBG) and hepatitis B virus (HBV) infection among people with diabetes.

DESIGN

A cross-sectional comparative study.

SETTING

Six township hospitals in Gansu Province, China in October 2018.

PARTICIPANTS

408 patients with diabetes were systematically recruited, and based on their characteristics 408 people without diabetes were randomly matched 1:1.

INTERVENTIONS

Venous blood was collected for HBV serological testing and blood glucose testing.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was comparison of hepatitis B surface antigen (HBsAg) positive rates between the two groups. The secondary outcome was the relationship between frequency of SMBG and HBsAg positivity.

RESULTS

HBsAg positive rate in people without diabetes was 2.0% and in those with diabetes was 4.2%. Whether in people without diabetes or patients with diabetes, higher frequency of SMBG was associated with higher HBsAg positive rate. Increases in the duration of diabetes were correlated with increasing rates of HBsAg. Compared with people without diabetes, logistic regression identified an association between diabetes and HBV infection (OR=2.8; 95% CI 1.0 to 7.6), but impaired fasting glucose was not (OR=2.3; 95% CI 0.5 to 9.9).

CONCLUSION

Routine blood glucose monitoring at home was associated with HBV infection, which meant people with diabetes may be at high risk of HBV infection. China is a country with high prevalence of both HBsAg and diabetes, and the increased risk of HBV infection in populations with diabetes needs more attention.

Using mHealth Applications to Promote Self-Managed Health Behaviors Among Teens

THEORETICAL PRINCIPLES

As technology use increasingly expands, the opportunity to capitalize on it for healthcare education, monitoring, and assessment has grown rapidly, especially among adolescent patients. As apps are developed, consideration should be given to self-management theory concepts.

PHENOMENA ADDRESSED

The proliferation of mobile health (mHealth) applications allows adolescents to access healthcare information in new, innovative ways. Many health applications focus on health promotion, fitness, and nutrition and others help persons with chronic disease. This article offers a compelling case for incorporating mHealth into teen healthcare by reviewing current data on teens' technology use, showing how mHealth aligns with self-management theory concepts, and offering a case scenario on mHealth-enhanced self-management care.

RESEARCH LINKAGES

The ability to combine accurate and immediate healthcare information with continual social support could radically improve teen's self-management behaviors, especially when mHealth apps use connectivity, a feedback loop, and concepts known to enhance self-management behaviors.

Remission of Type 2 Diabetes with Very Low-Calorie Diets-A Narrative Review

Very low-calorie diets (VLCD) are hypocaloric dietary regimens of approximately 400-800 kcal/day that result in 20-30% reductions in body weight, sometimes in just 12-16 weeks. A body of evidence demonstrates that adherence to VLCD in adults with type 2 diabetes (T2D) can result in marked improvements to glycemic control and even full T2D remission, challenging the convention that T2D is a lifelong disease. Although these data are promising, the majority of VLCD studies have focused on weight loss and not T2D remission as a primary endpoint. Moreover, there is a wide range of VLCD protocols and definitions of T2D remission used across these hypocaloric studies. Together the large degree of heterogeneity in VLCD studies, and how T2D remission is defined, leave many gaps in knowledge to efficacy and durability of VLCD approaches for T2D remission. This narrative review examines findings from a body of data from VLCD studies that specifically sought to investigate T2D remission, and discusses the efficacy of VLCD compared to other hypocaloric approaches, and who is likely to benefit from VLCD approaches for T2D remission.

Longitudinal Observation of Outcomes and Patient Access to Integrated Care Following Point-of-Care Glycemic Screening in Community Health Center Dental Safety Net Clinics

Introduction: Rates of diabetes/prediabetes continue to increase, with disparity populations disproportionately affected. Previous field trials promoted point-of-care (POC) glycemic screening in dental settings as an additional primary care setting to identify potentially at-risk individuals requiring integrated care intervention. The present study observed outcomes of POC hemoglobin A1c (HbA1c) screening at community health center (CHC) dental clinics (DC) and compliance with longitudinal integrated care management among at-risk patients attending dental appointments. Materials and Methods: POC HbA1c screening utilizing Food and Drug Administration (FDA)-approved instrumentation in DC settings and periodontal evaluation of at-risk dental patients with no prior diagnosis of diabetes/prediabetes and no glycemic testing in the preceding 6 months were undertaken. Screening of patients attending dental appointments from October 24, 2017, through September 24, 2018, was implemented at four Wisconsin CHC-DCs serving populations with a high representation of disparity. Subjects meeting at-risk profiles underwent POC HbA1c screening. Individuals with measures in the diabetic/prediabetic ranges were advised to seek further medical evaluation and were re-contacted after 3 months to document compliance. Longitudinal capture of glycemic measures in electronic health records for up to 2 years was undertaken for a subset (n = 44) of subjects with available clinical, medical, and dental data. Longitudinal glycemic status and frequency of medical and dental access for follow-up care were monitored. Results: Risk assessment identified 224/915 (24.5%) patients who met inclusion criteria following two levels of risk screening, with 127/224 (57%) qualifying for POC HbA1c screening. Among those tested, 62/127 (49%) exhibited hyperglycemic measures: 55 in the prediabetic range and seven in the diabetic range. Moderate-to-severe periodontitis was more prevalent in patients with prediabetes/diabetes than in individuals with measures in the normal range. Participant follow-up compliance at 3 months was 90%. Longitudinal follow-up documented high rates of consistent access (100 and 89%, respectively), to the integrated medical/DC environment over 24 months for individuals with hyperglycemic screening measures. Conclusion: POC glycemic screening revealed elevated HbA1c measures in nearly half of at-risk CHC-DC patients. Strong compliance with integrated medical/dental management over a 24-month interval was observed, documenting good patient receptivity to POC screening in the dental setting and compliance with integrated care follow-up by at-risk patients.

Effect of Group Patient Education on Glycemic Control Among People Living with Type 2 Diabetes in Vietnam: A Randomized Controlled Single-Center Trial

INTRODUCTION

In low- to middle-income countries such as Vietnam, urgent measures are required to prevent and control type 2 diabetes and its complications. This study measured the effect of a 3-month patient education and self-management intervention in a low-resource setting on diabetes knowledge and levels of blood glucose control.

METHODS

This was a single-center randomized controlled study among adult outpatients with type 2 diabetes. Patients were randomly assigned to 3-month community intervention consisting of group education for type 2 diabetes knowledge, diet, exercise in combination with usual diabetes care, or to usual diabetes care alone (control). Diabetes knowledge was measured with a modified Michigan University Diabetes Knowledge Test (MDKT). Other study outcomes included change in mean HbA1c, fasting blood glucose (FBG), and systolic blood pressure (SBP).

RESULTS

A total of 364 patients were randomized, 182 to the intervention group and 182 to control. The two groups were similar regarding main baseline characteristics. The male/female ratio was 45.1%/54.9% and mean age was 62.2 ± 9.3 years. Approximately half the patients (48.1%) were overweight and 15.7% were obese, mean baseline HbA1c was 8.21 ± 1.92%, and only 29.9% of participants had a baseline HbA1c < 7.0%. At baseline, diabetes knowledge was "very poor" or "poor" in 63.7% of patients. After a 3-month follow-up, the proportion achieving the target MDKT score increased from 37.4% to 81.3% in the intervention group and from 35.2% to 51.7% in the control (between-group difference P < 0.001). The estimate (SD) of the difference between intervention and control groups was - 1.63 (2.16), 95% CI - 2.07 to - 1.18. Mean changes from baseline HbA1c were - 0.54 ± 1.41% and - 0.18 ± 1.33% in the intervention and control groups, respectively (P = 0.012). Among those with poor glycemic control (HbA1c ≥ 7%) at baseline, mean changes at 3 months were - 0.80 ± 1.52% vs 0.41 ± 1.47%, respectively, (P = 0.013). Statistically significant decreases in FBG and SBP were also observed in the intervention group at 3 months, but not in the control group. Multivariate analysis revealed the variables with the strongest influence on blood glucose control at 3 months were study group, baseline MDKT score, diabetes duration, and baseline HbA1c (all P ≤ 0.05).

CONCLUSION

Provision of a structured educational program to Vietnamese people living with type 2 diabetes is effective at improving disease knowledge and is associated with better glycemic control. Larger and longer-term studies are now warranted to confirm these findings.

TRIAL REGISTRATION

This trial was retrospectively registered on 27 May 2020 through the https://clinicaltrials.gov site with the following identifier: NCT04403841.

Circulating microRNA-194 levels in Chinese patients with diabetic kidney disease: a case-control study

OBJECTIVE

MicroRNAs (miRNAs) regulate gene expression and are involved in diabetic kidney disease (DKD) pathogenesis. We investigated circulating miRNA-194 levels as a biomarker of DKD prevalence and incidence, and the relationship between miRNA-194 and CCAAT/enhancer binding protein (C/EBP) homologous protein (CHOP).

METHODS

We recruited 136 type-2 diabetes mellitus (T2DM) patients at the First People's Hospital of Lianyungang and 127 healthy individuals. Circulating miRNA-194 and CHOP levels were measured using quantitative reverse transcription qRT-PCR and enzyme-linked immunosorbent assay (ELISA), respectively. Anthropometric and biochemistry measurements were also made.

RESULTS

T2DM patients showed higher circulating miRNA-194 (p = 0.029) and lower circulating CHOP (p < 0.001) levels than controls. Circulating miRNA-194 levels were significantly higher in T2DM patients with a microalbumin/creatinine ratio (UmALB/Cr) ⩾ 300 mg/g (p < 0.001). In addition, there were significant intergroup differences in the circulating CHOP concentrations (p = 0.005). Bivariate analysis revealed that circulating miR-194 levels were negatively correlated with alpha-fetoprotein and CHOP levels (r = -0.222, -0.301; p = 0.018, 0.001, respectively), but positively correlated with fasting glucose, UmALB/Cr, Cr, Cystatin C, quantitative insulin check index (QUICKI) (r = 0.193, 0.446, 0.260, 0.339, and 0.250, respectively; p = 0.036, <0.001, 0.005, <0.001, and 0.006, respectively), particularly UmALB/Cr and Cystatin C (p < 0.001). Logistic regression analysis after adjusting for covariates associated with UmALB/Cr identified duration of T2DM, systolic blood pressure, Cr, estimated glomerular filtration rate, and waist circumference as independent factors associated with T2DM patients with UmALB/Cr > 300 (p = 0.030, 0.013, <0.001, <0.001, and 0.031, respectively).

CONCLUSION

Circulating miRNA-194 levels could be a novel biomarker for DKD.

Different information needs in subgroups of people with diabetes mellitus: a latent class analysis

BACKGROUND

Current evidence suggests that the information needs of people with diabetes mellitus differ across patient groups. With a view to being able to provide individualized information, this study aims to identify (i) the diabetes-related information needs of people with diabetes mellitus; (ii) different subgroups of people with specific information needs; and (iii) associated characteristics of the identified subgroups, such as sociodemographic characteristics, diabetes-related comorbidities, and well-being.

METHODS

This cross-sectional study was based on data from 837 respondents with diabetes mellitus who participated in the population-based KORA (Cooperative Health Research in the Augsburg Region) Health Survey 2016 in Southern Germany (KORA GEFU 4 study) (45.6% female, mean age 71.1 years, 92.8% Type 2 diabetes). Diabetes-related information needs were assessed with a questionnaire asking about patients' information needs concerning 11 diabetes-related topics, e.g. 'long-term complications' and 'treatment/therapy'. Subgroups of people with different information needs and associated characteristics were identified using latent class analysis.

RESULTS

We identified the following four classes of people with different information needs: 'high needs on all topics', 'low needs on all topics', 'moderate needs with a focus on complications and diabetes in everyday life', and 'advanced needs with a focus on social and legal aspects and diabetes research'. The classes differed significantly in age, years of education, type of diabetes, diabetes duration, diabetes-related comorbidities, smoking behaviour, diabetes education, current level of information, and time preference.

CONCLUSIONS

Knowledge about different patient subgroups can be useful for tailored information campaigns or physician-patient interactions. Further research is needed to analyse health care needs in these groups, changes in information needs over the course of the disease, and prospective health outcomes.

Community-Based Participatory Research Interventions to Improve Diabetes Outcomes: A Systematic Review

PURPOSE

The purpose of this study was to conduct a systematic evaluation of community-based participatory research (CBPR) interventions on diabetes outcomes. Understanding of effective CBPR interventions on diabetes outcomes is limited, and findings remain unclear.

METHODS

A reproducible search strategy was used to identify studies testing CBPR interventions to improve diabetes outcomes, including A1C, fasting glucose, blood pressure, lipids, and quality of life. Pubmed, PsychInfo, and CINAHL were searched for articles published between 2010 and 2020. Using a CBPR continuum framework, studies were classified based on outreach, consulting, involving, collaborating, and shared leadership.

RESULTS

A total of 172 were screened, and a title search was conducted to determine eligibility. A total of 16 articles were included for synthesis. Twelve out of the 16 studies using CBPR approaches for diabetes interventions demonstrated statistically significant differences in 1 or more diabetes outcomes measured at a postintervention time point. Studies across the spectrum of CBPR demonstrated statistically significant improvements in diabetes outcomes.

CONCLUSIONS

Of the 16 studies included for synthesis, 14 demonstrated statistically significant changes in A1C, fasting glucose, blood pressure, lipids, and quality of life. The majority of studies used community health workers (CHWs) to deliver interventions across group and individual settings and demonstrated significant reductions in diabetes outcomes. The evidence summarized in this review shows the pivotal role that CHWs and diabetes care and education specialists play in not only intervention delivery but also in the development of outward-facing diabetes care approaches that are person- and community-centered.

Maternal Arsenic Exposure and Gestational Diabetes: A Systematic Review and Meta-Analysis

Gestational diabetes mellitus (GDM) is a metabolic complication associated with adverse outcomes for mother and fetus. Arsenic (As) exposure has been suggested as a possible risk factor for its development. The aim of this meta-analysis was to provide a comprehensive overview of published evidence on the association between As and GDM. The systematic search from PubMed, MEDLINE, and Scopus was limited to full-length manuscripts published in peer-reviewed journals up to April 2020, identifying fifty articles. Ten studies met the inclusion criteria, nine for quantitative synthesis with a total of n = 1984 GDM cases. The overall pooled risk was 1.56 (95% Confidence Interval - CI = 1.23, 1.99) with moderate heterogeneity (χ2 = 21.95; I2% = 64). Several differences among the included studies that may account for heterogeneity were investigated. Stratification for exposure indicator confirmed a positive association for studies assessing urine As. A slightly higher risk was detected pooling studies based in Asia rather than in North America. Stratification for GDM diagnostic criteria showed higher risks when diagnosis was made according to the Canadian Diabetes Association (CDA-SOGC) or World Health Organization (WHO) criteria, whereas a lower risk was observed when adopting the American Diabetes Association (ADA) criteria. These results provide additional evidence for a possible association between As exposure and GDM, although the data need to be interpreted with caution due to heterogeneity.

NDSP 05: Prevalence and pattern of dyslipidemia in urban and rural areas of Pakistan; a sub analysis from second National Diabetes Survey of Pakistan (NDSP) 2016-2017

Objectives

Dyslipidemia is a major risk issue for the development of cardiovascular disease. The aim of our study was to observe the pattern and prevalence of dyslipidemia in Pakistani population.

Methodology

This is a sub analysis of a population based second National Diabetes Survey of Pakistan (NDSP) 2016-2017 in adults aged 20 years or above, carried out from February 2016 to August 2017 across Pakistan. Multi stage sampling technique was used for the stratification of population, based on rural and urban domains. District wise clusters and sub clusters were selected i.e. 27 and 46 in number. Subjects, consented to participate were requested to come after an overnight fast for anthropometric measurements, oral glucose tolerance test and fasting lipid profile (except for subjects with self-reported diabetes). Dyslipidemia was identified using Adult Treatment Panel III guidelines.

Results

A total of 10,834 subjects (43.8% male and 56.2% female) having mean age of 43.8 ± 14.0 years, participated in the survey. Of the subjects studied, 39.3% had hypercholesterolemia, 48.9% had hypertriglyceridemia, 39.7% had high LDL-C levels while 83.9% men and 90% women had low HDL levels. High cholesterol and triglyceride levels were highest in 50-59 years age group, while high LDL and low HDL was most common in 40-49 years age group. Diabetes, obesity and hypertension were found to be the significant determinants for dyslipidemia.

Conclusion

Prevalence of dyslipidemia seems to be very high in Pakistan, necessitating an urgent call for early screening and effective management through lifestyle intervention and appropriate lipid lowering drugs to prevent this important cardiovascular risk factor.

A Reduced Incretin Effect Mediated by the rs7903146 Variant in the TCF7L2 Gene Is an Early Marker of β-Cell Dysfunction in Obese Youth

OBJECTIVE

The risk genotype for the common variant rs7903146 of the transcription factor 7-like-2 (TCF7L2) gene has been found to affect the incretin response in healthy and obese adults; however, whether a similar functional defect is also present in obese adolescents remains unexplored. Herein, we examined the functional effect of the rs7903146 variant in the TCF7L2 gene on the incretin effect and determined its translational metabolic manifestation by performing deep phenotyping of the incretin system, β-cell function relative to insulin sensitivity, the gastrointestinal-induced glucose disposal (GIGD) in obese youth with normal and impaired glucose tolerance.

RESEARCH DESIGN AND METHODS

Thirty-nine obese adolescents without diabetes (median age 15 [25th, 75th percentile 14, 18] years; BMI 37 [33, 43] kg/m²) were genotyped for the rs7903146 variant of TCF7L2 and underwent a 3-h oral glucose tolerance test (OGTT) followed by an isoglycemic intravenous glucose infusion (iso-intravenous glucose tolerance test [IVGTT]) to match the plasma glucose concentrations during the OGTT and a hyperglycemic clamp with arginine stimulation. The incretin effect was measured as 100 * (AUC-SR_OGTT - AUC-SR_iso-IVGTT) / AUC-SR_OGTT, where AUC-SR = area under the curve of C-peptide secretion rate. Participants were grouped into tertiles according to the percentage incretin effect (high, moderate, and low) to describe their metabolic phenotype.

RESULTS

The presence of T risk allele for TCF7L2 was associated with a markedly reduced incretin effect compared with the wild-type genotype (0.3% [-7.2, 14] vs. 37.8% [12.5, 52.4], P < 0.002). When the cohort was stratified by incretin effect, the high, moderate, and low incretin effect groups did not differ with respect to anthropometric features, while the low incretin effect group exhibited higher 1-h glucose (P = 0.015) and a reduced disposition index, insulin sensitivity, and insulin clearance compared with the high incretin effect group. GIGD was reduced in the low incretin effect group (P = 0.001). The three groups did not differ with respect to intravenous glucose-induced insulin secretion and arginine response during the hyperglycemic clamp.

CONCLUSIONS

A reduced incretin effect and its association with the TCF7L2 variant rs7903146 identify an early metabolic phenotype in obese youth without diabetes, featuring a higher plasma glucose peak at 1 h; lower insulin secretion, sensitivity, and clearance; and GIGD.

Development of type 2 diabetes mellitus quality indicators in general practice by a modified Delphi method in Beijing, China

BACKGROUND

The service capacity of primary care has improved in China. General practice also takes growing responsibility in the management of type 2 diabetes mellitus, but there are concerns about the paucity of evidence of the quality of care delivered. And there is an absence of systematic quality indicators of type 2 diabetes mellitus in general practice in China. This study aimed to develop a set of type 2 diabetes mellitus quality indicators to facilitate quality measurement in general practice in China.

METHODS

Preliminary quality indicators were generated and refined by literature review and an expert consultation meeting. Two rounds of email-based Delphi survey and a consensus meeting were carried out to identify quality indicators. Delphi questionnaires with 43 indicators were sent to 30 participants in the first round. There were 16 general practitioners and 10 community health service center leaders from primary care, 3 endocrinologists and a primary care researcher in the first round. And 27 out of the 30 participants participated in the second round. The consensus meeting was held among 9 participants to refine the indicators and a last round of rating was carried out in the meeting. The indicators were rated in terms of importance and feasibility. The agreement criteria were defined as median ≥ 7.0 and ≥ 85.0% of ratings in the 7-9 tertile for importance; median ≥ 7.0 and ≥ 65.0, 70.0, 75.0% of ratings in the 7-9 tertile for feasibility respectively in the three rounds of rating.

RESULTS

After 2 rounds of Delphi survey and the consensus meeting, total 38 indicators achieved consensus for inclusion in the final set of indicators. The final set of indicators were grouped into 7 domains: access (5 indicators), monitoring (12 indicators), health counseling (7 indicators), records (2 indicators), health status (7 indicators), patient satisfaction (2 indicators) and self-management (3 indicators).

CONCLUSIONS

A set of 38 potential quality indicators of type 2 diabetes mellitus in general practice were identified by an iterative Delphi process in Beijing, China. Preliminary approach for measurement and data collection were described. However, the indicators still need to be validated by testing in a further study.

Prevalence of Gestational Diabetes in Triplet Pregnancies: A Retrospective Cohort Study and Meta-Analysis

Background: Over the last decades, there has been a substantial increase in the incidence of higher-order multiple gestations. Twin pregnancies are associated with an increased risk of gestational diabetes mellitus (GDM). The literature on GDM rates in triplet pregnancies is scarce. Methods: A retrospective cohort study was performed to assess the prevalence of GDM in women with a triplet pregnancy. GDM was defined through an abnormal oral glucose tolerance test (OGTT). A meta-analysis of GDM prevalence was also carried out. Results: A cohort of 60 women was included in the analysis. Of these, 19 (31.7%) were diagnosed with GDM. There were no differences in pregnancy outcomes between women with and without GDM. In the meta-analysis of 12 studies, which used a sound GDM definition, an estimated pooled prevalence of 12.4% (95% confidence interval: 6.9–19.1%) was found. In a leave-one-out sensitivity analysis, the estimated GDM prevalence ranged from 10.7% to 14.1%. Conclusion: The rate of GDM seems increased in women with triplets compared to singleton pregnancies. However, GDM did not impact short-term pregnancy outcomes.

The Association between Metformin Therapy and Lactic Acidosis

INTRODUCTION AND OBJECTIVES

There is increasing evidence to suggest that therapeutic doses of metformin are unlikely to cause lactic acidosis. The aims of this research were (1) to formally evaluate the association between metformin therapy and lactic acidosis in published case reports using two causality scoring systems, (2) to determine the frequency of pre-existing independent risk factors in published metformin-associated lactic acidosis cases, (3) to investigate the association between risk factors and mortality in metformin-associated lactic acidosis cases, and (4) to explore the relationship between prescribed metformin doses, elevated metformin plasma concentrations and the development of lactic acidosis in cases with chronic renal impairment.

METHODS

A systematic review was conducted to identify metformin-associated lactic acidosis cases. Causality was assessed using the World Health Organisation-Uppsala Monitoring Centre system and the Naranjo adverse drug reaction probability scale. Compliance to dosing guidelines was investigated for cases with chronic renal impairment as well as the association between steady-state plasma metformin concentrations prior to admission.

RESULTS

We identified 559 metformin-associated lactic acidosis cases. Almost all cases reviewed (97%) presented with independent risk factors for lactic acidosis. The prescribed metformin dose exceeded published guidelines in 60% of cases in patients with impaired kidney function. Metformin steady-state plasma concentrations prior to admission were predicted to be below the proposed upper limit of the therapeutic range of 5 mg/L.

CONCLUSIONS

Almost all cases of metformin-associated lactic acidosis reviewed presented with independent risk factors for lactic acidosis, supporting the suggestion that metformin plays a contributory role. The prescribed metformin dose, on average, exceeded the dosing recommendations by 1000 mg/day in patients with varying degrees of renal impairment but the predicted pre-admission plasma concentrations did not exceed the therapeutic range.

Diabetes stigma and its association with diabetes outcomes: a cross-sectional study of adults with type 1 diabetes

Aims: The aim of this study was to investigate the relationship between diabetes stigma as experienced by adults with type 1 diabetes and diabetes outcomes using the novel, validated measure of the Type 1 Diabetes Stigma Assessment Scale. Methods: A total of 1594 adults with type 1 diabetes completed a questionnaire on socio-economic factors, psychosocial health, and diabetes stigma and these self-reported data were linked with data from electronic clinical records on glycaemic control, diabetes duration, age, and diabetes-related complications. Bivariate analyses and multivariate linear regressions were performed to assess the relationship between diabetes stigma as measured by three subscales, Identity concern, Blame and judgement, and Treated differently on the one hand, and patient characteristics and diabetes outcomes on the other. Results: Endorsement of the stigma statements ranged from 3.6-78.3% of respondents. Higher stigma scores in relation to Identity concern and Blame and judgement were significantly associated with being female, of lower age, lower diabetes duration, and having at least one complication. Those who reported higher levels of perceived stigma reported significantly higher levels of diabetes distress (β = 0.37 (95% CI: 0.33-0.40), 0.35 (95% CI: 0.30-0.39), 0.41 (95% CI: 0.35-0.46)), and HbA1c levels (β = 0.11 (95% CI: 0.02-0.21), 0.28 (95% CI: 0.16-0.40), 0.26 (95% CI: 0.14-0.42) for Identity concern, Blame and judgement, and Treated differently, respectively). Conclusions: The findings demonstrated that diabetes stigma is negatively associated with both diabetes distress and glycaemic control and should be considered part of the psychosocial burden of adults with type 1 diabetes.

Basics and use of continuous glucose monitoring (CGM) in diabetes therapy

Background

For a long time, self-monitoring of blood glucose (SMBG) was widely viewed as the essential glucose measurement procedure in the therapy of insulin-treated people with diabetes. With increasing accuracy and simplified handling of continuous glucose monitoring (CGM) systems, this evolving technology challenges and at least partly replaces SMBG systems.

Content

Sensors of all currently available CGM systems measure glucose levels in the subcutaneous interstitial fluid for 6–14 days. The only available implantable sensor facilitates a measurement span of up to 6 months. Depending on the used system, glucose levels are either shown in real time (rtCGM systems) or after scanning (iscCGM systems). Functions such as alerts, alarms and trend arrows and data presentation encourage independent self-management of diabetes therapy. The high frequency of glucose data and the multitude of existing functions require an extensive training of people with diabetes and their caregivers.

Summary

CGM systems provide a much more detailed picture of glycemia in people with diabetes. Educated patients can use these data to react adequately to their glucose levels and therefore avoid hypoglycemic and hyperglycemic events. Studies showed that glycated hemoglobin (HbA1c) levels and hypoglycemic events can be significantly reduced by frequent use of CGM systems.

Metabolic and Genetic Determinants of Glucose Shape After Oral Challenge in Obese Youths: A Longitudinal Study

CONTEXT

The time-to-glucose-peak following the oral glucose tolerance test (OGTT) is a highly reproducible marker for diabetes risk. In obese youths, we lack evidence for the mechanisms underlying the effects of the TCF7L2 rs7903146 variant on glucose peak.

METHODS

We analyzed the metabolic phenotype and the genotype for the TCF7L2 rs7903146 in 630 obese youths with normal (NGT) and impaired (IGT) glucose tolerance. Participants underwent a 3-hour, 9-point OGTT to estimate, using the oral minimal model, the disposition index (DI), the static (φstatic) and dynamic (φdynamic) components β-cell responsiveness and insulin sensitivity (SI). In a subgroup (n = 241) longitudinally followed for 2 years, we estimated the effect of time-to-glucose-peak on glucose tolerance change.

RESULTS

Participants were grouped into early (<30 minutes) and late (≥30 minutes) glucose peakers. A delayed glucose peak was featured by a decline in φstatic (P < .001) in the absence of a difference in φdynamic. The prevalence of T-risk allele for TCF7L2 rs7903146 variant significantly increased in the late peak group. A lower DI was correlated with higher glucose concentration at 1 and 2 hours, whereas SI was inversely associated with 1-hour glucose. Glucose peak <30 minutes was protective toward worsening of glucose tolerance overtime (odds ratio 0.35 [0.15-0.82]; P = .015), with no subjects progressing to NGT or persisting IGT, in contrast to the 40% of progressor in those with late glucose peak.

CONCLUSION

The prevalence of T-risk allele for the TCF7L2 rs7903146 prevailed in the late time-to-glucose peak group, which in turn is associated with impaired β-cell responsiveness to glucose (φ), thereby predisposing to prediabetes and diabetes in obese youths.

The Barriers and Facilitators of Self-Management Among Adults with Type 2 Diabetes Mellitus: A Trans Theoretical Model (TTM)-Based Mixed Method Study in Iran

AIM

This study planned to determine:( 1) the behavioral intention or profile of patients with type 2 diabetes mellitus (T2DM) based on the stages of the change model, and( 2) to explore the perceived facilitators and barriers of self-management (SM) in a sample of Iranian patients with T2DM.

METHODS

This was a mixed method study, accomplished in two phases. In the quantitative phase, 246 subjects with T2DM participated. They were classified according to items such as regular use of blood-glucose-lowering drugs, having a healthy diet and performing physical activity to pre-action and action groups. Socio-demographic and anthropometric information were collected, and a phenomenological qualitative study was conducted, and data collection continued until saturation achieved by 10 subjects in pre-action and 12 subjects in action groups. Four focus group discussions in the field of SM were accomplished. Analysis of quantitative and qualitative data was conducted by the SPSS and MAXQDA software, respectively.

RESULTS

The mean age and duration of illness among the subjects were 53.9±7.1 and 6.9±4.9 years, respectively. The barriers of SM in action and pre-action stages were as follows: lower socio-economic status, poor performance of treatment team, physical-intellectual factors and lack of planning to change. The facilitators stated in the pre-action and action stage in the field of SM were satisfaction from treatment, planning, belief in diabetes, treatment team's support, nutritional knowledge, and religious beliefs.

CONCLUSION

This study indicated facilitator and barrier factors in SM based on TTM in action and pre-action groups. Healthcare professionals should consider these findings to improve the patients' outcomes.

A longitudinal follow-up study of a type 2 diabetes "lost to follow-up" cohort - positive effect on glycaemic control after changes in medication

The aim of this study was to evaluate whether patients with type 2 diabetes (T2D) who had stopped attending their diabetes treatment system (referred to as "lost to follow-up", LTF) but who succeeded in improving their glycaemic control after returning to the diabetes treatment system had changes in their diabetes medication when compared with similar patients who did not show improvement. "LTFs" who had baseline haemoglobin A_1 c (HbA_1 c) ≥53 mmol/mol and succeeded in reducing HbA_1 c ≥ 6 mmol/mol during a 12-30 month follow-up period after adhering again to their diabetes treatment system were compared with "LTFs" who had an unsatisfactory change in HbA_1 c or with "LTFs" who maintained good glycaemic control throughout the 12-30 month follow-up period. Unsatisfactory change in HbA_1 c was determined as HbA_1 c ≥ 53 mmol/mol and change <6 mmol/mol after the 12-30 month follow-up period in their diabetes treatment system or HbA_1 c < 53 mmol/mol when returning to the diabetes treatment system but ≥53 mmol/mol at the end of the 12-30 month follow-up period. "LTFs" with improvement in glycaemic control used a higher number of different anti-hyperglycaemic agents (P < 0.001) and their dosages of metformin increased (P < 0.05) when compared with "LTFs" without improvement or "LTFs" with satisfactory glycaemic control. Cholesterol-, LDL-cholesterol- and triglyceride-concentrations decreased during the 12-30 month follow-up period (P < 0.05) in "LTFs" with improved glycaemic control, but not in the other groups. "LTFs" with T2D who had poor glycaemic control seemed to require an increase in their anti-diabetic medication when attempting to improve their glycaemic control.

Cost-effectiveness of insulin degludec versus insulin glargine U100 in adults with type 1 and type 2 diabetes mellitus in Bulgaria

BACKGROUND

This analysis evaluates the cost-effectiveness of insulin degludec (degludec) versus biosimilar insulin glargine U100 (glargine U100) in patients with type 1 (T1DM) and type 2 diabetes mellitus (T2DM) in Bulgaria.

METHODS

A simple, short-term model was used to compare the treatment costs and outcomes associated with hypoglycaemic events with degludec versus glargine U100 in patients with T1DM and T2DM from the perspective of the Bulgarian National Health Insurance Fund. Cost-effectiveness was analysed over a 1-year time horizon using data from clinical trials. The incremental cost-effectiveness ratio (ICER) was the main outcome measure.

RESULTS

In Bulgaria, degludec was highly cost-effective versus glargine U100 in people with T1DM and T2DM. The ICERs were estimated to be 4493.68 BGN/quality-adjusted life year (QALY) in T1DM, 399.11 BGN/QALY in T2DM on basal oral therapy (T2DM_BOT) and 7365.22 BGN/QALY in T2DM on basal bolus therapy (T2DM_B/B), which are below the cost-effectiveness threshold of 39,619 BGN in Bulgaria. Degludec was associated with higher insulin costs in all three patient groups; however, savings from a reduction in hypoglycaemic events with degludec versus glargine U100 partially offset these costs. Sensitivity analysis demonstrated that the results were robust and largely insensitive to variations in input parameters. At a willingness-to-pay threshold of 39,619 BGN/QALY, the probability of degludec being cost-effective versus glargine U100 was 60.0% in T1DM, 99.4% in T2DM_BOT and 91.3% in T2DM_B/B.

CONCLUSION

Degludec is a cost-effective alternative to biosimilar glargine U100 for patients with T1DM and T2DM in Bulgaria. Degludec could be of particular benefit to those patients suffering recurrent hypoglycaemia and those who require additional flexibility in the dosing of insulin.

Association between dog ownership and type 2 diabetes in later life: the Helsinki birth cohort study

Dog ownership has been reported to have beneficial effects on physical activity and emotional well-being, both known to reduce the risk for type 2 diabetes (T2D). The aim of this study was to evaluate the association between dog ownership during the whole life course and having T2D in later life. The study subjects consisted of 731 people (307 men and 424 women) from the Helsinki Birth Cohort Study. We assessed dog ownership with questionnaires, for every decade of life as well as current dog ownership. We investigated the associations between dog ownership and T2D with generalised estimating equation models and with generalised linear models. At a mean age of 71.0 (standard deviation [SD] 2.6) years, 13% of the participants had T2D. Dog ownership prior to the clinical examination was not associated with T2D (p ≥ 0.51). In men, but not in women, current dog owners had greater odds of having T2D compared with the non-owners when adjusted for age when clinically examined, socio-economic status, smoking, leisure-time physical activity, chronic diseases (OR = 3.32, 95% confidence interval 1.25-8.79, p = 0.016). In the age group of people around 70 years, dog ownership is not associated with reduced odds for developing T2D. Abbreviations: BMI: body mass index; CI: confidence interval; GEE: generalised estimating equation; HBCS: Helsinki Birth Cohort Study; KIHD: Kuopio Ischemic Heart Disease; LTPA: leisure-time physical activity; MET: metabolic equivalent of task; OGTT: oral glucose tolerance test; OR: Odds ratio; SD: standard deviation; SES: socio-economic status; T2D: type 2 diabetes.

Relationship between number of contacts between previous dropouts with type 2 diabetes and health care professionals on glycaemic control: A cohort study in public primary health care

AIM

Previous study findings have shown that more frequent contacts with the diabetes care team predict better diabetes control. It is unknown whether this is true also for previous dropouts with type 2 diabetes (T2D). The aim of this study was to evaluate if those previous dropouts with T2D who succeeded to improve their glycaemic control had more frequent contacts with health care professionals in the public primary diabetes health care system than those dropouts who did not show improvement.

METHODS

In this "real life" retrospective cohort study, we identified 115 dropouts with T2D who were contacted by trained diabetes nurses and who returned to a public T2D-care system. Those previous dropouts who had baseline haemoglobin A_1c ≥53mmol/mol (7%) and had a reduction in HbA_1c≥6mmol/mol (0.5%) during the follow-up were compared with those with unsatisfactory change in HbA_1c (baseline HbA_1c≥53mmol/mol and change <6mmol/mol, or HbA_1c<53mmol/mol at the baseline measurement but above that in the end of the study period) or with those who remained at good glycaemic control over the study period. Trained diabetes nurses collected quantitative data from the patient records about visits and contacts during the follow-up.

RESULTS

Previous dropouts showing improvement had more visits to the diabetes nurse (p=0.003) and other nurses (p<0.001) than those with no improvement or those with satisfactory glycaemic control. Telephone calls not focusing on diabetes (p<0.001) were also more frequent among previous dropouts with improvement than among the others.

CONCLUSIONS

Especially previous dropouts with T2D who had poor glycaemic control, may benefit from more frequent contacts including visits and telephone calls. Recalling dropouts does not seem to lead to overuse of the T2D care-system by those recalled patients whose glycaemic control does not require special care.

Baseline characteristics of infected foot ulcers in patients with diabetes at a tertiary care hospital in Pakistan

OBJECTIVE:

Studies on diabetic foot ulcers (DFU) involving a representative sample of patients in Pakistan are scarce. This study aimed to determine baseline characteristics of infected DFUs in patients hospitalised at the Pakistan Institute of Medical Sciences Islamabad.

METHOD:

In this cross-sectional study, carried out during May 2015 and June 2016, foot ulcer characteristics of patients with DFUs were investigated and documented. From infected DFUs, aerobic bacterial pathogens were isolated, identified and evaluated for antimicrobial susceptibility.

RESULTS:

A total of 214 patients were recruited to the study, 62.6% of which were male, 90.2% were aged ≥40 years, 76.2% had type 1 diabetes and 78.5% had poor glycaemic control at time of presentation to hospital. Most patients had grade 3/moderate ulceration (based on the Wagner and International Working Group on the Diabetic Foot/Infectious Diseases Society of America criteria). Over half of the DFUs (57.9%) were of ≤3 months' duration and 70.1% were ≥3 cm². Of the patients with deep infection grade ulcers, 26.6% underwent amputation, accounting for their prolonged hospital stay (≥20 days). Significant differences were observed between patients with type 1 and type 2 diabetes with DFUs in relation to gender (p≤0.0001), ulcer size (p=0.0421) and duration of hospital stay (p=0.0253). The most significant predictors for lower extremity amputation were osteomyelitis (p=0.0114), retinopathy (p=0.0001) and neuropathy (p=0.0001. Piperacillin/tazobactam was found to be an effective antibiotic against the most commonly isolated Staphylococcus non-aureus (35.48%), Pseudomonas aeruginosa (22.26%), and Staphylococcus aureus (20.96%) species indentified in the DFU infections.

CONCLUSION:

The findings of this study may be helpful in the optimal management and appropriate treatment of patients with infected DFUs.

Additional Effect of Dietary Fiber in Patients with Type 2 Diabetes Mellitus Using Metformin and Sulfonylurea: An Open-Label, Pilot Trial

BACKGROUND

Metformin, sulfonylurea, and dietary fiber are known to affect gut microbiota in patients with type 2 diabetes mellitus (T2DM). This open and single-arm pilot trial investigated the effects of the additional use of fiber on glycemic parameters, insulin, incretins, and microbiota in patients with T2DM who had been treated with metformin and sulfonylurea.

METHODS

Participants took fiber for 4 weeks and stopped for the next 4 weeks. Glycemic parameters, insulin, incretins during mixed-meal tolerance test (MMTT), lipopolysaccharide (LPS) level, and fecal microbiota were analyzed at weeks 0, 4, and 8. The first tertile of difference in glucose area under the curve during MMTT between weeks 0 and 4 was defined as 'responders' and the third as 'nonresponders,' respectively.

RESULTS

In all 10 participants, the peak incretin levels during MMTT were higher and LPS were lower at week 4 as compared with at baseline. While the insulin sensitivity of the 'responders' increased at week 4, that of the 'nonresponders' showed opposite results. However, the results were not statistically significant. In all participants, metabolically unfavorable microbiota decreased at week 4 and were restored at week 8. At baseline, metabolically hostile bacteria were more abundant in the 'nonresponders.' In 'responders,' Roseburia intestinalis increased at week 4.

CONCLUSION

While dietary fiber did not induce additional changes in glycemic parameters, it showed a trend of improvement in insulin sensitivity in 'responders.' Even if patients are already receiving diabetes treatment, the additional administration of fiber can lead to additional benefits in the treatment of diabetes.

Predictive factors of non-HDL cholesterol in children and adolescents with type 1 diabetes mellitius: A cross-sectional study

AIMS

To assess predictors of non-HDL cholesterol in children and adolescents with T1DM.

METHODS

A cross-sectional study of 120 children and adolescents aged 7-16 with T1DM, but without any other chronic morbidities, at a referral outpatient clinic for the treatment of diabetes in Rio de Janeiro, Brazil. Socio-demographic, anthropometric, dietary, and clinical factors were assessed, which included measurements of serum lipids and glycated hemoglobin (HbA1c). Food intake was assessed by 24-h dietary recall. Multiple linear regression was adopted in the analysis.

RESULTS

The mean age of of the subjects was 11.74 ± 2.88 years, 53.3% were female, and the mean duration of T1DM was 6.68 ± 3.33 years. The mean energy intake from carbohydrates, proteins, and lipids was 51.98% (±9.20), 21.43% (±6.13), and 26.57% (±9.98), respectively. The energy intake from processed and ultra-processed foods represented 40.79% of total energy intake. The predictors of non-HDL cholesterol were: HbA1c (%) (p = 0.000, β = 8.5, CI: 4.8-12.1), duration of T1DM (p = 0.000, β = 2.8, CI: 1.3-4.3), and sex (p = 0.032, β = 10.1, CI: 0.9-19.4).

CONCLUSION

Glycemic control was the major modifiable predictor of non-HDL cholesterol concentrations, a significant indicator of cardiovascular risk.

Hypoglycaemia and type 1 diabetes are associated with an increased risk of fractures

People with diabetes have an increased risk of fractures, and in this study, the effect of hypoglycaemia and insulin on this risk was investigated. Type 1 diabetes and hypoglycaemia did increase the fracture risk, and prevention of hypoglycaemia is thus an important focus area in the prevention of fractures.

INTRODUCTION

Studies have shown that type 1 diabetes (T1D) and type 2 diabetes (T2D) are associated with increased risk of fractures. Especially, subjects with T1D have an increased risk of fractures. The purpose of this study was to investigate the association of T1D, hypoglycaemia and insulin on fracture risk.

METHODS

A cohort study with T1D subjects (n = 19,896) and T2D subjects (n = 312,188) matched with subjects from the general populated (n = 996,252) and a nested case-control study with T1D subjects with fracture (n = 895) as cases and T1D subjects without (n = 2685) as controls were conducted based on subjects from the Danish National Patient Registry (DNPR).

RESULTS

T1D (HR = 2.47, 95% CI 2.37 to 2.59), age (HR = 1.05, 95% CI 1.05 to 1.05), previous fracture (HR = 1.95, 95% CI 1.92 to 1.99) and being female (HR = 2.06, 95% CI 2.04 to 2.09) increased the risk of fractures. Also, T2D (HR = 1.14, 95% CI 1.11 to 1.18) increased the risk of proximal upper arm and shoulder fractures. T1D (HR = 2.41, 95% CI 2.20 to 2.65) increased the risk of hip and femoral region fractures. Hypoglycaemia (OR = 1.58, 95% CI 1.27 to 1.97) increased the risk of fractures, whereas insulin use did not change the risk.

CONCLUSIONS

Hypoglycaemic episodes are associated with increased fracture risk, and the frequency of hypoglycaemic episodes leading to hospital admission was above 16% for T1D subjects. Prevention of hypoglycaemia is thus an important focus area in the prevention of fractures.

BE-SMART (Basal Early Strategies to Maximize HbA1c Reduction with Oral Therapy): Expert Opinion

The past three decades have seen a quadruple rise in the number of people affected by diabetes mellitus worldwide, with the disease being the ninth major cause of mortality. Type 2 diabetes mellitus (T2DM) often remains undiagnosed for several years due to its asymptomatic nature during the initial stages. In India, 70% of diagnosed diabetes cases remain uncontrolled. Current guidelines endorse the initiation of insulin early in the course of the disease, specifically in patients with HbA1c > 10%, as the use of oral agents alone is unlikely to achieve glycemic targets. Early insulin initiation and optimization of glycemic control using insulin titration algorithms and patient empowerment can facilitate the effective management of uncontrolled diabetes. Early glucose control has sustained benefits in people with diabetes. However, insulin initiation, dose adjustment, and the need to repeatedly assess blood glucose levels are often perplexing for both physicians and patients, and there are misconceptions and concerns regarding its use. Hence, an early transition to insulin and ideal intensification of treatment may aid in delaying the onset of diabetes complications. This opinion statement was formulated by an expert panel on the basis of existing guidelines, clinical experience, and economic and cultural contexts. The statement stresses the timely and appropriate use of basal insulin in T2DM. It focuses on the seven vital Ts-treatment initiation, timing of administration, transportation and storage, technique of administration, targets for titration, tablets, and tools for monitoring.Funding: Sanofi.

Impaired Glucose Metabolism in Primary Aldosteronism Is Associated With Cortisol Cosecretion

CONTEXT

Primary aldosteronism (PA) is associated with higher cardiovascular morbidity and metabolic risks. Recent studies report glucocorticoid cosecretion as a relevant phenotype of PA, which could contribute to associated risks, including type 2 diabetes mellitus (T2DM). The relationship between autonomous cortisol secretion (ACS) and glucose metabolism in PA has not been investigated.

OBJECTIVE

To evaluate the prevalence of impaired glucose homeostasis in patients with PA according to cortisol cosecretion.

DESIGN

We performed oral glucose tolerance tests (OGTTs) and complete testing for hypercortisolism [1-mg dexamethasone suppression test (DST), late-night salivary cortisol, 24-hour urinary free cortisol] in 161 newly diagnosed patients with PA of the German Conn Registry. Seventy-six of 161 patients were reevaluated at follow-up. We compared our results to a population-based sample from the Cooperative Health Research in the Region of Augsburg (KORA)-F4 study matched to the participants with PA (3:1) by sex, age, and body mass index.

RESULTS

At the time of diagnosis, 125 patients (77.6%) had a pathological response in at least one of the Cushing screening tests; T2DM was diagnosed in 6.4% of these 125 cases. Patients with a pathological DST exhibited significantly higher 2-hour plasma glucose in OGTTs and were significantly more often diagnosed with T2DM than were patients with a normal DST (20% vs 0.8%, P < 0.0001) and matched controls from the KORA study (20.6% vs 5.9%, P = 0.022). Patients with PA without ACS tended to have higher homeostatic model assessment of insulin resistance levels than did KORA control subjects (P = 0.05).

CONCLUSION

ACS appears frequently in patients with PA and is associated with impaired glucose metabolism, which could increase the risk of T2DM. PA itself seems to enhance insulin resistance.

Misdiagnosis and Diabetic Ketoacidosis at Diagnosis of Type 1 Diabetes: Patient and Caregiver Perspectives

IN BRIEF Diabetic ketoacidosis (DKA) is a life-threatening complication that frequently occurs at diagnosis of type 1 diabetes, occurs more commonly when a patient is misdiagnosed, is the leading cause of death in children with type 1 diabetes, and is associated with worse long-term outcomes. Our retrospective online survey found that 25% of all participants were misdiagnosed and that misdiagnosis was associated with an 18% increased risk for DKA compared to those correctly diagnosed. Adult providers should consider type 1 diabetes when diagnosing type 2 diabetes, and pediatric providers should rule out type 1 diabetes when a patient reports nonspecific viral symptoms.

Safety and efficacy of antihyperglycaemic agents in diabetic kidney disease

Diabetic kidney disease (DKD) is the major contributor to the mortality and the financial burden of diabetes, accounting for approximately 50% of the cases of end-stage renal disease (ESRD) in the developed world. Several studies have already demonstrated that achieving blood pressure targets in DKD with agents blocking the renin-angiotensin system confer superior renoprotection when compared to other agents. However, the effects on renal outcomes of antihyperglycaemic agents in these patients have not been reported or studied broadly until recent years. The intent of this article is to review the available data on safety, efficacy, impact on renal outcomes and pathophysiology implications of the most utilized antihyperglycaemic agents in DKD/ESRD.

Effect of Oral Nutritional Supplements with Sucromalt and Isomaltulose versus Standard Formula on Glycaemic Index, Entero-Insular Axis Peptides and Subjective Appetite in Patients with Type 2 Diabetes: A Randomised Cross-Over Study

Oral diabetes-specific nutritional supplements (ONS-D) induce favourable postprandial responses in subjects with type 2 diabetes (DM2), but they have not been correlated yet with incretin release and subjective appetite (SA). This randomised, double-blind, cross-over study compared postprandial effects of ONS-D with isomaltulose and sucromalt versus standard formula (ET) on glycaemic index (GI), insulin, glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide 1 (GLP-1) and SA in 16 individuals with DM2. After overnight fasting, subjects consumed a portion of supplements containing 25 g of carbohydrates or reference food. Blood samples were collected at baseline and at 30, 60, 90, 120, 150 and 180 min; and SA sensations were assessed by a visual analogue scale on separate days. Glycaemic index values were low for ONS-D and intermediate for ET (p < 0.001). The insulin area under the curve (AUC0-180 min) (p < 0.02) and GIP AUC (p < 0.02) were lower after ONS-D and higher GLP-1 AUC when compared with ET (p < 0.05). Subjective appetite AUC was greater after ET than ONS-D (p < 0.05). Interactions between hormones, hunger, fullness and GI were found, but not within the ratings of SA; isomaltulose and sucromalt may have influenced these factors.

Efficacy and safety of evolocumab in individuals with type 2 diabetes mellitus: primary results of the randomised controlled BANTING study

AIMS/HYPOTHESIS

The study aimed to examine the efficacy of 12 weeks of monthly evolocumab or placebo in lowering LDL-cholesterol (LDL-C) in individuals with type 2 diabetes and hypercholesterolaemia or mixed dyslipidaemia and on a maximum-tolerated statin of at least moderate intensity.

METHODS

For this randomised, placebo-controlled outpatient study, eligible individuals were ≥18 years old with type 2 diabetes, HbA_1c <10% (86 mmol/mol), had been on stable pharmacological therapy for diabetes for ≥6 months and were taking a maximum-tolerated statin dose of at least moderate intensity. Lipid eligibility criteria varied by history of clinical cardiovascular disease. Participants were randomised 2:1 to evolocumab 420 mg s.c. or placebo. Randomisation was performed centrally via an interactive web-based or voice recognition system. Allocation was concealed using the centralised randomisation process. Treatment assignment was blinded to the sponsor study team, investigators, site staff and patients throughout the study. Co-primary endpoints were mean percentage change in LDL-C from baseline to week 12 and to the mean of weeks 10 and 12. Additional endpoints included LDL-C <1.81 mmol/l, LDL-C reduction ≥50% and other lipids. Exploratory analyses included percentage changes in fasting and post mixed-meal tolerance test (MMTT) lipoproteins and lipids, glucose metabolism variables and inflammatory biomarkers.

RESULTS

In total, 421 individuals were randomised and analysed, having received evolocumab (280 participants) or placebo (141 participants) (mean [SD] age 62 [8] years; 44% women; 77% white). Evolocumab decreased LDL-C by 54.3% (1.4%) at week 12 (vs 1.1% [1.9%] decrease with placebo; p < 0.0001) and by 65.0% (1.3%) at the mean of weeks 10 and 12 (vs 0.8% [1.8%] decrease with placebo; p < 0.0001); it also decreased non-HDL-cholesterol (HDL-C) by 46.9% (1.3%) at week 12 (vs 0.6% [1.8%] decrease with placebo) and by 56.6% (1.2%) at the mean of weeks 10 and 12 (vs 0.1% [1.6%] decrease with placebo). Evolocumab significantly improved levels of other lipids and allowed more participants to reach LDL-C <1.81 mmol/l or a reduction in LDL-C levels ≥50%. After an MMTT (120 min), there were favourable changes (p < 0.05; nominal, post hoc, no multiplicity adjustment) in chylomicron triacylglycerol (triglycerides), chylomicron cholesterol, VLDL-C and LDL-C. Evolocumab had no effect on glycaemic variables and was well tolerated.

CONCLUSIONS/INTERPRETATION

In statin-treated individuals with type 2 diabetes and hypercholesterolaemia or mixed dyslipidaemia, evolocumab significantly reduced LDL-C and non-HDL-C. Favourable changes (p < 0.05) were observed in postprandial levels of chylomicrons, VLDL-C and LDL-C.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02739984 FUNDING: This study was funded by Amgen Inc.

DATA AVAILABILITY

Qualified researchers may request data from Amgen clinical studies. Complete details are available at www.amgen.com/datasharing .

Current Understanding of Autophagy in Pregnancy

Autophagy is an evolutionarily conserved process in eukaryotes to maintain cellular homeostasis under environmental stress. Intracellular control is exerted to produce energy or maintain intracellular protein quality controls. Autophagy plays an important role in embryogenesis, implantation, and maintenance of pregnancy. This role includes supporting extravillous trophoblasts (EVTs) that invade the decidua (endometrium) until the first third of uterine myometrium and migrate along the lumina of spiral arterioles under hypoxic and low-nutrient conditions in early pregnancy. In addition, autophagy inhibition has been linked to poor placentation—a feature of preeclamptic placentas—in a placenta-specific autophagy knockout mouse model. Studies of autophagy in human placentas have revealed controversial results, especially with regard to preeclampsia and gestational diabetes mellitus (GDM). Without precise estimation of autophagy flux, wrong interpretation would lead to fixed tissues. This paper presents a review of the role of autophagy in pregnancy and elaborates on the interpretation of autophagy in human placental tissues.

Generalizability of the Self-Care of Diabetes Inventory Across Cultures and Languages: Italy and the United States

Measuring self-care behaviors is crucial in diabetes research worldwide. Having a common measure of self-care represents an unmet need limiting the development of the science. The Self-Care of Diabetes Inventory was developed to address limitations of previous tools that were not theoretically grounded, strong in psychometrics, and clinically validated. However, the generalizability and comparability of the Self-Care of Diabetes Inventory has not been tested across cultures and languages. The aim of this study was to test the invariance of the Self-Care of Diabetes Inventory measurement model between Italy and the United States. Data from two multicenter cross-sectional studies were used. Two diabetes clinics and two hospitals in Italy and the United States were involved. We enrolled 200 adults in Italy and 226 in the United States, all with a confirmed diagnosis of type 1 or type 2 diabetes. The Self-Care of Diabetes Inventory was used to measure self-care maintenance, monitoring, and management behaviors as described in the middle range theory of self-care of chronic illness. Configural, metric, scalar, and strict invariance were tested for each scale. Three of the four measurement equivalence levels were supported in the three Self-Care of Diabetes Inventory Scales, whereas strict invariance-the highest level-was reached only by the Self-Care Maintenance and Self-Care Monitoring Scales. Clear support for the use of the Self-Care of Diabetes Inventory in diabetes research was provided. Cross-national comparisons of self-care between groups of Italian and U.S. patients are supported, based on the invariance of the measurement model. Aggregation of research data obtained using the Self-Care of Diabetes Inventory across countries could support knowledge development in the field of diabetes self-care.

Continuous Glucose Monitoring: A Brief Review for Primary Care Practitioners

Glycated hemoglobin A1c (HbA1c) is routinely used as a marker of average glycemic control, but it fails to provide data on hypoglycemia and glycemic variability, both of which are associated with adverse clinical outcomes. Self-monitoring of blood glucose (SMBG), particularly in insulin-treated patients, is a cornerstone in the management of patients with diabetes. SMBG helps with treatment decisions that aim to reduce high glucose levels while avoiding hypoglycemia and limiting glucose variability. However, repeated SMBG can be inconvenient to patients and difficult to maintain in the long term. By contrast, continuous glucose monitoring (CGM) provides a convenient, comprehensive assessment of blood glucose levels, allowing the identification of high and low glucose levels, in addition to evaluating glycemic variability. CGM using newer detection and visualization systems can overcome many of the limitations of an HbA1c-based approach while addressing the inconvenience and fragmented glucose data associated with SMBG. When used together with HbA1c monitoring, CGM provides complementary information on glucose levels, thus facilitating the optimization of diabetes therapy while reducing the fear and risk of hypoglycemia. Here we review the capabilities and benefits of CGM, including cost-effectiveness data, and discuss the potential limitations of this glucose-monitoring strategy for the management of patients with diabetes. FUNDING: Sanofi US, Inc.