The Association Between Poor Glycemic Control and Health Care Costs in People With Diabetes: A Population-Based Study

Effects of the Part D Senior Savings Model on racial and ethnic disparities in healthcare costs

OBJECTIVE

The Centers for Medicare & Medicaid Services tested the Part D Senior Savings Model ("PDSS Model") in 2021, capping monthly out-of-pocket (OOP) insulin costs at $35. Diabetes disproportionately affects racial/ethnic minorities compared to their non-Hispanic White (White) counterparts, so this study compared the changes in racial/ethnic disparities in healthcare costs among insulin users between Medicare and non-Medicare populations in 2021.

METHODS

This study analyzed the Medical Expenditure Panel Survey (2020-2021). The intervention group comprised Medicare beneficiaries aged ≥65, while the comparison group included a near-elderly non-Medicare population. The study outcomes included annual OOP/total costs in 2021 dollars for insulin, medication, health services (medical), and overall healthcare. A difference-in-differences-in-differences approach was employed to assess the PDSS Model's effects between White and each racial/ethnic minority group.

RESULTS

The weighted sample included 1,056,386 insulin users (53.89% intervention). In 2020, among the intervention group, non-Hispanic Black (Black) and Hispanic had similar or higher insulin costs than White patients. Black-White differences in OOP insulin costs were lowered more among the intervention group (cost ratio [CR] = 0.12, 95% confidence interval = 0.06-0.22) than the comparison group. Black-White differences in OOP costs for medication, health services, and overall healthcare widened more among the intervention group by 61-64%. These patterns were not seen for other racial/ethnic disparities.

CONCLUSIONS

Among insulin users, Black may have benefited more from the PDSS Model than White patients, which may be associated with enhanced insulin access and lower needs for other healthcare. Future studies should examine the long-term and heterogeneous impact of the PDSS Model.

Diabetes diagnosis based on glucose control levels and time until diagnosis: a regression discontinuity approach to assess the effect on direct healthcare costs

We estimate the difference in direct healthcare costs of individuals diagnosed with diabetes depending on their glucose level, considering different timespans and subgroups. Using data from administrative registers of 285,450 individuals in Catalonia from 2013 to 2017, we used a fuzzy regression discontinuity design to estimate the causal effect of being diagnosed with diabetes at a given timespan (based on an average glucose value equal to or above 6.5%, the treated group) vs. not (having an average glucose level below the threshold, the control group) on healthcare costs across different timespans (6, 9, 12, 15, 18, 21, and 24 months after the first laboratory test) and distances, in days, between the laboratory test and the doctor's diagnosis. When average glucose level was the only independent parameter and the time until diagnosis was 30 days or less, at the cut-off value (6.5%) healthcare costs were between €3,887 and €5,789 lower for the treated group compared to the control group. Smaller differences were reported as the delay in diagnosis increased, even when additionally controlling for sociodemographic characteristics and health status. Our results highlight the importance of prompt diagnosis and might open the debate about the usefulness of the 6.5% reference value in the blood glucose level as the main diagnostic tool in diabetes.

Dual organ transplantation: Pancreas and Liver in the kidney axis

PURPOSE OF REVIEW

This article explores the benefits and challenges of dual organ transplants.

RECENT FINDINGS

Simultaneous liver-kidney transplant has become a valuable option for patients with both liver and kidney failure, especially since the introduction of clearer eligibility guidelines in 2017. When done for the appropriate candidate, it can significantly improve survival and quality of life. Similarly, simultaneous pancreas-kidney transplantation provides significant advantages for patients with diabetes-related kidney failure by addressing both glycemic control and kidney function, with significant improvement in diabetes associated complications and survival.

SUMMARY

While these procedures are complex, they offer promising solutions for managing difficult multiorgan conditions. Ongoing research and personalized patient care will be key to maximizing their benefits.

Evaluating Financial Incentives as a Tool to Increase Medication Adherence for Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a common chronic disease with high rates of complications. Although there are successful treatments, rates of medication non-adherence remain high. This study aims to evaluate the impact of financial incentives on medication adherence in people living with T2DM.

METHODS

PubMed, Scopus, and Embase were searched via the terms "medication adherence," "diabetes," and "financial/economic incentive." Data on study characteristics, incentive type, and impact were extracted. The outcome measures included the proportion of days covered (PDC), mean possession ratio (MPR), percent adherent (PDC/MPR > 80%), and others. Two pooled Bayesian meta-analyses were conducted, analyzing the mean differences in PDC or MPR and the percentage of adherent patients (MPR > 80%).

RESULTS

The search yielded 8244 results with 126 full-text articles reviewed. In total, 22 studies that met the inclusion criteria were included. Among these 22 studies, 16 reported that financial incentives significantly increased medication adherence in all, four reported that they did not lead to significant changes in adherence, and two studies reported differing results per subgroup. For the pooled meta-analyses, the effect of financial incentives on percent adherent was significant in three studies (weighted Cohen's D: 0.03, P = 0.02) and in the ten studies assessed PDC/MPR, financial incentives significantly increased adherence (weighted Cohen's D: 0.02, 95%, P < 0.01).

CONCLUSION

This systematic review and meta-analysis demonstrated that financial incentives lead to statistically significant but possibly clinically irrelevant increases in medication adherence for patients living with T2DM.

Association of the glycemic background patterns and the diabetes management efficacy in poorly controlled type 2 diabetes

BACKGROUND

Inadequate glycemic control in patients with type 2 diabetes (T2DM) is a major public health problem and a significant risk factor for the progression of diabetic complications.

AIM

To evaluate the effects of intensive and supportive glycemic management strategies over a 12-month period in individuals with T2DM with glycated hemoglobin (HbA1c) ≥ 10% and varying backgrounds of glycemic control.

METHODS

This prospective observational study investigated glycemic control in patients with poorly controlled T2DM over 12 months. Participants were categorized into four groups based on prior glycemic history: Newly diagnosed, previously well controlled with recent worsening, previously off-target but now worsening, and HbA1c consistently above 10%. HbA1c levels were monitored quarterly, and patients received medical, educational, and dietary support as needed. The analysis focused on the success rates of good glycemic control and the associated factors within each group.

RESULTS

The study showed significant improvements in HbA1c levels in all participants. The most significant improvement was observed in individuals newly diagnosed with diabetes: 65% achieved an HbA1c target of ≤ 7%. The results varied between participants with different glycemic control histories, followed by decreasing success rates: 39% in participants with previously good glycemic control, 21% in participants whose glycemic control had deteriorated compared to before, and only 10% in participants with persistently poor control, with mean HbA1c levels of 6.3%, 7.7%, 8.2%, and 9.7%, respectively. After one year, 65.2% of the "newly diagnosed patients", 39.3% in the "previously controlled group", 21.9% in the "previously off-target but now worsened'" group and 10% in the "poorly controlled from the start" group had achieved HbA1c levels of 7 and below.

CONCLUSION

In poorly controlled diabetes, the rate at which treatment goals are achieved is associated with the glycemic background characteristics, emphasizing the need for tailored strategies. Therefore, different and comprehensive treatment approaches are needed for patients with persistent uncontrolled diabetes.

Type 1 Diabetes: Evaluating a Transition Care Model From Pediatric to Adult Care at the McGill University Health Centre

OBJECTIVE

Our aim in this study was to describe a type 1 diabetes mellitus (T1DM) transition care model by assessing clinic attendance, glycemic management, and diabetes-related hospitalizations.

METHODS

This work is a descriptive, longitudinal, single-centre study of patients with T1DM, who were 18 to 25 years of age and referred to our transition clinic from 2012 to 2021 (N=179).

RESULTS

Our data analysis demonstrates an average clinic attendance rate of 79% and mean time between last pediatric and first adult visit of 6.9±5.8 months. Glycated hemoglobin levels at last pediatric visit, first transition visit, and last transition visit were 8.92±1.84%, 9.03±1.84%, and 8.47±1.74%, respectively. There was no change in frequency of diabetes-related hospitalizations after transfer to transition clinic.

CONCLUSIONS

Youth attending our transition clinic had high clinic attendance and improved glycemic management at their last transition visit compared with the last pediatric visit without an increase in diabetes-related hospitalizations. This work highlights the potential importance of comprehensive support in addressing psychosocial and lifestyle challenges during the critical transition period from pediatric to adult care.

Electronic health Literacy gaps among adults with diabetes in the United States: Role of socioeconomic and demographic factors

Background

Digital health technologies hold promises for enhancing healthcare and self-management in diabetes. However, disparities in Electronic Health Literacy (EHL) exist among diabetes populations. This study investigates EHL trends and demographic differences among adults with diabetes in the United States from 2011 to 2018.

Methods

We analyzed data from the 2011-2018 National Health Interview Study (NHIS) on 27,096 adults with diabetes. The primary outcome was EHL, determined by responses to internet usage questions. Trends in EHL were assessed using the Rao Scott Chi-Square Test. Multivariate logistic regression was used to investigate the association between EHL and various comorbidities, socioeconomic and demographic subgroups.

Results

Analytic sample (N = 27,096) represents 10.6 million adults (mean age 62.3, 52.5 % Females) in the USA surveyed between 2011 and 2018. The mean rate of EHL was 38.9 % and trended upward from 35.3 % to 46.8 % over the 2011-2018 period. In a fully adjusted logistic regression model, multiple socioeconomic factors were associated with EHL. Age was inversely associated with odds of EHL (aOR 0.95, 95 % CI: 0.95-0.95). Black individuals had lower odds of EHL compared to Whites (aOR 0.63, 95 % CI: 0.56-0.71). Low-income (<100 % and 100-200 % of federal poverty limit) were negatively associated with EHL. Furthermore, limited English proficiency was associated with lower odds of EHL (aOR 0.29, 95 % CI: 0.22-0.38).

Conclusion

The study identified ongoing disparities in EHL among adults with diabetes based on age, race/ethnicity, income, and language proficiency, highlighting the need for targeted interventions to improve digital health access for all.

Application of the path analysis model to evaluate the role of distress, mental health literacy and burnout in predicting self-care behaviors among patients with type 2 diabetes

INTRODUCTION

Mental complications of diabetes are one of the main obstacles to the implementation of self -care behaviors that have been less studied. Therefore, this study was conducted to survey the effective factors in predicting burnout and self-care behaviors among patients with type 2 diabetes.

METHODS

In this Path analysis, 1280 patients with type 2 diabetes were selected from Mashhad (Iran) in 2023 to 2024. Four scales, the mental health literacy (MHL) scale, diabetes burnout scale, diabetes distress scale, and self-care behavior scale were used for data gathering. AMOS software checked the direct and indirect paths between the variables.

RESULTS

In the path analysis, variables of MHL and diabetes distress predicted 25% variance of diabetes burnout (R2 = 0.25), and diabetes distress (total effect = 0.491) had the greatest impact on predicting diabetes burnout. Variables of MHL, diabetes distress, and diabetes burnout predicted 12% variance of Self-care behaviors (R2 = 0.12) and MHL (total effect = -0.256), age of onset of diabetes (total effect = 0.199), and diabetes burnout (total effect = - 0.167) had the greatest impact on prediction of self-care behaviors.

CONCLUSION

MHL could reduce diabetes distress and burnout and eventually promote self-care behaviors among patients with type 2 diabetes. Therefore, screening and identifying psychological problems (such as distress and burnout) and designing interventions to increase MHL can ultimately increase the health of patients with diabetes.

Family Support and Type 2 Diabetes Self-management Behaviors in Underserved Latino/a/x Patients

BACKGROUND

Latino/a/x families experience persistent Type 2 diabetes mellitus (T2DM) disparities, including higher rates of diagnosis and mortality due to disease complications than their non-Hispanic White counterparts. Though greater social support is associated with improved disease outcomes for Latino/a/x patients with diabetes, research has yet to identify the specific pathways through which social support, and specifically family support, influences self-management.

PURPOSE

This study tested a theoretical model highlighting the mechanisms and pathways linking social support and physical health. Specifically, self-efficacy and depression were tested as psychological pathways connecting family support to diabetes self-management behaviors and diabetes morbidity in Latino/a/x patients with T2DM.

METHODS

Data from 177 patients were analyzed using structural equation modeling. Measures included diabetes-specific family support needed and received, depressive symptoms, self-efficacy in diabetes management, diabetes self-management behaviors, health appraisal, and hemoglobin A1c.

RESULTS

Greater diabetes-specific family support was significantly associated with more frequent engagement in diabetes self-management behaviors, both directly (p < .001) and through diabetes self-efficacy's partial mediation of this relationship (p = .013). Depression was not significantly associated with either family support (support received, p = .281; support needed, p = .428) or self-management behaviors (p = .349).

CONCLUSIONS

Family support and diabetes self-efficacy may be important modifiable psychosocial factors to target via integrated care interventions aimed at supporting Latino/a/x patients with T2DM. Future research is needed to test empirically based, culturally adapted interventions to reduce T2DM-related health disparities in this population.

Mediterranean Diet Combined with Regular Aerobic Exercise and Hemp Protein Supplementation Modulates Plasma Circulating Amino Acids and Improves the Health Status of Overweight Individuals

Plant protein is considered a sustainable health-promoting strategy to prevent metabolic syndrome. Lifestyle changes (including dietary patterns and exercise) have been demonstrated to exert an effect on human health by modulating the biochemical status in humans. The objective of this study was to assess whether supplementation with hemp protein within a Mediterranean diet context together with exercise could help to ameliorate the metabolic statuses of patients prone to developing metabolic syndrome. For this study, 23 patients followed with Mediterranean diet and engaged in aerobic exercise according to the WHO's recommendations, while also being supplemented with hemp protein, for 12 weeks. A comparison of anthropometric, biochemical, and mineral data as well as amino acid values was made between the start and the end of the study, with the subjects acting as their own control group. Statistical analyses included a paired t-test, Wilcoxon paired test, Pearson correlation coefficient, and Sparse Partial Least Squares Discriminant Analysis to evaluate significant differences and correlations among parameters. There were statistically significant changes in total cholesterol, HDL-C (+52.3%), LDL-C (-54.0%), and TAG levels (-49.8%), but not in glucose plasma levels. Following the intervention, plasma concentrations of some amino acids, including α-aminoadipic acid, phosphoethanolamine, and 1-metylhistidine, increased, whereas those of asparagine and alanine declined. Different correlations between amino acids and the other parameters evaluated were reported and discussed. A Mediterranean diet combined with regular aerobic exercise, together with protein supplementation, can highly improve the metabolic parameters and anthropometric parameters of subjects with obesity and impaired glucose levels, ameliorating their health status and likely delaying the development of metabolic syndrome.

Independent Correlates of Glycemic Control among Adults with Diabetes in South Africa

BACKGROUND

Globally, the prevalence of diabetes is increasing, especially in low- and middle-income countries (LMICs), including those in the sub-Saharan African region. However, the independent socioeconomic correlates of glycemic control as measured by hemoglobin A1C have yet to be identified. Therefore, the aim of this analysis was to understand the independent correlates of glycemic control in South Africa.

METHODS

Data from the 2016 South Africa Demographic and Health Survey on adults with diabetes were used for this analysis. The dependent variable, glycemic control, was defined using hemoglobin A1c (HbA1c). Independent variables included: age, gender, ethnicity, marital status, region, urban/rural residence, ability to read, education, insurance, wealth, occupation, and employment in the last year. Analysis of variance was used to test for differences in mean HbA1c for each category of all independent variables, and a fully adjusted linear regression model was used to identify independent correlates of glycemic control (HbA1c).

RESULTS

Among the 772 people included in this analysis, there were significant differences in mean HbA1c by age (p < 0.001), ethnicity (p < 0.001), place of residence (p = 0.024), wealth index (p = 0.001), and employment in the last year (p = 0.008). Independent correlates of HbA1c included age, ethnicity, and wealth index.

CONCLUSIONS

This study used data from a large diverse population with a high prevalence of diabetes in sub-Saharan Africa and provides new evidence on the correlates of glycemic control and potential targets for interventions designed to lower HbA1c and improve diabetes-related health outcomes of adults in South Africa.

An Economic Evaluation of the Relationship Between Glycemic Control and Total Healthcare Costs for Adults with Type 2 Diabetes: Retrospective Cohort Study

INTRODUCTION

Glycemic control is associated with better outcomes among individuals with type 2 diabetes (T2D). This research examines total US all-cause medical costs for adults with T2D with recommended glycemic control (HbA1c < 7%) compared to poor glycemic control (HbA1c ≥ 7%).

METHODS

The study used administrative claims data linked to HbA1c laboratory test results from January 1, 2015 through June 30, 2021 to identify adults with T2D with a recorded HbA1c test. Patients with recommended glycemic control at index date were propensity score matched to patients with poor glycemic control. General linear models and two-part models were used to compare all-cause outpatient, drug, acute care and total costs for 1 year post index date.

RESULTS

The study included 59,830 propensity-matched individuals. Results indicate that recommended glycemic control, compared to poor glycemic control, was associated with statistically significantly lower all-cause acute care ($23,868 ± $21,776 vs. $24,352 ± $22,223), drug ($10,277 ± $14,671 vs. $10,540 ± $14,928), and total medical costs ($41,381 ± $42,757 vs. $42,054 ± $43,422) but significantly higher outpatient costs ($7290 ± $12,028 vs. $7026 ± $11,587) (all p < 0.0001). Sensitivity analyses examined results based upon alternative HbA1c thresholds of ≤ 6.5% and < 8%. Results were generally robust to alternative HbA1c thresholds, with higher HbA1c thresholds associated with higher all-cause total costs as well as increased savings for having HbA1c below threshold.

CONCLUSIONS

Glycemic control was associated with significantly lower all-cause total, drug, and acute care medical costs. Given the high prevalence of T2D in the USA, our results suggest potential economic benefits associated with glycemic control for healthcare providers.

Effectiveness of a hybrid technology enabled care model as measured by ICHOM standard set on established and managed type 2 diabetes already using medications: A RWE retrospective study

Aims

Diabetes is a pressing global health issue, demanding innovative strategies for improved treatment. However, traditional care often falls short of patient goals. To address this, digital health solutions, including smartphone apps and remote monitoring, have emerged as crucial in diabetes management. This study aims to assess a comprehensive intervention, combining remote continuous data monitoring (RCDM) with in-clinic care, for enhancing diabetes-related outcomes. Additionally, it seeks to evaluate the effectiveness of the digital RCDM component by comparing adherent and non-adherent patients.

Methods

Conducted in the United Arab Emirates, a retrospective study involved 89 patients primarily on anti-diabetic medications. They were split into two groups based on adherence to RCDM. Over time, significant improvements were observed across various parameters.

Results

Notably, patients exhibited weight loss (-4.0 ± 5.3, p < 0.001), reduced waist circumference (-4.74 ± 7.8, p < 0.001), lowered HbA1c levels (-1.00 ± 1.3, p < 0.001), decreased systolic BP (-3.1 ± 13.1, p = 0.035), and diminished diastolic BP (-3.4 ± 9.9, p = 0.002) annually. Furthermore, patients adhering to the GluCare model demonstrated substantial HbA1c reductions (-1.53 ± 1.5, p < 0.001), improved lipid profiles, notably decreased total Cholesterol (-16.6 ± 50.3, p = 0.034), and lowered LDL levels (-18.65 ± 42.6, p = 0.006).

Conclusions

The intervention model effectively managed T2D patients through a comprehensive approach, yielding notable improvements in HbA1c levels and other outcomes within a year. The study underscores the limitations of traditional care and reliance simply on pharmacotherapy, and emphasizes the need for a hyper-personalized, and continuous approach for T2D management.

Protein-based nutritional strategies to manage the development of diabetes: evidence and challenges in human studies

Type 2 diabetes mellitus (T2DM) is one of the most prevalent diseases in modern society, governed by both genetic and environmental factors, such as nutritional habits. This metabolic disorder is characterized by insulin resistance, which is related to high blood glucose levels, implying negative health effects in humans, hindering the healthy ageing of people. The relationship between food and health is clear, and the ingestion of specific nutrients modulates some physiological processes, potentially implying biologically relevant changes, which can translate into a health benefit. This review aims to summarize human studies published in which the purpose was to investigate the effect of protein ingestion (in native state or as hydrolysates) on human metabolism. Overall, several studies showed how protein ingestion might induce a decrease of glucose concentration in the postprandial state (area under the curve), although it is highly dependent on the source and the dose. Other studies showed no biological effects upon protein consumption, mostly with fish-derived products. In addition, the major challenges and perspectives in this research field are highlighted, suggesting the future directions, towards which scientists should focus on. The dietary intake of proteins has been proven to likely exert a beneficial effect on diabetes-related parameters, which can have a biological relevance in the prevention and pre-treatment of diabetes. However, the number of well-designed human studies carried out to date to demonstrate the effects of specific proteins or protein hydrolysates in vivo is still scarce.

Mukattash T, Alefishat EA. Glycemic control and its associated factors among diabetic heart failure outpatients at two major hospitals in Jordan

Patients with heart failure (HF) are generally at higher risk of developing type 2 diabetes and having uncontrolled blood glucose. Furthermore, the prevalence of uncontrolled blood glucose in patients with HF is largely unknown. Identifying the factors associated with poor blood glucose control is a preliminary step in the development of effective intervention programs. The current cross-sectional study was conducted at two major hospitals to explore the factors associated with blood glucose control among patients with heart failure and type 2 diabetes. In addition to sociodemographic, medical records were used to collect medical information and a validated questionnaire was used to evaluate medication adherence. Regression analysis showed that poor medication adherence (OR = 0.432; 95%CI 0.204-0.912; P<0.05) and increased white blood cells count (OR = 1.12; 95%CI 1.033-1.213; P<0.01) were associated with poor glycemic control. For enhancing blood glucose control among patients with HF and diabetes, future intervention programs should specifically target patients who have high WBC counts and poor medication.

Relationship between the insulin use and stigma in type 2 diabetes mellitus

AIMS

This study aimed to investigate the relationship between insulin use and stigma in Type 2 Diabetes Mellitus (T2DM).

METHODS

The study was carried out in the endocrinology and metabolic disorders outpatient clinic of a state hospital between February and October 2022. The study was carried out with 154 patients, 77 of them were treated with insulin while 77 were treated with peroral antidiabetic drugs (PAD). The patient identification form and Type 2 Diabetes Stigma Assessment Scale (DSAS-2) were used for data collection. The data were analyzed by using IBM SPSS 26.0 software.

RESULTS

DSAS-2 total score, treated differently, blame and judgment, and self-stigma subscales were higher in insulin-treated T2DM patients compared to the patients treated with PAD. There was a positive relationship between the number of daily injections and the DSAS-2 total score (r = 0.554). Multiple linear regression showed that type of the treatment, treatment duration, number of daily injections and perceived level of health were the determinants of the DSAS-2 score.

CONCLUSIONS

Stigma was high in insulin-treated T2DM patients and as the number of daily injections increased, the level of the perceived stigma increased. We recommend considering the high level of perceived stigma in insulin-treated T2DM patients while preparing nursing investigations.

COMBINSI (COMBat to INSufficient Insulin therapy) - A Portuguese project in type 2 diabetes

BACKGROUND

Inadequate glycemic control in type 2 diabetes (T2D) increases the risk of diabetes-related complications. Insulin initiation is often delayed for several years. This study aims to estimate the adequacy of insulin therapy prescription to people living with T2D in a primary care setting.

MATERIAL AND METHODS

This was a cross-sectional study based on adults with T2D in a Portuguese local health unit between January 2019 and January 2020. Subjects under insulin therapy were compared with non-insulin-treated subjects with Hemoglobin A1c (HbA1c) ≥9% regarding clinical and demographic characteristics. The proportion of insulin-treated subjects in both of these groups was defined as insulin therapy index.

RESULTS

Our study included 13,869 adults living with T2D, among whom 11.5% were treated with insulin therapy and 4.1% had HbA1c ≥ 9% and were not under insulin therapy. Insulin therapy index was 73.9%. When comparing with non-insulin-treated subjects with HbA1c ≥ 9%, insulin-treated subjects were significantly older (75.8 vs 66.2 years p < 0.001), had lower HbA1c (8.3 vs 10.3% p < 0.001), lower estimated glomerular filtration rate (66.4 vs 74.0 ml/min/1.73 m²p < 0.001), lower LDL-cholesterol (87.1 vs 105.8 mg/dl), and higher rates of atherosclerotic cardiovascular disease (32.7 vs 16.7% p < 0.001).

CONCLUSION

Insulin therapy is underprescribed in T2D, with over 1-in-4 people living with T2D not being prescribed insulin despite deficient glycemic control. These findings highlight the need for insulin therapy when glycemic control is inadequate under other interventions.

Factors Associated With Diabetes Distress Among Patients With Poorly Controlled Type 2 Diabetes

Objective

Examine factors associated with increased diabetes distress (DD) among patients with type 2 diabetes with DD assessed by Diabetes Distress Scale (DDS) total and subscale scores (emotional burden, physician-related distress, regimen-related distress, and interpersonal distress).

Methods

Cross-sectional analysis of data from veterans with persistently poorly controlled diabetes mellitus. Multivariable linear regression models included baseline patient characteristics (independent variables) and DDS total and subscale scores (dependent variable).

Results

The cohort's (N = 248) mean age was 58 years (SD 8.3); 21% were female, 79% were non-White, and 5% were Hispanic/Latinx. Mean hemoglobin A1c (HbA1c) was 9.8%, and 37.5% had moderate to high DD. Hispanic/Latinx ethnicity (β=0.41; 95% CI 0.01, 0.80), baseline HbA1c (0.07; 95% CI 0.01,0.13), and higher Personal Health Questionnaire-8 (PHQ-8) scores (0.07; 95% CI 0.05, 0.09) were associated with higher total DD. Hispanic/Latinx ethnicity (0.79; 95% CI 0.25, 1.34) and higher PHQ-8 (0.05; 95% CI 0.03, 0.08) were associated with higher interpersonal-related distress. Higher HbA1c (0.15; 95% CI 0.06, 0.23) and higher PHQ-8 scores (0.10; 95% CI 0.07, 0.13) were associated with higher regimen-related distress. The use of basal insulin (0.28; 95% CI 0.001, 0.56) and higher PHQ-8 (0.02; 95% CI 0.001, 0.05) were associated with higher physician-related distress. Higher PHQ-8 (0.10; 95% CI 0.07, 0.12) was associated with higher emotional burden.

Conclusion

Hispanic/Latinx ethnicity, depressive symptoms, uncontrolled hyperglycemia, and insulin use were associated with higher risk for DD. Future research should explore these relationships, and interventions designed to reduce diabetes distress should consider accounting for these factors.

Legume-Derived Bioactive Peptides in Type 2 Diabetes: Opportunities and Challenges

Diabetes mellitus is a complex disorder characterized by insufficient insulin production or insulin resistance, which results in a lifelong dependence on glucose-lowering drugs for almost all patients. During the fight with diabetes, researchers are always thinking about what characteristics the ideal hypoglycemic drugs should have. From the point of view of the drugs, they should maintain effective control of blood sugar, have a very low risk of hypoglycemia, not increase or decrease body weight, improve β-cell function, and delay disease progression. Recently, the advent of oral peptide drugs, such as semaglutide, brings exciting hope to patients with chronic diabetes. Legumes, as an excellent source of protein, peptides, and phytochemicals, have played significant roles in human health throughout human history. Some legume-derived peptides with encouraging anti-diabetic potential have been gradually reported over the last two decades. Their hypoglycemic mechanisms have also been clarified at some classic diabetes treatment targets, such as the insulin receptor signaling pathway or other related pathways involved in the progress of diabetes, and key enzymes including α-amylase, α-glucosidase, and dipeptidyl peptidase-IV (DPP-4). This review summarizes the anti-diabetic activities and mechanisms of peptides from legumes and discusses the prospects of these peptide-based drugs in type 2 diabetes (T2D) management.

Exploration of the health needs of patients with poorly controlled type 2 diabetes using a user-centred co-production approach in the area of mHealth: an exploratory sequential mixed-method protocol

INTRODUCTION

Research on the needs and preferences of patients with poorly controlled type 2 diabetes mellitus (T2DM) with mobile health (mHealth) service is limited. With the principles of co-production, this study aims to address this research gap by exploring the health needs of Chinese patients with poorly controlled T2DM.

METHODS AND ANALYSIS

This study uses a three-phase, exploratory sequential mixed-method design. Phase 1 aims to assess the health needs of patients with poorly controlled T2DM by conducting semi-structured interviews with patients, doctors and nurses. Participants will be recruited by purposive sampling with maximum variation. Content analysis will be employed. Phase 2 will form item generation and develop the mHealth need scale. The scale will be subject to pilot testing and psychometric evaluation, including content validity, construct validity, discriminant validity, internal validity and test-retest reliability. Phase 3 will explore the priority of health needs perceived by patients with poorly controlled T2DM through a cross-sectional study. The measurement tools include an mHealth needs scale, the Summary of Diabetes Self-care Activities Questionnaire, the Diabetes Empowerment Scale-Short Form, the Diabetes Health Literacy Scale and the eHealth Literacy Scale. Multiple regression techniques with a hierarchical block design will be used for the model building to identify the factors contributing to the heterogeneity of the perceived mHealth needs. The findings of phase 1 and phase 3 will be integrated using data correlation, comparison and consolidation.

ETHICS AND DISSEMINATION

The Ethics Committee of the School of Nursing, Sun Yat-sen University, has approved this study (No. 2021ZSLYEC). The results of this study will be disseminated through conference presentations and peer-reviewed publications.

Admission Blood Glucose Level as a Predictor of Outcome in Intensive Care Patients: A Cross-Sectional Study

INTRODUCTION

In the Intensive care unit (ICU), hyperglycemia is often observed; commonly associated with pre-existing diabetes or pre-diabetes or in nondiabetic patients. This study aimed to assess the role of admission blood sugar levels with outcomes in ICU patients.

METHODS

A total of 100 patients above 18 years of age were included in the study. A detailed history regarding the patient's age, sex, and any chronic illness were taken. Heart rate, systolic blood pressure, and Glasgow coma scale (GCS) scores were recorded. Admission blood glucose level, blood urea, total leucocyte count, and serum electrolytes were measured; and the outcome was noted.

RESULTS

The number of diabetics was significantly higher (65.5%) in the random blood sugar (RBS) ≥180 group. Hyponatremia was significantly associated with hyperglycemia. Patients with hyperglycemia had serum bicarbonate <18. A significantly greater number of patients with hyperglycemia had GCS scores of <8, and required mechanical ventilation. The duration of ICU stay and non-survivors were significantly higher in the hyperglycemia group. Random blood sugar at admission as a factor to assess outcome showed a sensitivity of 68.4 and specificity of 59.3 with a cut-off value of 197.

CONCLUSION

Admission of random blood sugar was significantly associated with poor outcomes. More stringent surveillance as well as routine blood glucose checks at the time of hospital admission should be emphasized.

Community Health Workers as Trust Builders and Healers: A Cohort Study in Primary Care

PURPOSE

Improving patients' self-care for chronic disease is often elusive in the context of social deprivation. We evaluated whether a practice-integrated community health worker (CHW) intervention could encourage effective long-term self-management of type 2 diabetes mellitus (T2DM).

METHODS

This cohort study, in a safety-net primary care practice, enrolled patients with uncontrolled T2DM and psychosocial risk factors. Patients were identified through a practice diabetes registry or by clinicians' referrals. The CHWs engaged patients in trust building and sensemaking to understand their social context, identify goals, navigate health care, and connect to community resources. Primary outcome was progress through 3 prospectively defined stages of self-care: outreach (meeting face-to-face); stabilization (collaborating to address patients' life circumstances); and self-care generativity (achieving self-care competencies). Secondary outcomes were change in hemoglobin A1c (HbA1c) and need for urgent care, emergency department, or hospital visits.

RESULTS

Of 986 participating patients, 27% remained in outreach, 41% progressed to stabilization, and 33% achieved self-care generativity. Repeated measures ANOVA demonstrates an overall decline in HbA1c, without group differences, through the 4th HbA1c measurement (mean follow-up 703 days). Beginning at the 5th HbA1c measurement (mean 859 days), the self-care generativity group achieved greater declines in HbA1c, which widened through the 10th measurement (mean 1,365 days) to an average of 8.5% compared with an average of 8.8% in the outreach group and 9.0% in the stabilization group (P = .003). Rates of emergency department and hospital visits were lower in the self-care generativity group.

CONCLUSIONS

Practice-linked CHWs can sustainably engage vulnerable patients, helping them advance self-management goals in the context of formidable social disadvantage.

The Cost-Effectiveness of Oral Semaglutide in Spain: A Long-Term Health Economic Analysis Based on the PIONEER Clinical Trials

INTRODUCTION

Novel glucagon-like peptide-1 (GLP-1) receptor agonist oral semaglutide has demonstrated greater improvements in glycated hemoglobin (HbA1c) and body weight versus oral medications empagliflozin and sitagliptin, and injectable GLP-1 analog liraglutide, in the PIONEER clinical trial program. Based on these data, the present analysis aimed to evaluate the long-term cost-effectiveness of oral semaglutide versus empagliflozin, sitagliptin and liraglutide in Spain.

METHODS

Outcomes were projected over patients' lifetimes using the IQVIA CORE Diabetes Model (v9.0), discounted at 3.0% annually. Cohort characteristics and treatment effects were sourced from PIONEER 2 and 4 for the comparisons of oral semaglutide 14 mg versus empagliflozin 25 mg and liraglutide 1.8 mg, respectively, and PIONEER 3 for oral semaglutide 7 and 14 mg versus sitagliptin 100 mg. Costs were accounted from a healthcare payer perspective in 2020 euros (EUR). Patients were assumed to receive initial therapies until HbA1c exceeded 7.5% and then treatment-intensified to basal insulin.

RESULTS

Oral semaglutide 14 mg was associated with improvements in quality-adjusted life expectancy of 0.13, 0.19 and 0.06 quality-adjusted life years (QALYs) versus empagliflozin 25 mg, sitagliptin 100 mg and liraglutide 1.8 mg, respectively, with direct costs EUR 168 higher versus empagliflozin and EUR 236 and 1415 lower versus sitagliptin and liraglutide, respectively. Oral semaglutide 14 mg was associated with an incremental cost-effectiveness ratio (ICER) of EUR 1339 per QALY gained versus empagliflozin and was considered dominant (clinically superior and cost saving) versus sitagliptin and liraglutide. Additional analyses demonstrated that oral semaglutide 7 mg was associated with improvements of 0.11 QALYs and increased costs of EUR 226 versus sitagliptin and was therefore associated with an ICER of EUR 2011 per QALY gained.

CONCLUSION

Oral semaglutide 14 mg was dominant versus sitagliptin and liraglutide, and cost-effective versus empagliflozin, for the treatment of type 2 diabetes in Spain.

Long non-coding RNA screening and identification of potential biomarkers for type 2 diabetes

BACKGROUND

To investigate new lncRNAs as molecular markers of T2D.

METHODS

We used microarrays to identify differentially expressed lncRNAs and mRNAs from five patients with T2D and paired controls. Through bioinformatics analysis, qRT-PCR validation, ELISA, and receiver operating characteristic (ROC) curve analysis of 100 patients with T2D and 100 controls to evaluate the correlation between lncRNAs and T2D, and whether lncRNAs could be used in the diagnosis of T2D patients.

RESULTS

We identified 68 and 74 differentially expressed lncRNAs and mRNAs, respectively. The top five upregulated lncRNAs are ENST00000381108.3, ENST00000515544.1, ENST00000539543.1, ENST00000508174.1, and ENST00000564527.1, and the top five downregulated lncRNAs are TCONS_00017539, ENST00000430816.1, ENST00000533203.1, ENST00000609522.1, and ENST00000417079.1. The top five upregulated mRNAs are Q59H50, CYP27A1, DNASE1L3, GRIP2, and lnc-TMEM18-12, and the top five downregulated mRNAs are GSTM4, PODN, GLYATL2, ZNF772, and CLTC. Examination of lncRNA-mRNA interaction pairs indicated that the target gene of lncRNA XR_108954.2 is E2F2. Multiple linear regression analysis showed that XR_108954.2 (r = 0.387, p < 0.01) and E2F2 (r = 0.368, p < 0.01) expression levels were positively correlated with glucose metabolism indicators. Moreover, E2F2 was positively correlated with lipid metabolism indicators (r = 0.333, p < 0.05). The area under the ROC curve was 0.704 (95% CI: 0.578-0.830, p = 0.05) for lncRNA XR_108954.2 and 0.653 (95% CI: 0.516-0.790, p = 0.035) for E2F2.

CONCLUSIONS

This transcriptome analysis explored the aberrantly expressed lncRNAs and identified E2F2 and lncRNA XR_108954.2 as potential biomarkers for patients with T2D.

Pharmacist-led intervention in treatment non-adherence and associated direct costs of management among ambulatory patients with type 2 diabetes in southwestern Nigeria

BACKGROUND

Non-adherence to recommended therapy remains a challenge to achieving optimal clinical outcome with resultant economic implications.

OBJECTIVE

To evaluate the effect of a pharmacist-led intervention on treatment non-adherence and direct costs of management among patients with type 2 diabetes (T2D).

METHOD

A quasi-experimental study among 201-patients with T2D recruited from two-tertiary healthcare facilities in southwestern Nigeria using semi-structured interview. Patients were assigned into control (HbA1c < 7%, n = 95) and intervention (HbA1c ≥ 7%, n = 106) groups. Baseline questionnaire comprised modified 4-item Medication Adherence Questions (MAQ), Perceived Dietary Adherence Questionnaire (PDAQ) and International Physical Activity Questionnaire, to assess participants' adherence to medications, diet and physical activity, respectively. Post-baseline, participants were followed-up for 6-month with patient-specific educational intervention provided to resolve adherence discrepancies in the intervention group only, while control group continued to receive usual care. Subsequently, direct costs of management for 6-month pre-baseline and 6-month post-baseline were estimated for both groups. Data were summarized using descriptive statistics. Chi-square, McNemar and paired t-test were used to evaluate categorical and continuous variables at p < 0.05.

RESULTS

Mean age was 62.9 ± 11.6 years, and 160(79.6%) were females. Glycated haemoglobin (HbA1c) was 6.1 ± 0.6% (baseline) and 6.1 ± 0.8% at 6-month post-baseline (p = 0.094) for control group, and 8.7 ± 1.5% (baseline) versus 7.8 ± 2.0% (6-month), p < 0.001, for the intervention. Post-baseline, response to MAQ items 1 (p = 0.017) and 2 (p < 0.001) improved significantly for the intervention. PDAQ score increased significantly from 51.8 ± 8.8 at baseline to 56.5 ± 3.9 at 6-month (p < 0.001) for intervention, and from 56.3 ± 4.0 to 56.5 ± 3.9 (p = 0.094) for the control group. Physical activity increased from 775.2 ± 700.5 Metabolic Equivalent Task (MET) to 829.3 ± 695.5MET(p < 0.001) and from 901.4 ± 743.5MET to 911.7 ± 752.6MET (p = 0.327) for intervention and control groups, respectively. Direct costs of management per patient increased from USD 327.3 ± 114.4 to USD 333.0 ± 118.4 (p = 0.449) for the intervention, while it decreased from USD 290.1 ± 116.97 to USD289.1 ± 120.0 (p = 0.89) for control group, at baseline and 6-month post-baseline, respectively.

CONCLUSION

Pharmacist-led intervention enhanced adherence to recommended medications, diet and physical activity among the intervention patients, with a corresponding significant improvement in glycaemic outcome and an insignificant increase in direct costs of management. There is a need for active engagement of pharmacists in management of patients with diabetes in clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04712916 . Retrospectively-registered.

The effect of comorbidities on glycemic control among Colombian adults with diabetes mellitus: a longitudinal approach with real-world data

BACKGROUND

Achieving an optimal glycemic control has been described to reduce the incidence of diabetes mellitus (DM) related complications. The association between comorbidities and glycemic control remains unclear. Our aim is to evaluate the effect of comorbidities on glycemic control in people living with DM.

METHODS

A retrospective longitudinal study on data from the National Registry of Chronic Kidney Disease from 2014 to 2019 in Colombia. The outcome was poor glycemic control (PGC = HbA1c ≥7.0%). The association between each comorbidity (hypertension (HTN), chronic kidney disease (CKD) or obesity) and PGC was evaluated through multivariate mixed effects logistic regression models. The measures of effect were odds ratios (OR) and their 95% confidence intervals (CI). We also evaluated the main associations stratified by gender, insurance, and early onset diabetes as well as statistical interaction between each comorbidity and ethnicity.

RESULTS

From 969,531 people at baseline, 85% had at least one comorbidity; they were older and mostly female. In people living with DM and CKD, the odds of having a PGC were 78% (OR: 1.78, CI 95%: 1.55-2.05) higher than those without CKD. Same pattern was observed in obese for whom the odds were 52% (OR: 1.52, CI 95%: 1.31-1.75) higher than in non-obese. Non-significant association was found between HTN and PGC. We found statistical interaction between comorbidities and ethnicity (afro descendant) as well as effect modification by health insurance and early onset DM.

CONCLUSIONS

Prevalence of comorbidities was high in adults living with DM. Patients with concomitant CKD or obesity had significantly higher odds of having a PGC.

Improved glycemic control in 3,592 adults with type 2 diabetes mellitus initiating a tubeless insulin management system

AIMS

To compare glycemic outcomes in adults with type 2 diabetes mellitus (T2DM) before and 90 days after initiating Omnipod® or Omnipod DASH® Insulin Management Systems.

METHODS

In this retrospective observational study (N = 3,592) change in HbA1c level, total daily dose (TDD) of insulin (n = 3,053), and frequency of self-reported hypoglycemic events (HE, <70 mg/dL, n = 2,922) were assessed overall and by prior treatment modality (multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII)), age group, and baseline HbA1c category.

RESULTS

Change (mean ± SD) in HbA1c was -1.3 ± 1.7% [-14 ± 19 mmol/mol] overall, -1.4 ± 1.7% [-15 ± 19 mmol/mol] for prior MDI users, and -0.9 ± 1.5% [-10 ± 16 mmol/mol] for prior CSII users (p<0.0001). The percentage of patients with HbA1c ≥9% [≥75 mmol/mol] decreased (49% to 19%), and with HbA1c <7% [<53 mmol/mol] increased (10% to 22%) (p<0.0001). Prior therapy, age, and baseline HbA1c category were factors affecting change in HbA1c (p<0.05). Reductions in TDD (overall, -33 ± 52U, p<0.0001) and HE per week (overall, -0.5 ± 2.0, p<0.0001), were seen regardless of prior treatment, age, or baseline HbA1c.

CONCLUSIONS

Omnipod System use was associated with statistically and clinically meaningful reductions in HbA1c, TDD, and HE compared to prior treatments in T2DM.

Needle-free jet injection of insulin glargine improves glycemic control in patients with type 2 diabetes mellitus: a study based on the flash glucose monitoring system

Background: To investigate the effects of insulin glargine injection given with a QS-P jet injector on the glucose profile using a professional mode flash glucose monitoring (FGM) system in patients with type 2 diabetes mellitus (T2DM).Research design and methods: In this randomized, controlled, cross-sectional study, 66 patients with T2DM who received insulin glargine (12-18 IU/day) injection were enrolled. The patients were randomly divided into group A (jet injector before insulin pen) and group B (insulin pen before jet injector). Each subject injected insulin daily before breakfast. We analyzed the changes in the glucose profile using a professional mode FGM system.Results: Treatment with a jet injector led to significantly lower 24-h mean glucose, maximum blood glucose, area under the curve (AUC) > 10.0 mmol/L, time above range and increased AUC < 3.9 mmol/L and time below range than those when using an insulin pen. There was no difference in glycemic variability between the two groups. We observed that patients using a jet injector had significantly lower mean glucose between 12:00 to 22:00.Conclusions: Needle-free jet injection of insulin glargine was more effective than use of an insulin pen for good glycemic control in patients with T2DM.Clinical trial registration: www.clinicaltrials.gov identifier is NCT04093284.

Triglyceride glucose (TyG) index as a predictor of incident type 2 diabetes among nonobese adults: a 12-year longitudinal study of the Korean Genome and Epidemiology Study cohort

The rate of undiagnosed type 2 diabetes tends to increase in lean Koreans, while the triglyceride glucose (TyG) index has been proposed as a surrogate marker of peripheral insulin resistance. We investigated the longitudinal relationship between TyG and incident type 2 diabetes among apparently healthy Korean adults. We assessed 4285 lean adults without diabetes aged 40-69 years from the Korean Genome and Epidemiology Study. Participants were divided into 4 groups according to quartiles of TyG index, calculated as ln [fasting triglycerides (mg/dL) × fasting plasma glucose (mg/dL)/2]. We prospectively assessed the hazard ratios (HRs) with 95% confidence intervals (CIs) for incident type 2 diabetes, based on the American Diabetes Association criteria, using multivariate Cox proportional hazards regression models, over 12 years after the baseline survey. During the follow-up period, 631 (14.7%) participants had newly developed type 2 diabetes. The HRs of incident type 2 diabetes in each TyG index quartile were 1.00, 1.63 (95%CI, 1.18-2.24), 2.30 (95%CI, 1.68-3.14), and 3.67 (95%CI, 2.71-4.98), respectively, after adjusting for age, sex, body mass index, waist circumference, smoking status, alcohol intake, and physical activity. Higher TyG index precedes and significantly predicts type 2 diabetes among community-dwelling middle aged and elderly lean Koreans.

Overview of Clinical Trials on Type 2 Diabetes Mellitus: A Comprehensive Analysis of the ClinicalTrials.gov Database

PURPOSE

A better understanding of the current features of type 2 diabetes mellitus (T2DM)-related clinical trials is important for improving designs of clinical trials and identifying neglected areas of research. It was hypothesized that the trial registration policy promoted the designs of T2DM-related trials over the years. Therefore, this study aimed to present a comprehensive overview of T2DM-related clinical trials registered in the ClinicalTrials.gov database.

METHODS

T2DM-related clinical trials registered in the ClinicalTrials.gov database were searched and assessed the characteristics of the relevant trials. We searched PubMed and Google Scholar for the publication statuses of the primary completed trials.

RESULTS

Overall, 5117 T2DM-related trials were identified for analysis. Of the interventional trials, 71.5% had a primary treatment purpose while only 8.9% were prevention or health service. There were more interventional trials registered prior to patient recruitment between 2012 and 2019 than between 2004 and 2011 (44.6% vs 19.9%, P<0.001). The period between 2012 and 2019 also had more trials that enrolled <100 participants (59.2% vs 50.9%), were single-center studies (60.7% vs 50.6%), had non-randomized allocations (11.3% vs 6.3%), were open-label (49.2% vs 45.6%), and had smaller sample sizes than the period between 2004 and 2011 (all P<0.001). The five-year cumulative publication rates after primary completion of the trials were <40%.

CONCLUSION

Although the ClinicalTrials.gov database did not include all clinical trials, the trials registered in the ClinicalTrials.gov database still accounted for most of the clinical studies. Encouragingly, more interventional trials were registered prior to patient recruitment over the years. The majority of T2DM-related clinical trials focused on drug-related treatment, and trials regarding prevention in T2DM should be promoted. More attention should be paid to improve the publication and dissemination of clinical trials results.

Improved Glycemic Control Following Transition to Tubeless Insulin Pump Therapy in Adults With Type 1 Diabetes

Continuous subcutaneous insulin infusion (CSII) treatment may improve long-term glycemic outcomes and enhance quality of life compared with a multiple daily injection (MDI) insulin regimen for people with type 1 diabetes. As the number of people treated with CSII via a tubeless insulin pump is increasing, there is growing interest in the long-term glycemic outcomes of this treatment option across diverse populations. This multicenter, retrospective study evaluated glycemic control in 156 adults with type 1 diabetes initiating tubeless insulin pump therapy following transition from either MDI or CSII with a tubed insulin pump. In this study, use of the tubeless insulin pump over 12 months was associated with significant improvement in A1C in adults with type 1 diabetes, most notably in those with an A1C ≥9.0% and those previously treated with MDI.

Improving Diabetes Control Using Lean Six Sigma Quality Improvement in an Endocrine Clinic in a Large Accountable Care Organization

This article describes a quality improvement project to reduce the number of patients with diabetes who have poor glycemic control in a large tertiary care endocrinology clinic. The project used the Lean Six Sigma Define-Measure-Analyze-Improve-Control process improvement methodology to develop clinic workflow processes for obtaining A1C measurements in a timely manner to facilitate interventions to improve glycemic control. The percentage of patients with poorly controlled diabetes (A1C >9.0% or missing value in the past 12 months) significantly improved from 26.4% at baseline to 16% (P <0.001), and the proportion of patients with an A1C test within 3-6 months of an appointment improved from 76 to 92%.

Insulin Knowledge, Handling, and Storage among Diabetic Pilgrims during the Hajj Mass Gathering

BACKGROUND

Diabetes is one of the most common underlying health conditions among Hajj pilgrims. Many diabetics manage their condition using insulin, which requires appropriate storage conditions to maintain its stability and effectiveness. We aimed to investigate insulin knowledge, storage, and handling among diabetic pilgrims during Hajj to identify specific areas for improvement.

METHOD

Adult diabetic pilgrims from 22 countries were interviewed using a structured questionnaire during the 2019 Hajj.

RESULTS

The study enrolled 277 diabetic pilgrims with a mean age of 58.4 years (SD = 10.4, range: 20-83) and male : female ratio of 1.6 : 1. Most participants (86.4%) were literate and reported using insulin for a mean of 7.1 years (SD = 5.3, range: 1-23). Over 95% of pilgrims brought their insulin with them from their country of origin, where they also received most of their insulin storage information, mainly from physicians (77.8%) and pharmacists (59.6%). Pilgrims' knowledge regarding insulin storage was just above average (mean knowledge score = 0.51; SD = 0.23). Pilgrims who were literate and previously received education on insulin storage, those with a higher level of education, and those with a longer duration of insulin therapy, had significantly higher knowledge scores. Pilgrims' storage and handling of their insulin during Hajj also varied depending on the stages of their pilgrimage journey.

CONCLUSION

Inadequate knowledge and inappropriate practices regarding insulin handling and storage were identified among diabetic Hajj pilgrims, which could compromise the quality of insulin and lead to health hazards. Improving diabetic pilgrims' knowledge of diabetes management, including insulin storage, will be beneficial during the pilgrimage and beyond.

Antidiabetic Food-Derived Peptides for Functional Feeding: Production, Functionality and In Vivo Evidences

Bioactive peptides released from the enzymatic hydrolysis of food proteins are currently a trending topic in the scientific community. Their potential as antidiabetic agents, by regulating the glycemic index, and thus to be employed in food formulation, is one of the most important functions of these peptides. In this review, we aimed to summarize the whole process that must be considered when talking about including these molecules as a bioactive ingredient. In this regard, at first, the production, purification and identification of bioactive peptides is summed up. The detailed metabolic pathways described included carbohydrate hydrolases (glucosidase and amylase) and dipeptidyl-peptidase IV inhibition, due to their importance in the food-derived peptides research field. Then, their characterization, concerning bioavailability in vitro and in situ, stability and functionality in food matrices, and ultimately, the in vivo evidence (from invertebrate animals to humans), was described. The future applicability that these molecules have due to their biological potential as functional ingredients makes them an important field of research, which could help the world population avoid suffering from several diseases, such as diabetes.