5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2024

Handgrip strength, cardiometabolic risk and body composition in youth with type 1 diabetes: the Diactive-1 Cohort Study

Objective

This study aimed to explore the association between handgrip strength, cardiometabolic risk (CMR) and body composition in youth with type 1 diabetes.

Methods

For this prospective cohort study, muscular fitness was assessed via handgrip test and relativised by weight, and body composition, evaluated through dual-energy X-ray absorptiometry in type 1 diabetes patients aged 6-18 years. CMR score included z-scores for total body fat, blood pressure, glycated haemoglobin (HbA1c), low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglyceride-glucose index.

Results

Eighty-three patients were analysed at baseline and 1-year follow-up (44.6% females, mean age 12.77 years). Individuals with high handgrip strength tended to have lower CMR and body fat compared with those with low handgrip strength. Over a year, individuals with high handgrip strength showed reduced HbA1c, CMR and subcutaneous fat. Consistently meeting high handgrip strength criteria resulted in reductions in HbA1c levels, CMR score and subcutaneous adipose tissue compared with those who never complied or lost compliance during follow-up. Additionally, subjects classified with high handgrip strength both at baseline and follow-up had a lower likelihood of being classified with high CMR (OR=0.241, 95% CI 0.121 to 0.947, p=0.044).

Conclusions

High handgrip strength was associated with significant cardiometabolic and body composition benefits in youth with type 1 diabetes. This tool could be considered of potential clinical value for incorporating assessments like handgrip tests to monitor and address cardiometabolic health.

Adequate sleep duration accentuates the effect of glucagon-like peptide-1 receptor variant on HbA1c: A gene-environment interaction study

BACKGROUND

Both glucagon-like peptide-1 receptor (GLP1R) agonists and lifestyle modifications are widely adopted in managing glycemia. However, the joint effects of GLP1R agonists with lifestyle on glycemic traits have not been evaluated.

METHODS

This gene-environment study tested the interaction between GLP1R-rs10305492 variant, consistent with the effect of GLP1R agonist therapies, and four lifestyle factors (diet, physical activity, sleep duration, and chronotype) for glucose and glycated hemoglobin (HbA1c) levels among 263,846 UK Biobank participants. Linear regression models were conducted to evaluate the effects of the rs10305492 and lifestyle factors on glucose and HbA1c levels.

RESULTS

GLP1R-rs10305492-AA/AG genotype combined a healthy diet, regular physical activity, adequate sleep duration, or morning chronotype were associated with lower glucose and HbA1c levels (all P for trend < 0.001). A synergistic effect was found between rs10305492 and sleep duration on HbA1c, suggesting a recommended adequate sleep duration (7-8 h/day) may amplify the HbA1c lowering effect of GLP1R agonists. Joint effects of the rs10305492 and adequate sleep were associated with a 26 % reduced risk of hyperglycemia (>7.8 mmol/L) risk and a 22 % lower of high HbA1c (>39 mmol/mol or 5.7 %).

CONCLUSIONS

Combining GLP1R agonists with adequate sleep may provide additional benefits for glycemic control in clinical practice.

Common mistakes concerning diabetes management in daily clinical practice

Diabetes mellitus is a chronic metabolic disease, potentially leading to dire complications. Although there are numerous pharmaceutical treatments available, management of the disease is frequently not optimal. Managing diabetes in daily clinical practice can be challenging, and several common mistakes may occur. Healthcare providers must be aware of these errors to provide adequate patient care. In this review, some frequent mistakes in diabetes management are analyzed, focusing on factors such as medication management, blood glucose level monitoring, inadequate addressing of complications and comorbidities, lifestyle choices, patient education, and overall health counselling.

Evaluation of diabetes care parameters in patients with diabetes: A population-based cross-sectional study in Khuzestan province (southwest of Iran)

Background

Diabetes is becoming a worldwide concern. Optimal diabetes control reduces diabetes complications.

Objectives

We aimed to measure the principal diabetes care parameters to recognize the main deficits in care for patients with diabetes in the region.

Methods

This cross-sectional study is based on the Khuzestan Comprehensive Health Study (KCHS) data. Of all participants, 4673 (15.3%) were identified to have diabetes. We invited the known cases of diabetes to complete a checklist about their diabetes through face-to-face interviews, and we obtained a blood sample to measure their HbA1c.

Results

Of all participants of the KCHS study, 312 patients with diabetes who met the inclusion criteria were identified. Mean (± SD) HbA1c was 8.5% (± 1.8), and 225 (72.1%) of the participants had poor glycemic control. About 45.2% had blood pressure less than 130/80 mmHg, and 24% had FBS lower than 130 mg/dl. Nearly 37.8% of the participants had LDL < 100 mg/dl and 40% TG < 150 mg/dl. Of all participants, 38.5% had undergone retinal examination, 13.8% had their foot examined, and 39.4% had done urine micro-albumin /Cr test. HbA1c level had a statistically significant relationship with gender (P = 0.012), occupation (P = 0.007), nephropathy (P = 0.004) and retinopathy (P < 0.001).

Conclusions

This study showed that less than half of the participants achieved the optimal ADA goals for diabetes care, therefore it is necessary to revise the basic protocols of diabetes care in the region to improve diabetes management.

Health beyond biology: the extended health hypothesis and technology

There are ethical dilemmas faced by clinicians when responding to using unregistered medical devices, such as innovative internet technologies for managing type 1 diabetes mellitus. This chronic disease significantly impacts patients' health, requiring intensive daily activities like blood glucose monitoring, insulin injections, and specific dietary recommendations. Recent technological advances, including continuous glucose monitors and insulin pumps, have been shown to improve glycemic control. Di-it Yourself Artificial Pancreas Systems are emerging open-source automated delivery methods initiated by the diabetes community, although they are not clinically evaluated and present a liability challenge for healthcare providers. To use them or not? Should parents and healthcare providers use such technology that helps, but is not proven?Having all of that in mind, we argue that the World Health Organization's (WHO) definition of health is outdated, advocating for the "Extended Health Hypothesis". This hypothesis claims that health extends beyond traditional biological boundaries to include essential functional structures like diabetes-related technology, making technology a part of a patient's health. This view aligns with the "Extended Mind Hypothesis," suggesting that health should include elements beyond organic material if they are vital to a patient's functions.In the commentary, we highlight that both naturalist and normative conceptions of health support the extended health hypothesis, emphasizing that human health is not confined to organic material. This perspective raises critical questions about whether devices like insulin pumps and continuous glucose monitors are integral to a patient's health and whether their malfunction constitutes a form of disease. Devices are considered integral to health, there is no ethical dilemma in using unregistered medical devices for managing type 1 diabetes. Finally, we call for reevaluating the definitions of health and patients, particularly for children with type 1 diabetes using advanced technologies. It asserts that the optimal use of such devices represents a new form of health, creating a health-device symbiosis that should be evaluated with the child's best interests in mind.

Utilization of Diabetes Self-Management Education and Support Among Medicare Beneficiaries Newly Diagnosed With Diabetes in Arkansas, 12 Months Postdiagnosis (2015-2018)

PURPOSE

The purpose of the study was to determine the rate of diabetes self-management education and support (DSMES) utilization among Medicare fee-for-service (FFS) and Medicare Advantage (MA) populations with type 2 diabetes in Arkansas.

METHODS

The Arkansas All-Payer Claims Database was used to identify Medicare FFS and MA beneficiaries diagnosed with type 2 diabetes from 2015 to 2018. Claims from 2013 to 2020 were analyzed to determine newly diagnosed individuals from 2015 to 2018. The criteria included 1 outpatient diabetes claim in the index year and at least 1 inpatient or outpatient claim in the 2 years following the initial claim. A total of 15 648 Medicare FFS individuals and 7520 MA individuals with newly diagnosed type 2 diabetes were identified. The use of DSMES 1 year following the diagnosis dates for both Medicare FFS and MA populations was assessed. Descriptive statistics and multiple logistic regression analyses were conducted to understand the factors associated with DSMES utilization.

RESULTS

DSMES utilization consistently remained lower in the MA population compared to Medicare FFS (2.3% vs 4.9%). The adjusted analysis indicated that factors such as older age, living in a rural area, belonging to a racial group other than White, and MA enrollment were associated with a lower likelihood of receiving DSMES.

CONCLUSIONS

DSMES utilization in Arkansas, where the prevalence of diabetes is higher than the national average, is notably low. There is a need for coordinated efforts at various levels to enhance access to DSMES.

Prevalence and association of sleep duration and different volumes of physical activity with type 2 diabetes: the first evidence from CHARLS

OBJECTIVES

This study aimed to examine the prevalence of type 2 diabetes (T2D) and the independent and joint associations of sleep duration and different volumes of physical activity (PA) with T2D in the China Health and Retirement Longitudinal Study (CHARLS).

METHODS

The prevalence of T2D among the Chinese population aged 45 years and older was estimated for the years 2011, 2013, 2015, 2018, and 2020. Data from 2020 were used to examine the independent and joint associations of sleep duration and different volumes of PA with T2D. Sleep duration was classified into three categories: short (< 6 h/day), normal (6-8 h/day), and long (> 8 h/day). PA volumes were classified based on the IPAQ recommendations as follows: light-volume PA (LPA, < 600 MET-minutes/week), moderate-volume PA (MPA, 600-3000 MET-minutes/week), and vigorous-volume PA (VPA, > 3000 MET-minutes/week). The data were statistically analyzed using a t-test and analysis of variance (ANOVA). Multivariate logistic regression models were used to examine the independent and joint associations of PA and sleep duration with T2D.

RESULTS

The prevalence of T2D in the LPA and short sleep groups increased from 13.35% (95% CI = 10.41-16.75) and 11.52% (95% CI = 10.01-13.15) in 2011 to 17.27% (95% CI = 15.09-19.62) and 16.28% (95% CI = 15.34-17.25) in 2020, respectively. Compared with LPA, VPA was associated with lower odds of T2D (Model 3, OR = 0.82, 95% CI = 0.69-0.97). Compared to individuals with normal sleep duration, those with short sleep duration had a higher likelihood of T2D (Model 3, OR = 1.10, 95% CI = 1.08-1.22), whereas long sleep duration did not show a significant association (Model 3, OR = 1.03, 95% CI = 0.86-1.23). The risk of developing T2D was approximately 35% lower for individuals with LPA and normal sleep duration compared to those with LPA and short sleep duration (Model 3, OR = 0.65, 95% CI = 0.46-0.91). In the VPA group, the mitigation effect of exercise on T2D was observed regardless of sleep duration (Model 3, short: OR = 0.73, 95% CI = 0.56-0.95; normal: OR = 0.65, 95% CI = 0.51-0.85; long: OR = 0.63, 95% CI = 0.45-0.89).

CONCLUSIONS

The prevalence of T2D among middle-aged and older adults in China increased substantially from 2011 to 2020. Short sleep duration is associated with higher odds of developing T2D. However, engaging in VPA mitigates this risk, even in those with insufficient sleep.

The Interactions Between Diet and Gut Microbiota in Preventing Gestational Diabetes Mellitus: A Narrative Review

Recent studies have revealed that dysbiosis, defined as alterations in gut microbiota, plays an important role in the development and the progression of many non-communicable diseases, including metabolic disorders, such as type 2 diabetes mellitus and gestational diabetes mellitus (GDM). The high frequency of GDM makes this disorder an important public health issue, which needs to be addressed in order to reduce both the maternal and fetal complications that are frequently associated with this disease. The studies regarding the connections between gut dysbiosis and GDM are still in their early days, with new research continuously emerging. This narrative review seeks to outline the mechanisms through which a healthy diet that protects the gut microbiota is able to prevent the occurrence of GDM, thus providing medical nutritional therapeutic perspectives for the management of GDM.

Social Determinants of Health for Cardiovascular-Kidney-Metabolic Syndrome Among Patients With Diabetes

Context

Cardiovascular-kidney-metabolic (CKM) syndrome is a recently introduced term that is a complex disease consisting of cardiovascular disease, renal disease, obesity, and diabetes. The association of social determinants of health (SDOH) with CKM syndrome is not fully known.

Objective

We aimed to assess SDOH affecting CKM syndrome among adult patients with diabetes at follow-up at a tertiary hospital in Ethiopia.

Methods

A cross-sectional hospital-based study was used. Data were collected using a Kobo toolbox and entered into SPSS version 29 for further analysis.

Results

A total of 422 adult patients with diabetes were included in this study. The mean ± SD age of the patients was 54.14 ± 13.74 years. Fifty-two percent of the patients were male. In this study, 52.4% had cardiovascular kidney metabolic syndrome. Male patients (AOR: 1.73; 95% CI, 1.01-2.94), lost to follow-up for more than a year due to lack of money (AOR: 2.69; 95% CI, 1.01-7.22), missed an appointment due to lack of transportation in the past 1 year (AOR: 2.98; 95% CI, 1.21-7.33), were patients with disability (AOR: 1.97; 95% CI, 1.12-3.48), had hypertension (AOR: 3.12; 95% CI, 1.85-5.28), had obesity (AOR: 2.27, 95% CI, 1.17, 4.40), and were in retirement (AOR: 2.12; 95% CI, 1.04-4.30) these being more significantly associated with CKM syndrome.

Conclusion

More than half of patients had CKM syndrome. More attention should be given to SDOH, including male sex, financial constraints, transportation issues, disability, and retirement.

The practice, nature, and impact of nurse-led type 2 diabetic foot prevention services and educational programs in Sub-Saharan Africa: a scoping review

Objective

The objective of this study is to assess the scope of existing practice, nature, and impact of nurse-led type 2 diabetic foot prevention services and educational programmes in Sub-Saharan Africa (SSA).

Introduction

Type 2 diabetes mellitus (T2DM) in SSA imposes a heavy burden on current healthcare services. Complications such as foot ulcers can have a significant impact on patient care and healthcare resources. It is imperative to identify patients at risk of developing diabetic foot complications and empower them with diabetes self-management education and support from specialised foot clinics is crucial. However, the availability of such programmes and services in SSA is limited.

Inclusion criteria

Studies of nurse-led diabetic foot prevention services and/or educational programmes in low- or middle-income countries in SSA for adults with T2DM, written in English, between August 2013 and March 2024 were considered.

Methods

Following the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for conducting and reporting scoping reviews, searches were conducted on four electronic databases (CINAHL, ProQuest, MEDLINE, and Scopus) and Google Scholar. The titles and abstracts were scrutinised. All eligible papers were retrieved and screened for full text.

Results

The review included ten studies (across 14 papers), all of which focused on nurse-led diabetes self-management education (DSME) programmes in SSA. There are no specific educational programmes or services led by nurses that focus exclusively on diabetic foot prevention. The analysis highlighted the components of successful nurse-led DSMEs that led to positive glycaemic control and self-care behaviors, including the focus on behavior change and the DSME should be co-produced with service users. The theoretical aspects of the DSME include evidence-based, structured, interactive, culturally and linguistically appropriate group-based activities. The DSME should be delivered over a period of several weeks, and sessions should last between 1.5 and 2 h. Barriers to delivery and participation include the rainy season, stockouts, time and resources needed, and a DSME that meets diverse levels of literacy and education.

Conclusion

There is a heightened need for nurse-led, co-produced, culturally congruent, frugal, and sustainable education interventions or programmes. There is also a need for diabetic foot screening and foot ulcer prevention services that can operate sustainably alongside these educational interventions through task-shifted, simple, and frugal initiatives.

Overcoming therapeutic inertia in newly diagnosed type 2 diabetes: Protocol of a randomized, quality improvement trial

Therapeutic inertia, the delay in the appropriate initiation and intensification of recommended therapies, is a major contributor to the lack of improvement in type 2 diabetes outcomes over the past decade. Therapeutic inertia during the period following diagnosis, when improvements in glycemic control can have lasting benefits, is often overlooked. Technology and team-based care approaches can effectively address therapeutic inertia. Here, we describe the protocol for a randomized, quality improvement trial targeting metformin-related therapeutic inertia among adults with recently diagnosed type 2 diabetes and a hemoglobin A1c <8 %. Service areas within an integrated healthcare delivery system were randomized to 1) usual care, 2) physician education on therapeutic inertia, and 3) physician education on therapeutic inertia paired with proactive outreach by a clinical pharmacist. The physician education sessions were offered to primary care providers working in the service areas randomized to Arm 2 and Arm 3, and proactive outreach by a clinical pharmacist was performed for patients of the providers in service areas randomized to Arm 3. Outcomes will be abstracted from the EHR at 6, 12, and 18 months following the physician education sessions. The primary outcome will be the proportion of patients with an HbA1c <7 % at each of the follow-up time points. Outcome abstraction and analyses will occur in late 2024. This trial seeks to rigorously evaluate care strategies that can shift stagnant type 2 diabetes outcomes. Our protocol, along with the pending results, may offer examples to other healthcare systems working to improve type 2 diabetes care.

Association of Low Protein-to-Carbohydrate Energy Ratio with Cognitive Impairment in Elderly Type 2 Diabetes Patients

BACKGROUND/OBJECTIVES

The relationship between macronutrient intake and cognitive decline in older adults with type 2 diabetes mellitus (T2DM) remains underexplored.

METHODS

This cross-sectional study aimed to evaluate the association between the protein-to-carbohydrate energy ratio (%E:P) and cognitive impairment among 192 elderly T2DM patients. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) and the Self-Administered Gerocognitive Exam (SAGE), while dietary intake data, including (%E:P), was gathered using a validated semi-quantitative food frequency questionnaire.

RESULTS

Participants had a mean age of 71 ± 6 years, 46.4% were female, and the median BMI was 30 ± 4 kg/m2. After adjusting for confounding variables, patients in the highest (%E:P) tertile showed significantly higher MoCA and SAGE scores compared to those in the lowest tertile (p < 0.005). We identified an optimal (%E:P) threshold of 0.375 for predicting cognitive impairment, with a sensitivity of 53% and specificity of 64%.

CONCLUSIONS

These findings suggest that a lower (%E:P) ratio may be a risk factor for cognitive impairment in elderly T2DM patients. Monitoring this ratio may serve as an early detection tool for cognitive deterioration. Moreover, current protein intake recommendations for older adults with T2DM may be insufficient to prevent cognitive impairment. Further research is needed to establish optimal dietary guidelines for this population.

Relationship among nursing support for parents of adolescents diagnosed with Type 1 Diabetes, parental monitoring of adolescents and the self-efficacy of adolescents with Type 1 Diabetes

BACKGROUND

This study aims to explore the connection between parental monitoring in the treatment of adolescents with type 1 diabetes mellitus (T1DM), the self-efficacy of adolescents with diabetes, and nurse assistance provided to parents of adolescents with T1DM.

METHODS

This cross-sectional descriptive study consisted of 115 adolescents aged 10-18 with T1DM and their parents. Study data were collected through the "Diabetes Management Self-Efficacy Scale in Adolescents with T1DM", "Introductory Information Form", "Nurse-Parent Support Tool (NPST)" and "Parental Monitoring of Diabetes Care Questionnaire in Adolescents with T1DM".

RESULTS

Only 31.3 % of the study adolescent participants reported monitoring their blood sugar less than four times per day, and the frequency of blood sugar monitoring increased with increasing parental supervision (p = 0.021). When diabetes was managed only by parents, adolescents' perceptions of their self-management were statistically significant and high (p = 0.015). Neither the level of nurse-parent support nor the connection between parental monitoring and adolescents' self-efficacy was statistically significant.

CONCLUSIONS

Adolescents with T1DM should receive support from both parents and medical professionals. In particular, nurses should closely inquire about the adolescent's and family's disease management strategies during hospital visits and health monitoring.

Impact of Continuous Glucose Monitoring Versus Blood Glucose Monitoring to Support a Carbohydrate-Restricted Nutrition Intervention in People with Type 2 Diabetes

Introduction: Low- and very-low-carbohydrate eating patterns, including ketogenic eating, can reduce glycated hemoglobin (HbA1c) in people with type 2 diabetes (T2D). Continuous glucose monitoring (CGM) has also been shown to improve glycemic outcomes, such as time in range (TIR; % time with glucose 70-180 mg/dL), more than blood glucose monitoring (BGM). CGM-guided nutrition interventions are sparse. The primary objective of this study was to compare differences in change in TIR when people with T2D used either CGM or BGM to guide dietary intake and medication management during a medically supervised ketogenic diet program (MSKDP) delivered via continuous remote care. Methods: IGNITE (Impact of Glucose moNitoring and nutrItion on Time in rangE) study participants were randomized to use CGM (n = 81) or BGM (n = 82) as part of a MSKDP. Participants and their care team used CGM and BGM data to support dietary choices and medication management. Glycemia, medication use, ketones, dietary intake, and weight were assessed at baseline (Base), month 1 (M1), and month 3 (M3); differences between arms and timepoints were evaluated. Results: Adults (n = 163) with a mean (standard deviation) T2D duration of 9.7 (7.7) years and HbA1c of 8.1% (1.2%) participated. TIR improved from Base to M3, 61-89% for CGM and 63%-85% for BGM (P < 0.001), with no difference in change between arms (P = 0.26). Additional CGM metrics also improved by M1, and improvements were sustained through M3. HbA1c decreased by ≥1.5% from Base to M3 for both CGM and BGM arms (P < 0.001). Diabetes medications were de-intensified based on change in medication effect scores from Base to M3 (P < 0.001). Total energy and carbohydrate intake decreased (P < 0.001), and participants in both arms lost clinically significant weight (P < 0.001). Conclusion: Both the CGM and BGM arms saw similar and significant improvements in glycemia and other diabetes-related outcomes during this MSKDP. Additional CGM-guided nutrition intervention research is needed.

Health outcomes reported by healthcare providers and clients of a community-based medically tailored meal program

BACKGROUND

Medically tailored meal (MTM) programs provide home-delivered meals to people living with serious illness and poor nutritional status. Client outcome studies have found evidence of decreased healthcare utilization and cost savings associated with MTM program participation, and inconclusive evidence of change in health measures. The purpose of this study was to use a novel observational framework to describe the client profile and change in health outcomes using routinely collected health and program data from a community-based MTM program at MANNA (Philadelphia, PA).

METHODS

Clients reported their self-rated health and experiences of food insecurity and malnutrition. Healthcare providers reported clients' body mass index, systolic blood pressure, and hemoglobin A1C. These health outcomes, measured at program intake and 3-6 months later, were linked with administrative data for 1,959 clients who completed at least two months of MTM services in 2020, 2021, and 2022.

RESULTS

Clients exhibited substantial heterogeneity in demographics and health status at intake. Self-reported malnutrition risk decreased significantly over program duration (p < .001). Nearly one-third of clients with poor health reported improvement over time. Over 60% of clients with obesity experienced stable BMI. Clients with hypertension experienced significant improvements in systolic blood pressure (p < .001). Clients with diabetes and available data (n = 45) demonstrated significant reduction in hemoglobin A1C (p = .005).

CONCLUSION

We found evidence that participation in MANNA's MTM program was associated with favorable health outcomes for clients with serious illness and nutritional risk. Community-based organizations can maximize the completeness of their data by focusing on routinely collected internal data like validated health screeners and surveys.

The Role of Obesity as a Cardiac Disease Risk Factor in Patients with Type 2 Diabetes

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of death globally and is closely associated with obesity and type 2 diabetes mellitus (T2DM). This review examines the interplay between obesity, T2DM, and CVD, highlighting the increasing prevalence and economic burden of these conditions.

RECENT FINDINGS

Pharmacologic therapies, particularly glucagon-like peptide-1 receptor agonists, show promise in substantial weight loss and subsequent reduction of adverse cardiovascular events in obese individuals with and without diabetes. Obesity significantly contributes to the development of insulin resistance and T2DM, further escalating CVD risk. The common co-occurrence of these three conditions may involve several other pathophysiological mechanisms, such as chronic inflammation, increased visceral adiposity, and endothelial dysfunction. Until recently, lifestyle modifications and bariatric surgery had been the primary methods for weight loss and mitigating obesity-associated cardiovascular risk. Newer pharmacological options have led to a paradigm shift in our approach to obesity management as they provide substantial benefits in weight loss, glycemic control, and cardiovascular risk reduction.

Perceived glucose levels matter more than CGM-based data in predicting diabetes distress in type 1 or type 2 diabetes: a precision mental health approach using n-of-1 analyses

AIMS/HYPOTHESIS

Diabetes distress is one of the most frequent mental health issues identified in people with type 1 and type 2 diabetes. Little is known about the role of glucose control as a potential contributor to diabetes distress and whether the subjective perception of glucose control or the objective glycaemic parameters are more important for the experience. With the emergence of continuous glucose monitoring (CGM), this is a relevant question as glucose values are now visible in real-time. We employed a precision monitoring approach to analyse the independent associations of perceived and measured glucose control with diabetes distress on a daily basis. By using n-of-1 analyses, we aimed to identify individual contributors to diabetes distress per person and analyse the associations of these individual contributors with mental health at a 3 month follow-up.

METHODS

In this prospective, observational study, perceived (hypoglycaemia/hyperglycaemia/glucose variability burden) and measured glucose control (time in hypoglycaemia and hyperglycaemia, CV) were assessed daily for 17 days using an ecological momentary assessment (EMA) approach with a special EMA app and CGM, respectively. Mixed-effect regression analysis was performed, with daily diabetes distress as the dependent variable and daily perceived and CGM-measured metrics of glucose control as random factors. Individual regression coefficients of daily distress with perceived and CGM-measured metrics were correlated with levels of psychosocial well-being at a 3 month follow-up.

RESULTS

Data from 379 participants were analysed (50.9% type 1 diabetes; 49.6% female). Perceived glucose variability (t=14.360; p<0.0001) and perceived hyperglycaemia (t=13.637; p<0.0001) were the strongest predictors of daily diabetes distress, while CGM-based glucose variability was not significantly associated (t=1.070; p=0.285). There was great heterogeneity between individuals in the associations of perceived and measured glucose parameters with diabetes distress. Individuals with a stronger association between perceived glucose control and daily distress had more depressive symptoms (β=0.32), diabetes distress (β=0.39) and hypoglycaemia fear (β=0.34) at follow-up (all p<0.001). Individuals with a stronger association between CGM-measured glucose control and daily distress had higher levels of psychosocial well-being at follow-up (depressive symptoms: β=-0.31; diabetes distress: β=-0.33; hypoglycaemia fear: β=-0.27; all p<0.001) but also higher HbA1c (β=0.12; p<0.05).

CONCLUSIONS/INTERPRETATION

Overall, subjective perceptions of glucose seem to be more influential on diabetes distress than objective CGM parameters of glycaemic control. N-of-1 analyses showed that CGM-measured and perceived glucose control had differential associations with diabetes distress and psychosocial well-being 3 months later. The results highlight the need to understand the individual drivers of diabetes distress to develop personalised interventions within a precision mental health approach.

[Developing cultural competence for better support]

Culture, in its broadest sense, can have an impact on diabetes management. Taking into account cultural particularities in the care of patients seems essential to offering them care that is equitable and meaningful to them. Developing nurses' cultural competence through reflection, training and experience could be a lever enabling them to achieve this objective of quality and relevance of care.

Unhealthy plant-based diet is associated with a higher cardiovascular disease risk in patients with prediabetes and diabetes: a large-scale population-based study

BACKGROUND

The role of plant-based dietary patterns in preventing cardiovascular disease (CVD) among individuals with prediabetes and diabetes remains unclear. We aimed to evaluate the associations of plant-based diet index (PDI), healthful PDI (hPDI), and unhealthful PDI (uPDI) with cardiovascular disease (CVD) risk and explore potential contributing factors among people with prediabetes and diabetes.

METHODS

A total of 17,926 participants with prediabetes and 7798 with diabetes were enrolled from the UK Biobank between 2006 and 2010 and followed until the end of 2020. We calculated the PDI, hPDI, and uPDI based on 18 major food groups including plant-based foods and animal-based foods and applied Cox proportional hazard models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD risk related to PDI, hPDI, and uPDI. Decomposition analysis was performed to assess the role of dietary components, and mediation analysis was performed to assess the potential mediating role of serum biomarkers underlying these associations.

RESULTS

A total of 2324 CVD events were documented among individuals with prediabetes, while 1461 events occurred among patients with diabetes. An inverse association was found between hPDI and CVD risk among individuals with prediabetes (HR T3 vs. T1 = 0.88, 95% CI = 0.79-0.98, Ptrend = 0.025) but not those with diabetes. A positive association was found between uPDI and CVD risk among individuals with prediabetes (HR T3 vs. T1 = 1.17, 95% CI = 1.05-1.30, Ptrend = 0.005) and those with diabetes (HR T3 vs. T1 = 1.14, 95% CI = 1.00-1.29, Ptrend = 0.043). High-sugar-sweetened beverages (SSB) intake accounted for 35% of the hPDI-CVD association and 15% of the uPDI-CVD association among individuals with prediabetes, whereas low intake of whole grain accounted for 36% of the association among patients with diabetes. Elevated cystatin C levels explained the largest proportion of the association between uPDI and CVD risk among individuals with prediabetes (15%, 95% CI = 7-30%) and diabetes (44%, 95% CI = 9-86%).

CONCLUSIONS

Adherence to an unhealthy plant-based diet is associated with a higher CVD risk in people with prediabetes or diabetes, which may be partially attributed to low consumption of whole grains, high intake of SSB, and high blood cystatin C levels.

Exploring the interplay between emotional attitudes towards diabetes, eating behaviour and glycaemic control in patients with type 2 diabetes mellitus

OBJECTIVE

This study aimed to assess the association between emotional attitudes towards diabetes, eating behaviour styles and glycaemic control in outpatients with type 2 diabetes.

DESIGN

Observational study.

SETTING

Endocrinology Division of Hospital de Clínicas de Porto Alegre, Brazil.

PARTICIPANTS

Ninety-one outpatients diagnosed with type 2 diabetes. Baseline assessments included data on clinical parameters, lifestyle factors, laboratory results, eating behaviour styles and emotional attitudes. All patients received nutritional counseling following diabetes recommendations. A follow-up visit was scheduled approximately 90 days later to evaluate changes in weight, medication dosages and glycated Hb (HbA1c) values. Patients were categorised based on their emotional attitude scores towards diabetes (positive or negative), and their characteristics were compared using appropriate statistical tests.

RESULTS

At baseline, no differences were observed in the proportion of patients with good glycaemic control, eating behaviour styles and emotional attitudes. However, patients with a positive attitude towards the disease exhibited a significantly better response in glycaemic control compared with the reference group (OR = 3·47; 95 % CI = 1·12, 10·75), after adjusting for diabetes duration, sex and medication effect score. However, when BMI was included in the model, the association did not reach statistical significance. Therefore, these results should be interpreted with caution.

CONCLUSIONS

Patients with a positive attitude towards diabetes showed a greater reduction in HbA1c levels following nutritional counseling. However, baseline BMI could be a potential confounding factor.

Does Online Social Support Affect the Eating Behaviors of Polish Women with Insulin Resistance?

BACKGROUND

Insulin resistance, a key factor in developing type 2 diabetes mellitus, is linked to various health conditions. The basis of its treatment is lifestyle modification. However, adherence to nutritional and other medical recommendations can be challenging for chronic disease patients due to many factors, including demographics, social context, gender, age, and the patient's baseline health condition. This study aims to evaluate the impact of online support group members on the diet quality of women with insulin resistance.

METHODS

This study was conducted as an online survey consisting of KomPAN (validated food frequency questionnaire) augmented with questions regarding using professional counseling and membership in support groups. The study covered 1565 women with insulin resistance, 1011 of whom were associated with the online support group.

RESULTS

The mean pHDI (pro-health diet index) was 5.18 ± 2.69 in the support groups and 4.86 ± 2.69 in the control group (p = 0.0319. There were no significant differences in the nHDI (non-health diet index). We found that the pHDI is associated with financial situations, the household's situation, occupation education level, and medical or dietitian care, whereas occupation, medical, and dietitian care affect the nHDI. Membership in support groups is related to a higher pHDI and state of self-assessment of nutritional knowledge.

CONCLUSIONS

Our study indicates a relationship between participation in online support groups and dietary behaviors and the subjective assessment of nutrition knowledge. Future research should focus on elucidating the mechanisms behind these influences and exploring how these communities can be optimized for broader public health initiatives.

Exploring Food Preferences as a Pre-Step for Developing Diabetes-Friendly Options in Adults with Diabetes and Prediabetes

Given the low compliance with healthy eating among patients with diabetes, personalized dietary plans incorporating their food preferences are urgently needed. However, few studies have explored the food preferences of adults with diabetes or prediabetes (AdDMP). We aimed to examine taste and food preferences among AdDMP, comparing them by sex, age, and weight status. A total of 415 AdDMP completed the survey via Amazon Mechanical Turk in 2023 (53% women, 47% men; 20-70 years old). Food/taste preferences were measured using Likert-type scales for six taste-cluster food groups, as well as basic tastes/spicy flavor. Open-ended questions assessed comfort, favorite, and least favorite foods, which were then categorized into five groups. Independent t-tests, analysis of variance, and Tukey-HSD were performed to compare outcomes across the groups. Men, the 41-70-year-old group, and the obese group regarded warm food as a comfort food more than in other comparable groups, while women and the 20-30-year-old group tend to prefer fruits and vegetables. Additionally, men expressed a significantly higher preference for salty-/umami-/fat-tasting foods compared to women. These findings underscore the need to align dietary expectations with reality for AdDMP. Future research should focus on strategies to accommodate their preferences within a healthy eating framework.

Impact of the COVID-19 Pandemic on Lifestyle Behavior and Clinical Care Pathway Management in Type 2 Diabetes: A Retrospective Cross-Sectional Study

Background and Objectives: In Italy, as in the rest of the world, government restrictions aimed at containing the spread of COVID-19 primarily imposed limitations on social relationships and personal behavior. This situation significantly affected the management of chronic illnesses, including type 2 diabetes (T2D). The objective was to evaluate the perceptions of patients with T2D regarding the quality of care received during the COVID-19 pandemic and the impact on dietary and physical activity behaviors. Materials and Methods: We conducted a retrospective cross-sectional survey. Data were collected from June to July 2023 using the convenience sampling of patients with T2D, and the Patient Assessment of Chronic Illness Care (PACIC) and Medi-Lite questionnaires were administered. Results: During the research period, out of the 130 subjects who met all enrollment criteria, 103 patients were included in this study (79.23%). The results of the administered questionnaires were heterogeneous. The average scores from the PACIC Questionnaire for each question displayed significant variability, indicating a range of experiences in the quality of care. In the Medi-Lite survey, fruit, cereals, and olive oil showed the highest adherence levels, with mean scores ranging from 2.58 (SD ± 1.18) for fruit to 1.89 (SD ± 0.34) for olive oil and 1.97 (SD ± 0.17) for cereals. Patients who reported increased food intake during the lockdown attributed it to having more time to prepare meals. Physical activity levels remained unchanged for 48 patients, decreased for 45 patients, and only 9 patients managed to exercise more during the COVID-19 restrictions. Conclusions: Healthcare systems must prioritize comprehensive care plans for T2D that address not only physical health, but also emotional and social well-being. Post-pandemic, promoting healthier lifestyles and empowering patients to manage their condition is crucial. A multidisciplinary and multidimensional approach could support the care of vulnerable individuals, such as patients with T2D, especially during crises like pandemics or other dramatic events.

Effect of Pharmacist-Led Interventions on Diabetes Distress Among People With Type 2 Diabetes

PURPOSE

The purpose of this study was to determine the effectiveness of pharmacist-led interventions on diabetes distress and glucose management among people with type 2 diabetes (T2DM) in a community care clinic.

METHODS

Adults with T2DM were recruited during routine visits at the pharmacist-run clinic. Participants completed a baseline A1C, demographic survey, Diabetes Distress Scale (DDS), and Patient Health Questionnaire-2 (PHQ-2). Depending on DDS subscale-specific responses, participants qualified for pharmacist-led educational interventions based on the ADCES7 Self-Care Behaviors™. After 6 months, participants completed another A1C, satisfaction survey, DDS, and PHQ-2. Data analysis included descriptive statistics and paired t tests.

RESULTS

Among 53 participants at baseline, diabetes distress was present in 77.4%; emotional burden was most common in 64.2%, followed by regimen distress in 45.3%, interpersonal distress in 34.0%, and physician distress in 20.8%. After the intervention, significant reductions occurred in mean overall DDS score (2.0 to 1.7), emotional burden (2.4 to 1.8), regimen distress (2.3 to 1.7), A1C (7.0% to 6.5%; 53.0 to 47.5 mmol/mol), and PHQ-2 score (1.6 to 1.0). Participants were highly satisfied with the service, their knowledge, and self-management skills following completion of the study.

CONCLUSIONS

Diabetes distress was present in most participants despite glucose management that was largely achieving treatment goals. Pharmacist-led educational interventions significantly reduced overall DDS score, emotional burden, regimen distress, A1C, and PHQ-2 score. The results of this study suggest that people with T2DM should receive routine screening for diabetes distress and that pharmacists can positively affect diabetes management and emotional well-being through tailored education.

Diabetes and obesity: the role of stress in the development of cancer

Diabesity is a condition where an individual has both diabetes and obesity, which can lead to severe complications including cardiovascular disease, a leading cause of mortality. Recently, cancer has become a leading cause of excess hospitalizations, and both diabetes and obesity are associated with a higher risk of developing several types of cancer. In this review, we propose that chronic stress significantly increases this association. Managing diabetes and obesity is challenging as they both cause significant distress. The relationship between stress and cancer is interconnected, with anxiety and depression being common in cancer patients. Cancer diagnosis and treatment can cause lasting changes in the body's neuroendocrine system, with stress causing an excessive release of catecholamines and prostaglandins in patients undergoing cancer surgery, which promotes the spread of cancer to other parts of the body. Furthermore, stress could significantly increase the risk of cancer in patients with diabetes, obesity, or both.

Higher fibre and lower carbohydrate intake are associated with favourable CGM metrics in a cross-sectional cohort of 470 individuals with type 1 diabetes

AIMS/HYPOTHESIS

The aim of this work was to investigate the association between macronutrient intakes and continuous glucose monitoring (CGM) metrics in individuals with type 1 diabetes.

METHODS

In 470 individuals with type 1 diabetes of the GUTDM1 cohort (65% female, median age 40 [IQR 28-53] years, median diabetes duration 15 [IQR 6-29] years), we used logistic regression to establish associations between macronutrient intakes and the CGM metrics time in range (TIR, time spent between 3.9-10.0 mmol/l blood glucose, optimally set at ≥70%) and time below range (TBR, <3.9 mmol/l blood glucose, optimally set at <4%). ORs were expressed per 1 SD intake of nutrient and were adjusted for other macronutrient intakes, age, sex, socioeconomic status, BMI, duration of type 1 diabetes, pump use, insulin dose and alcohol intake.

RESULTS

The median (IQR) TIR was 67 (51-80)% and TBR was 2 (1-4)%; the mean ± SD energy intake was 6879±2001 kJ, fat intake 75±31 g, carbohydrate intake 162±63 g, fibre intake 20±9 g and protein intake 70±24 g. A higher fibre intake and a lower carbohydrate intake were associated with higher odds of having a TIR≥70% (OR [95% CI] 1.64 [1.22, 2.24] and 0.67 [0.51, 0.87], respectively), whereas solely a higher carbohydrate intake was associated with TBR<4% (OR 1.34 [95% CI 1.02, 1.78]).

CONCLUSIONS/INTERPRETATION

A higher fibre intake is independently associated with a higher TIR. A higher carbohydrate intake is associated with less time spent in hypoglycaemia, a lower TIR and a higher time above range. These findings warrant confirmatory (interventional) investigations and may impact current nutritional guidelines for type 1 diabetes.

Clinical Health Psychology Perspectives in Diabetes Care: A Retrospective Cohort Study Examining the Role of Depression in Adherence to Visits and Examinations in Type 2 Diabetes Management

BACKGROUND

Depression in type 2 diabetes mellitus (T2DM) impacts glycemic control and complications. This study examines the influence of depression on compliance with recommended annual diabetes assessments in patients within the Local Healthcare Authority of Romagna. From a clinical health psychology perspective, understanding how depression influences patients' engagement in managing their conditions is crucial. This insight can help improve healthcare services by ensuring they address mental health needs and thereby enhance treatment effectiveness and overall patient outcomes.

METHODS

This retrospective cohort study included residents of Romagna with incident T2DM from 2015 to 2017, followed from 1 January 2018 to 31 December 2022. Depression was identified via hospital discharge records or antidepressant prescriptions. Adherence to diabetes care guidelines was measured using the Guideline Composite Indicator (GCI).

RESULTS

The study included 13,285 patients, with a mean age of 61.1 years. Prevalence of post-diabetes depression increased from 3.0% in 2018 to 8.9% in 2022. Initial analyses showed higher GCI rates among patients with depression. However, propensity-score adjustment revealed that by 2021-2022, patients with pre-diabetes depression had 5% lower compliance rates (p-value ≤ 0.05). Older adults with depression had reduced adherence, while younger adults with post-diabetes depression had higher adherence rates.

CONCLUSIONS

Depression significantly affects adherence to diabetes care guidelines in T2DM patients, particularly among older adults. Integrated care models addressing both diabetes and depression are crucial for improving health outcomes.

Low-Carbohydrate Dietary Interventions for Metabolic Control in Individuals With Type 2 Diabetes Mellitus: An Overview of Systematic Reviews

CONTEXT

Dietary interventions providing different amounts of carbohydrates have been proposed as a means of achieving glycemic control and weight loss in type 2 diabetes mellitus (T2DM); however, the supporting evidence is heterogeneous, making this recommendation difficult to apply in nutritional clinical practice.

OBJECTIVE

The aim was to assess the quality of evidence from meta-analyses on low-carbohydrate (LC) dietary interventions for glycemic control, weight loss, and lipid profile in individuals with T2DM.

DATA SOURCES

The MEDLINE, Web of Science, and Scopus databases were searched until September 2023.

DATA EXTRACTION

A systematic review was conducted. Systematic reviews with meta-analysis of randomized clinical trials designed to assess glycated hemoglobin (HbA1c) reductions in individuals with T2DM were eligible. The AMSTAR-2 critical appraisal tool was used to evaluate the methodological aspects of all included studies. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to assess the certainty of the evidence.

DATA ANALYSIS

The LC interventions were associated with a reduction in HbA1c (%) of -0.42 (-1.45 to -0.09; high certainty of evidence) without considering follow-up time; at up to 3 months of follow-up of -0.28 (-0.13 to -0.43); at up to 6 months of follow-up of -0.40 (-0.61 to -0.09); at 6 to 12 months of follow-up of -0.32 (-0.49 to 0.11); and at >12 months of follow-up time of -0.31 (-0.14 to -0.65) compared with control diets.

CONCLUSION

LC diets can help reduce HbA1c in individuals with T2DM in the short term (up to 3 months). However, dietary recommendations must always be individualized, as the studies reviewed herein analyzed different populations and used different definitions of what constitutes an LC diet.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO no. CRD42023404197.

Culturally adapted mobile application for optimizing metabolic control in type 1 diabetes: a pilot study

Objective

To evaluate whether use of a culturally adapted mobile application (app) for adolescents with type 1 diabetes is associated with improved metabolic control.

Methods

The Dominican Republic's National Institute of Diabetes, Endocrinology, and Nutrition and the Learning to Live clinic recruited 23 pediatric participants for the study. Blood tests were performed before and after use of the app for a period of 3 months. Based on the user profile, participants were encouraged to use the app's bolus insulin calculator after each meal. The app included a list of regionally and culturally specific foods, color-coded to indicate a high glycemic index (GI) as red; medium GI as yellow; and low GI as green. The color-coding was designed to assist participants in making healthier eating choices.

Results

There were statistically significant improvements in lipid profile. Mean high-density lipoprotein values rose to acceptable levels, while low-density lipoproteins and triglyceride levels fell to the recommended values. The overall quality of life increased, although glycated hemoglobin levels showed no statistically significant changes.

Conclusion

The findings of this study suggest that using this culturally tailored app can help young patients with type 1 diabetes to improve metabolic health.

The Evaluation of Selected Trace Elements in Blood, Serum and Blood Cells of Type 2 Diabetes Patients with and without Renal Disorder

BACKGROUND

An appropriate diet is the basis for the treatment of type 2 diabetes (T2DM). However, there are no strict recommendations regarding the content of micronutrients and their modifications in the presence of chronic kidney disease (CKD). Therefore, we decided to investigate whether T2DM patients, including those with CKD, have different levels of chromium, nickel, cobalt, magnesium, and zinc in various blood elements compared to healthy individuals.

METHODS

We divided our subjects into three groups: the control group (individuals without T2DM and proper renal function), those with T2DM and proper renal function, and those with T2DM and GFR < 60 mL/min/1.73 m2.

RESULTS

We observed higher levels of chromium in all materials examined in patients with T2DM and impaired renal function. Both study groups found higher levels of nickel in samples of whole blood and red blood cells. Patients with T2DM and proper renal function had higher levels of serum manganese. Both study groups had lower levels of serum zinc. We observed higher levels of chromium in all materials examined in patients with T2DM and impaired renal function. Both study groups found higher levels of nickel in samples of whole blood and red blood cells. Patients with T2DM and proper renal function had higher levels of serum manganese. Both study groups had lower levels of serum zinc.

CONCLUSIONS

In order to ensure effective care for patients with T2DM, it is necessary to improve the standard diet, including the content of micronutrients and their modification in patients with concomitant CKD.

Psychological and Clinical Challenges in the Management of Type 1 Diabetes during Adolescence: A Narrative Review

Adolescence, a critical period of physical and psychological development, presents unique challenges in type 1 diabetes (T1D) management due to endocrinological changes, reduced therapeutic adherence, and elevated susceptibility to psychological issues such as depression, anxiety, and eating disorders. This narrative review explores the impact of psychological and behavioral factors on glycemic control in adolescents with T1D. We examine the prevalence and influence of mental health disorders, lifestyle factors, harmful behaviors, and social dynamics on diabetes management and glycemic outcomes. Strategies for improving metabolic control are also reviewed, including cognitive behavioral therapy, technological devices, and educational interventions. The importance of tailored psychological support, family involvement, and targeted interventions to improve adherence to treatment and glycemic control in adolescents with T1D should be emphasized.

Is chromium(III) supplementation beneficial for dietary rodent models of prediabetes?

Chromium as the trivalent ion is believed to pharmaceutically active, increasing insulin sensitivity in high doses in genetic rodent models of diabetes. However, contradictory results have been obtained chemical rodent models of diabetes. The current review analyses the effects of dietary Cr supplementation of rodent models of prediabetes, where the condition is administered using a high-fat or high-sugar diet. Rat model studies display a range of quality, with studies utilizing basal diets of known Cr content suggesting Cr beneficially affects insulin sensitivity. Mouse model studies display too much heterogeneity in results for any firm conclusions to be drawn. Comparison of these results with those of clinical trials suggest that the effective dose of Cr may be proportionally lower for rodents than humans, if one exists for humans.

Diabetes self-management and its influencing factors among adults with type 2 diabetes mellitus in rural Sri Lanka: A cross-sectional study

Background

Diabetes Self-Management (DSM) is pivotal in managing diabetes. However, poor engagement in DSM has been observed in rural Sri Lankan settings. Thus, identifying factors influencing DSM is crucial for nurses and other healthcare professionals.

Objectives

This study aimed to describe DSM among adults with Type 2 Diabetes Mellitus (T2DM) in rural Sri Lanka and to examine whether perceived stress, health literacy, self-efficacy, and family support can predict DSM among adults with T2DM in rural Sri Lanka.

Methods

This correlational predictive study used a simple random sampling technique to recruit 160 adults with T2DM from an outpatient clinic at a secondary care hospital in a rural area of Sri Lanka. Data were collected from March to April 2024 using socio-demographic and standardized questionnaires to examine predictive factors of DSM, including perceived stress, health literacy, self-efficacy, and family support. Data analysis was conducted using descriptive statistics and standard multiple linear regression analysis.

Results

Approximately half of the participants had uncontrolled T2DM (Fasting Plasma Glucose (FPG) >126) and sub-optimal DSM. The analysis revealed that all variables could explain 39.3% of the variance in DSM among rural Sri Lankan adults with T2DM. However, DSM was significantly predicted by self-efficacy (β = 0.530, p = 0.001), harmful family involvement (β = -0.169, p = 0.038), and health literacy (β = -0.162, p = 0.020).

Conclusion

The findings emphasized the need for further development of interventions to increase self-efficacy and reduce harmful family involvement to enhance DSM among adults with T2DM. Nurses and other healthcare providers should target family members' engagement to improve self-efficacy among this population.

Considerations to Better Meet the Needs of People Living With Diabetes While in Prison or Detention

Diabetes care within prison walls offers challenges and opportunities for both health care providers and individuals living with diabetes. To meet the challenges, providers and patients work together to manage diabetes within the limitations imposed by imprisonment. Upon release, patients face new challenges, as they transition from incarceration into the community.

Cooking Well with Diabetes: A Healthy Cooking School for Diabetes Prevention and Management

One in ten Americans suffers from type 2 diabetes, which, if not managed well, can result in severe complications, disability, and premature death. Diabetes education classes can play a pivotal role in providing practical education on diabetes and self-care behaviors, with a particular emphasis on dietary management, which is often regarded as the most demanding diabetes self-care behavior. The Texas A&M AgriLife Extension Service developed Cooking Well with Diabetes (CWWD), a four-week interactive diabetes education series, with each week consisting of a lecture on healthy eating coupled with cooking lessons featuring diabetes-friendly recipes. The current study aimed to examine the effectiveness of CWWD in improving the frequency of healthy food preparation and consumption of program participants. Secondary data from 2017 to 2023 was analyzed involving 1574 adults from 59 predominantly rural Texas counties. Data from self-reported pre and post evaluations showed improvements in healthy food preparation and consumption behaviors. The curriculum enabled Extension Educators to introduce healthful dietary behaviors to a diverse group of clients. The curriculum can be adapted by Extension Educators in other states reaching a broader audience. The findings will inform future research aimed at planning and implementing successful diabetes education programs.

Social Risk and Clinical Outcomes Among Adults With Type 2 Diabetes

Importance

No clear process exists for categorizing social risks in a way that informs effective social risk screening and intervention development.

Objective

To investigate social risk profiles and associations of those profiles with clinical outcomes in adults with diabetes using latent profile analysis.

Design, Setting, and Participants

For this cross-sectional study, a latent profile analysis was conducted using data for adults with type 2 diabetes collected at 2 primary care clinics in the Southeastern US from 2013 to 2014. Data were analyzed from November to December 2023.

Main Outcomes and Measures

Participants completed validated questionnaires for 26 social risk factors within 5 domains of social determinants of health: socioeconomic, neighborhood, education, food, and social and community context. In addition, participants completed questions that assessed psychological risk and behavioral risk. A 3-step latent profile analysis was used to identify different subgroups within the sample. Profiles were then regressed on outcomes of hemoglobin A1c (HbA1c), blood pressure, and quality of life.

Results

A total of 615 participants (mean [SD] age, 61.3 [10.9] years; 379 men [61.6%]) were included. Five latent class profiles were identified. The lowest risk group had significantly higher mental health-related quality of life compared with a group with higher neighborhood risk (β, 1.11; 95% CI, 0.67 to 1.55). The second group had low economic risk but high neighborhood risk and served as the reference group. The third group had high economic and neighborhood risk and had significantly higher blood pressure (β, 8.08; 95% CI, 2.16 to 14.01) compared with the reference. The fourth group had high psychological and behavioral risks but low socioeconomic and neighborhood risks. This group had significantly higher HbA1c (β, 0.47; 95% CI, 0.01 to 0.92) and lower mental health-related quality of life (β, -1.83; 95% CI, -2.41 to -1.24) compared with the reference. The highest risk group indicated high risk in all domains, had significantly higher HbA1c (β, 1.07; 95% CI, 0.50 to 1.63), and had lower mental health-related quality of life (β, -2.15; 95% CI, -2.87 to -1.42) compared with the reference.

Conclusions and Relevance

These findings suggest that social risk profiles can be identified according to social, psychological, and behavioral risk domains and the health outcome of concern among adults with diabetes. Future work should consider the use of social risk profiles in intervention development and testing.

Promoting Resilience in Stress Management for Adolescents With Type 1 Diabetes: A Randomized Clinical Trial

Importance

Type 1 diabetes (T1D) requires demanding self-management health behaviors, and adolescents with T1D are at risk for poor psychosocial and medical outcomes. Developing resilience skills may help adolescents with T1D and elevated distress navigate common stressors and achieve positive outcomes.

Objective

To test the efficacy of the Promoting Resilience in Stress Management (PRISM) intervention on levels of hemoglobin A1c (HbA1c), diabetes distress, self-management behaviors, resilience, and quality of life among adolescents.

Design, Setting, and Participants

This phase 3, parallel, 1:1 randomized clinical trial that followed up 172 participants for 12 months was conducted from January 1, 2020, to November 30, 2022, at each of 2 children's hospitals, in Seattle, Washington, and Houston, Texas. Participants were ages 13 to 18 years with T1D for at least 12 months and elevated diabetes distress.

Intervention

PRISM, a manualized, skills-based, individual intervention program that teaches stress management, goal setting, reframing, and meaning-making, facilitated by a coach and accompanied by a digital app, was delivered in three 30- to 60-minute sessions approximately 2 weeks apart.

Main Outcomes and Measures

The 2 primary outcomes, diabetes distress and HbA1c levels, and 3 secondary outcomes, resilience, quality of life, and engagement in self-management behaviors, were assessed at baseline and 6 and 12 months after baseline. Linear mixed-effects regression models were used to evaluate associations between PRISM or usual care (UC) and these outcomes at both time points for the intention-to-treat population.

Results

Among 172 adolescents (mean [SD] age, 15.7 [1.6] years), 96 were female (56%), and their baseline mean (SD) HbA1c level was 8.7% (2.0%). No differences were evident between PRISM and UC recipients in HbA1c levels (β, -0.21 [95% CI, -0.65 to 0.22]; P = .33) or diabetes distress (β, -2.71 [95% CI, -6.31 to 0.90]; P = .14) or any participant-reported outcome (eg, β, 2.25 [95% CI, -0.30 to 4.80]; P = .08 for self-management behaviors) at 6 months. At 12 months, there was no statistically significant difference between arms in HbA1c levels (β, -0.26 [95% CI, -0.72 to 0.19]; P = .25); however, PRISM recipients reported significantly greater amelioration of diabetes distress (β, -4.59 [95% CI, -8.25 to -0.94]; P = .01) and improvement in self-management behaviors (β, 3.4 [95% CI, 0.9 to 5.9]; P = .01) compared with UC recipients.

Conclusions and Relevance

The findings in this randomized clinical trial of psychosocial and behavioral improvements associated with PRISM at 12 months illustrate the value of a strengths-based intervention. Integrating resilience skills-building with traditional diabetes care may be a promising approach for improving outcomes among adolescents with T1D and elevated diabetes distress.

Trial Registration

ClinicalTrials.gov number: NCT03847194.

Knowledge and prescribing behaviour of Flemish general practitioners regarding novel glucose-lowering medications: Online cross-sectional survey

AIMS

To determine the knowledge and prescribing behaviour regarding new type 2 diabetes medication in general practice. Physicians in Belgium are bound by the prescription criteria which do not always correspond to the international guidelines.

DESIGN & METHOD

A mixed methods study with an online questionnaire was conducted in Flanders to collect data on demographic characteristics, theoretical knowledge, and prescribing behaviour, using ten theoretical questions and six clinical cases, based on the American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) guidelines and the Belgian reimbursement criteria.

RESULTS

201 GPs and GPs in training were included in this study with a median age of 30 years and 68 % female participants. On the knowledge questionnaire, the mean test result was 7.15/15 (= 48 %) with a median of 8. Further analysis showed that 90 % of the respondents correctly recommended a sodium-glucose cotransporter 2 (sglt2) inhibitor when the clinical case showed a comorbidity of heart failure, whereas only 42 % suggested correctly a glucagon-like peptide 1 (GLP-1) agonist if presence of cardiovascular disease. Subgroup analysis showed no statistically significant demographic differences in obtained test results. Regarding prescription behaviour, 23 % of the respondents would prescribe medication that did not match the reimbursement criteria in at least one of the 6 proposed clinical cases.

CONCLUSION

This study highlights the need for enhanced knowledge and updated prescribing practices among Flemish GPs and Trainee GPs to effectively manage patients with T2DM.

Rationale and design of the KP ENRICH trial: A food is medicine intervention in low-income high-risk adults with diabetes within Kaiser Permanente

BACKGROUND

Food insecurity is associated with poor glycemic control and increased risk for diabetes-related complications. The clinical benefit of addressing these challenges through a medically supportive grocery prescription (GRx) program in patients with type 2 diabetes mellitus (T2D) remains unclear. We report the aims and design of a randomized clinical trial to evaluate the effectiveness of a 6-month GRx intervention on hemoglobin A1c (HbA1c) levels among low-income adults with T2D.

METHODS

The Kaiser Permanente Evaluating Nutritional Interventions in Food-Insecure High-Risk Adults (KP ENRICH) Study is a pragmatic randomized trial enrolling 1100 participants within Kaiser Permanente Northern California and Southern California, two integrated health care delivery systems serving >9 million members. Medicaid-insured adults with T2D and baseline HbA1c ≥7.5% will be randomized at a 1:1 ratio to either GRx, delivered as $100 per month for select items from among a curated list of healthful food groups in an online grocery ordering and home-delivery platform along with biweekly digital nutrition educational materials, or control, consisting of free membership and deliveries from the online grocery platform but without curated food groups or purchasing dollars. The primary outcome is 6-month change in HbA1c. Secondary outcomes include 12-month change in HbA1c, and 6- and 12-month change in medical resource utilization, food security, nutrition security, dietary habits, diabetes-related quality of life, and dietary self-efficacy.

CONCLUSIONS

The results of this large randomized clinical trial of GRx will help inform future policy and health system-based initiatives to improve food and nutrition security, disease management, and health equity among patients with T2D.

The association of depression and sleep disorders in patients with type 1 diabetes in Taiwan

The association between depression and sleep disorders in patients with type 1 diabetes mellitus (T1DM) in Taiwan is underexplored. We used a nationwide population-based dataset to evaluate the association of T1DM with these conditions in Taiwan from 2001 to 2019. Patients with T1DM were identified as cases, and 2 control groups were used for comparison: patients with type 2 diabetes mellitus (T2DM) and nondiabetic patients. Age, sex, date of diagnosis, and multiple comorbidities were included and matched using propensity score matching between cases and controls. The primary outcome of this study was to identify new occurrences of the first diagnosis of depression or sleep disorders. After matching, this study included 27,029 T1DM cases, 54,058 T2DM controls, and 108,116 nondiabetic controls. Patients with T1DM exhibited a 1.55-fold higher risk of developing depression (hazard ratio [HR] 1.55, 95% confidence intervals [CI] 1.48-1.61) and a 1.41-fold higher risk of experiencing sleep disorders (HR 1.41, 95% CI 1.37-1.46) compared to nondiabetic controls. Similarly, patients with T2DM displayed elevated risks of both depression (HR 1.39, 95% CI 1.34-1.43) and sleep disorders (HR 1.40, 95% CI 1.37-1.44) relative to non-diabetic controls. When comparing the T1DM and T2DM groups, T1DM patients demonstrated a slightly higher risk of depression (HR 1.11, 95% CI 1.07-1.16) but no significant difference in the risk of sleep disorders compared to T2DM patients. These results were consistent regardless of different ages or sexes. This study demonstrates a significant association between diabetes mellitus and the risk of depression and sleep disorders in a large cohort of Taiwanese patients.

Efficacy of Self-Review of Lifestyle Behaviors with Once-Weekly Glycated Albumin Measurement in People with Type 2 Diabetes: A Randomized Pilot Study

INTRODUCTION

Lifestyle management, including appropriate modifications of nutrition, exercise, and medication behaviors, is essential for optimal glycemic control. The absence of appropriate monitoring methods to validate the lifestyle change may hinder the modification and continuation of behaviors. In this study, we evaluated whether once-weekly glycated albumin (GA) measurement received via a smartphone application could improve glycemia management in patients with type 2 diabetes mellitus by supporting self-review and modification of lifestyle behaviors.

METHODS

This open-label, randomized controlled, single-center study in Japan with an 8-week intervention period was conducted in individuals with type 2 diabetes mellitus and HbA1c levels between 7.0 and 9.0% (53‒75 mmol/mol). The intervention was once-weekly home monitoring of GA with a daily self-review of lifestyle behaviors using a smartphone application, in addition to conventional treatment.

RESULTS

A total of 98 participants (72.0% males; age 63.2 ± 11.4 years; HbA1c 7.39 ± 0.39% [57.3 ± 4.3 mmol/mol]) were randomly assigned to the intervention or control group. Significant decreases of the GA and HbA1c levels from the baseline to the last observation day were observed in the intervention group (- 1.71 ± 1.37% [- 39.1 ± 31.3 mmol/mol] and - 0.32 ± 0.32% [- 3.5 ± 3.5 mmol/mol], respectively). Significant decreases of the body weight, waist circumference, and caloric expenditure (p < 0.0001 and p = 0.0003, p = 0.0346, respectively), but not of the caloric intake (p = 0.678), were also observed in the intervention group as compared with the control group.

CONCLUSIONS

Self-review of lifestyle behaviors in combination with once-weekly GA home testing received via a smartphone application might potentially benefit glycemic management in people with type 2 diabetes mellitus.

TRIAL REGISTRATION

jRCTs042220048.

Association between Diet Quality and Eating Behavior in Type 2 Diabetes Adults: A Cross-Sectional Study

Type 2 diabetes mellitus (T2DM) has become a global epidemic. To effectively control T2DM, individuals must adhere to a high-quality diet that encompasses not only healthy dietary patterns but also promotes positive eating behaviors. We conducted a cross-sectional study on 314 patients with T2DM, and we evaluated the diet quality and also examined the associations between eating behavior, diet quality, and anthropometric and clinical factors in T2DM patients. We used the Diet Quality Index-International and Dutch Eating Behavior Questionnaire to assess dietary characteristics. We found that women had a significantly higher diet quality than men (61.40 vs. 58.68, p = 0.002) but were also more prone to emotional eating (2.00 vs. 1.53, p < 0.001) and restrained eating (2.39 vs. 2.05, p = 0.002). Restrained eating correlated with duration of diabetes (r = -0.169, p = 0.003), body mass index (r = 0.182, p = 0.001), and external eating with glycated hemoglobin (r = 0.114, p = 0.044). Patients with emotional eating had a higher vitamin C adequacy score (β = 0.117, p = 0.045). External eating was positively associated with grain adequacy (β = 0.208, p < 0.001) and negatively associated with empty-calorie food moderation score (β = -0.125, p = 0.032). For restrained eating, we found associations with vitamin C adequacy (β = -0.138, p = 0.017) and fruit adequacy (β = 0.125, p = 0.033). In conclusion, the results of this study provide valuable insight into dietary behavior and emphasize the importance of promoting healthy eating habits for T2DM patients.

Assessing the feasibility and acceptability of a diabetes-specific nurse-led multicomponent smoking cessation intervention in diabetes education: study protocol for an open-label pragmatic randomised controlled trial

INTRODUCTION

Smoking cessation is an essential, but often overlooked aspect of diabetes management. Despite the need for tailored smoking cessation support for individuals with diabetes, evidence of effective interventions for this cohort is limited. Additionally, individuals with diabetes do not easily adopt such interventions, resulting in low uptake and abstinence rates. This protocol describes a study that aims to assess the feasibility and acceptability of a unique smoking cessation intervention, based on the best evidence, theory and the needs of individuals with diabetes, among patients and service providers, the diabetes nurse educators.

METHODS AND ANALYSIS

This is an open-label pragmatic randomised controlled trial. Between 80 and 100 individuals with type 1 or type 2 diabetes who smoke will be recruited from the diabetes outpatients at the main acute public hospital in Malta, starting in August 2023. Participants will be randomly assigned (1:1 ratio) to the intervention or control arm for 12 weeks. The experimental intervention will consist of three to four smoking cessation behavioural support sessions based on the 5As (Ask, Advise, Assess, Assist and Arrange) algorithm, and a 6-week supply of nicotine replacement therapy. The control intervention will consist of an active referral to the Maltese National Health Service's one-to-one smoking cessation support service, which is based on motivational interviewing. The primary feasibility and acceptability outcomes include the recruitment and participation rates, resources used, problems identified by the nurses, the nurses' perceived challenges and facilitators to implementation and the nurses' and patients' acceptability of the study intervention. Data analyses will be descriptive, with quantitative feasibility and acceptability outcomes reported with 95% confidence intervals.

ETHICS AND DISSEMINATION

Ethical clearance was obtained from the Faculty of Health Sciences Research Ethics Committee, University of Malta. The study results will be disseminated through conference presentations and a publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05920096.

The expert consensus on care and education for patients with diabetic kidney disease in Taiwan

Increasing prevalence of type 2 DM (T2DM) and diabetic kidney disease (DKD) has posed a great impact in Taiwan. However, guidelines focusing on multidisciplinary patient care and patient education remain scarce. By literature review and expert discussion, we propose a consensus on care and education for patients with DKD, including general principles, specifics for different stages of chronic kidney disease (CKD), and special populations. (i.e. young ages, patients with atherosclerotic cardiovascular disease or heart failure, patients after acute kidney injury, and kidney transplant recipients). Generally, we suggest performing multidisciplinary patient care and education in alignment with the government-led Diabetes Shared Care Network to improve the patients' outcomes for all patients with DKD. Also, close monitoring of renal function with early intervention, control of comorbidities in early stages of CKD, and nutrition adjustment in advanced CKD should be emphasized.

Type 2 Diabetes

Type 2 diabetes (T2D) is a prevalent disease that increases risk for vascular, renal, and neurologic complications. Prevention and treatment of T2D and its complications are paramount. Many advancements in T2D care have emerged over the past 5 years, including increased understanding of the importance of early intensive glycemic control, mental health, social determinants of health, healthy eating patterns, continuous glucose monitoring, and the benefits of some drugs for preventing cardiorenal disease. This review summarizes the evidence supporting T2D prevention and treatment, focusing on aspects that are commonly in the purview of primary care physicians.

Effects of Dietary Carbohydrate Concentration and Glycemic Index on Blood Glucose Variability and Free Fatty Acids in Individuals with Type 1 Diabetes

Monitoring glycemic control status is the cornerstone of diabetes management. This study aimed to reveal whether moderate-carbohydrate (CHO) diets increase the risk of free fatty acid (FFA) levels, and it presents the short-term effects of four different diet models on blood sugar, glycemic variability (GV), and FFA levels. This crossover study included 17 patients with type 1 diabetes mellitus to identify the effects of four diets with different CHO contents and glycemic index (GI) on GV and plasma FFA levels. Diet 1 (D1) contained 40% CHO with a low GI, diet 2 (D2) contained 40% CHO with a high GI, diet 3 (D3) contained 60% CHO with a low GI, and diet 4 (D4) contained 60% CHO with a high GI. Interventions were performed with sensor monitoring in four-day periods and completed in four weeks. No statistical difference was observed among the groups in terms of blood glucose area under the curve (p = 0.78), mean blood glucose levels (p = 0.28), GV (p = 0.59), and time in range (p = 0.567). FFA and total triglyceride levels were higher in the D1 group (p < 0.014 and p = 0.002, respectively). Different diets may increase the risk of cardiovascular diseases by affecting GI, FFA, and blood glucose levels.

People with type 1 diabetes exhibit lower exercise capacity compared to a control population with similar physical activity levels

AIMS

We aimed to assess physical activity (PA) levels, adherence to PA guidelines, and fitness capacity in individuals with type 1 diabetes (T1D) and control population.

METHODS

This cross-sectional study included 232 T1D and 248 controls. PA levels (IPAQ-SF questionnaire), adherence to guidelines (>150 min/week of moderate-to-vigorous PA), fitness capacity (VO2max, maximal incremental test on a cycle ergometer and 1RM test) were assessed, along with other clinical variables.

RESULTS

Total PA levels (T1D 2202 ± 1839 vs. controls 2357 ± 2189 METs/min/week), adherence (T1D 53.1 % vs controls 53.2 %), and sedentariness (T1D 27.3 % vs. controls 25.1 %) were similar between groups. However, participants with T1D exhibited significantly lower levels of VO2max (29.1 ± 10.5 vs. 32.5 ± 11.5 mlO2/kg/min, p < 0.001), work capacity (2.73 ± 1.03 vs. 3 ± 10 W/kg of body weight, p = 0.004) and strength capacity (2.29 ± 0.53 vs. 2.41 ± 0.79 kg/kg body weight in 1RM, p = 0.01) than controls, after adjusting for sex and age.

CONCLUSIONS

Individuals with T1D exhibit lower fitness capacity compared to a control population, regardless of age and sex, even when presenting similar levels of total physical activity and adherence to guidelines.