Reversing Type 2 Diabetes: A Narrative Review of the Evidence

The Diabetes Remission in India (DiRemI) study: Protocol for a prospective matched-control trial

BACKGROUND

The global rise in diabetes, particularly in India, poses a significant public health challenge, with factors such as limited awareness, financial strain, and cultural considerations hindering its effective management. Although lifestyle changes have shown promising results, their consistent implementation and maintenance continue to pose challenges. Most studies have focused primarily on dietary modifications, overlooking other essential aspects of lifestyle intervention. The DiRemI study aims to address these gaps by evaluating the efficacy of a comprehensive one-year program that combines diet, exercise, psychological support, and medical management to achieve weight loss, diabetes remission, and improved glycemic control among patients with type 2 diabetes (T2D) in India, while also considering the unique needs of the Indian population.

METHODS

The DiRemI study is a prospective, open-label, matched-group trial aimed at assessing the impact of a one-year online integrated intensive lifestyle intervention (ILI) comprising dietary modifications, physical activity, psychological support, and medical management on weight loss and remission in adult T2D patients (aged 30-70 years), with a body mass index (BMI) between 25 and 35 kg/m2, and disease duration of <15 years. ILI will be compared with routine medical care (RMC). Participants will be recruited from three clinics: one providing ILI and two others providing RMC. The co-primary outcome will be weight loss and remission at 12 months, with a follow-up at 18 months. The proposed sample size is 360 participants (180 each in intervention and control group).

DISCUSSION

The DiRemI study represents the first large-scale remission study in India to show the effectiveness of an integrated approach in the remission and management of T2D and its complications. The findings of this study hold the potential to report evidence-based strategies for managing T2D both in India and globally, thus alleviating the substantial burden of diabetes on public health systems.

TRIAL REGISTRATION

Clinical Trials Registry, India (Registered Number: CTRI/2023/06/053885).

Perspective of Continuous Glucose Monitoring-Based Interventions at the Various Stages of Type 2 Diabetes

Continuous glucose monitoring (CGM) is now advocated for the clinical management of individuals with type 1 diabetes (T1D). However, this glucose monitoring strategy is not routinely used in type 2 diabetes (T2D), given the large population, significant cost implications and relatively limited supporting evidence. T2D is a more heterogenous condition compared with T1D with various glucose lowering therapies that do not necessarily require CGM to ensure within target glucose levels. While all individuals with T2D may benefit from CGM at certain time points, the whole T2D population does not necessarily require this technology continuously, which should be prioritized based on patient benefit and cost effectiveness. In this pragmatic opinion piece, we describe the rationale and evidence for CGM use in different subgroups of individuals with T2d, divided according to the stage of the condition, glycemic therapies, presence of diabetes complications, or associated co-morbidities. We discuss a total of 16 T2D subgroups and provide a clinical view on CGM use in each, based on current evidence while also highlighting areas of knowledge gaps. This work provides health care professionals with a simple guide to CGM use in different T2D groups and gives suggestion for future studies to justify expansion of this technology.

Response to lowering plasma glucose is characterised by decreased oxyntomodulin: Results from a randomised controlled trial

BACKGROUND

With the prevalence of diabetes reaching an epidemic level, there is a growing interest in the investigation of its remission. Proglucagon-derived peptides (PGDP) have been shown to have a glucose-regulating effect. However, whether they play a role in diabetes remission remains poorly understood.

AIM

To investigate changes in plasma levels of PGDP in glycaemic responders versus non-responders.

METHODS

The study was a randomised placebo-controlled trial comprising 18 adults with prediabetes (registered at www.

CLINICALTRIALS

gov as NCT03889210). Following an overnight fast, participants consumed ketone β-hydroxybutyrate (KEβHB)-supplemented beverage and placebo beverage in crossover manner. Serial blood samples were collected from baseline to 150 min at 30-min intervals. The endpoints were changes in glucagon-like peptide-1 (GLP-1), glicentin, oxyntomodulin, glucagon, and major proglucagon fragment (MPGF). Participants were stratified into the 'responders' and 'non-responders' subgroups based on their glycaemic changes following the ingestion of KEβHB. The area under the curve (AUC) was calculated to estimate the accumulated changes in the studied PGDP and compared using paired-t test between the KEβHB and placebo beverages.

RESULTS

Responders had a significantly greater reduction in plasma glucose compared with non-responders following acute ketosis (p < 0.001). The AUC0-150 for oxyntomodulin was significantly lower following the KEβHB beverage compared with the placebo (p = 0.045) in responders, but not in non-responders (p = 0.512). No significant differences in AUCs0-150 were found for GLP-1, glicentin, glucagon, and MPGF in either responders or non-responders.

CONCLUSION

Oxyntomodulin is involved in lowering plasma glucose and may play an important role in diabetes remission.

Obesity management for the treatment of type 2 diabetes: emerging evidence and therapeutic approaches

Excess adiposity can contribute to metabolic complications, such as type 2 diabetes mellitus (T2DM), which poses a significant global health burden. Traditionally viewed as a chronic and irreversible condition, T2DM management has evolved and new approaches emphasizing reversal and remission are emerging. Bariatric surgery demonstrates significant improvements in body weight and glucose homeostasis. However, its complexity limits widespread implementation as a population-wide intervention. The identification of glucagon-like peptide 1 (GLP-1) and the development of GLP-1 receptor agonists (GLP-1RAs) have improved T2DM management and offer promising outcomes in terms of weight loss. Innovative treatment approaches combining GLP-1RA with other gut and pancreatic-derived hormone receptor agonists, such as glucose-dependant insulinotropic peptide (GIP) and glucagon (GCG) receptor agonists, or coadministered with amylin analogues, are demonstrating enhanced efficacy in both weight loss and glycemic control. This review aims to explore the benefits of bariatric surgery and emerging pharmacological therapies such as GLP-1RAs, and dual and triple agonists in managing obesity and T2DM while highlighting the caveats and evolving landscape of treatment options.

Does type 2 diabetes duration influence the effectiveness of an aerobic exercise intervention: Results from the INTENSITY study

BACKGROUND

Studies suggest that longer durations of T2DM increase the risk of T2DM complications and premature mortality. However, whether T2DM duration impacts the efficacy of an aerobic exercise intervention is unclear.

OBJECTIVE

The purpose of this study was: 1) to compare changes in body composition, cardiorespiratory fitness, and glycemia between individuals with short- and long-duration T2DM after aerobic exercise and 2) to determine whether these changes were associated with changes in glycemia by T2DM duration.

METHODS

A secondary analysis of the INTENSITY study (NCT03787836), including thirty-four adults (≥19 years) with T2DM who participated in 28 weeks of aerobic exercise training for 150 minutes per week at a moderate-to-vigorous intensity (4.5 to 6.0 metabolic equivalents (METs)). Using pre-established cut-points, participants were categorized into two groups 1) short-duration T2DM (<5 years) or 2) long-duration T2DM (≥5 years). Glycemia was measured by glycated hemoglobin (HbA1c), body composition by BodPod, and cardiorespiratory fitness by a measure of peak oxygen consumption (VO2peak). All measurements were performed at baseline, 16 weeks, and 28 weeks.

RESULTS

Participants in the short-duration T2DM group experienced decreases in fat mass (kg) (p = 0.03), HbA1c (p = 0.05), and an increased relative VO2peak (p = 0.01). Those with long-duration T2DM experienced decreases in fat mass (kg) (p = 0.02) and HbA1c (p <0.001) and increased fat-free mass (p = 0.02). No significant differences were observed between groups in any outcomes. Changes in fat mass (r = 0.54, p = 0.02), and body fat percentage (r = 0.50, p = 0.02) were significantly associated with the change in HbA1c in those with a long-duration T2DM only.

CONCLUSION

Our results suggest T2DM duration did not differently impact the efficacy of a 28-week aerobic exercise intervention. However, changes in body composition were associated with better glycemia in individuals with longer T2DM duration only.

Effect of a two-only-meals-a-day and exercise lifestyle on HbA1c and anti-diabetic medication in a follow-up study of subjects with type 2 diabetes attending a free clinic in a north Maharashtra city

Background

Type 2 Diabetes (T2D) is a global challenge with rising prevalence, inadequate compliance, and poor outcomes.

Aims

Assess the effect of a 2-only-daily-meals with exercise lifestyle (2-OMEX) on (a) HbA1c, (b) anti-diabetic medication count (ADMC), (c) Kcal intakes, body weight, fasting insulin, and subjective well-being.

Materials and Methods

This is a single-arm follow-up study conducted in a free 2-OMEX clinic in 2019-2020. Information for two meals and exercise compliance was obtained during the clinic visit. HbA1c was tested by HPLC and fasting insulin by the CLIA/CMIA method in private laboratories.

Results

Eligible subjects (f = 49, m = 116) completing two or more visits and 60 days of follow-up had a mean age of 55.92 (10.43) years, a T2D duration of 8.20 (6.28) years, and a median observation period of 140 days. Statistically significant changes included HbA1c decline from 7.69 (1.70) to 7.00 (1.20) gm% (equivalent by the LogNormal method to 1.088 gm%), average weight loss at 5%(m), and 2%(f). ADMC declined from 2.32 to 2.14, the difference being significant with the WSR test (z = 2.0087, P = 0.0223). Subjects attaining anti-diabetic medication-free and normoglycemic status (HbA1c < 6.5 gm%) were 20 (12%). The number attaining HbA1c ≤ 7 gm%) significantly rose from 73 (44%) to 101 (61%) with an ADMC of 1.9 (chi-square = 9.531, df1, P = 0.0020203). Participants reported 'feeling energetic' (79%), feeling lighter (50%), and better sleep (35%). Average energy intakes dropped by 120 Kcal to 1580/day. Fasting insulin remained unchanged, from 12.61 (11.06) to 12.34 (11.78) mlU/L. The dropout rate was 35%.

Conclusions

The 2-OMEX lifestyle showed a sizeable, favorable, and significant change in HbA1c, body weight, ADMC use in five months, and subjective benefits. Studies are necessary for remission impact and pathways.

Optimizing Diabetes Management Using a Low-Calorie Diet in Saudi Arabia: A Cost-Benefit Analysis

BACKGROUND

Low-calorie diets, high in protein and low in carbohydrates, are commonly recommended for patients with pre-diabetes and type 2 diabetes. The objective of this study was to carry out a cost-benefit analysis (CBA) of a low-calorie versus a standard diet from the perspective of the Saudi Arabian health system.

METHODS

The CBA compares costs and benefits of the two diet strategies over a 1-year time horizon. Costs included diet and diabetes treatment-related resources while benefits were measured in terms of the costs of diabetes complications avoided. Data on costs and benefits were collected from published literature and subject matter experts. Incremental costs were estimated as the cost difference between low-calorie and standard diet. Incremental benefits were estimated as cost difference from medical complications when following a low-calorie or standard diet. The incremental absolute cost-benefit ratio was calculated to show the difference between the costs and benefits of the low-calorie diet. Incremental relative cost-benefit ratio was calculated to show the cost per dollar of benefit obtained. Monte Carlo simulation modeled variability in outcomes due to variation in costs and uncertainty of diabetes complications.

RESULTS

The 1 year cost of standard diet was US$2515 ± 156 compared to US$2469 ± 107 per patient for a low-calorie diet. Incremental benefit is estimated at US$21,438 ± 7367 per patient. The estimated incremental absolute cost-benefit ratio was US$ - 21,360 establishing that benefits are greater than costs, while the estimated incremental relative cost-benefit ratio is 0.0037, establishing that benefits are 270 times greater than costs.

CONCLUSION

The low-calorie diet was the dominant strategy compared to the standard diet in modeled scenarios. These findings highlight the importance of a low-calorie diet as part of diabetes management programs for outpatients with type 2 diabetes.

'Super Rehab': can we achieve coronary artery disease regression? A feasibility study protocol

INTRODUCTION

Patients diagnosed with coronary artery disease (CAD) are currently treated with medications and lifestyle advice to reduce the likelihood of disease progression and risk of future major adverse cardiovascular events (MACE). Where obstructive disease is diagnosed, revascularisation may be considered to treat refractory symptoms. However, many patients with coexistent cardiovascular risk factors, particularly those with metabolic syndrome (MetS), remain at heightened risk of future MACE despite current management.Cardiac rehabilitation is offered to patients post-revascularisation, however, there is no definitive evidence demonstrating its benefit in a primary prevention setting. We propose that an intensive lifestyle intervention (Super Rehab, SR) incorporating high-intensity exercise, diet and behavioural change techniques may improve symptoms, outcomes, and enable CAD regression.This study aims to examine the feasibility of delivering a multicentre randomised controlled trial (RCT) testing SR for patients with CAD, in a primary prevention setting.

METHODS AND ANALYSIS

This is a multicentre randomised controlled feasibility study of SR versus usual care in patients with CAD. The study aims to recruit 50 participants aged 18-75 across two centres. Feasibility will be assessed against rates of recruitment, retention and, in the intervention arm, attendance and adherence to SR. Qualitative interviews will explore trial experiences of study participants and practitioners. Variance of change in CAD across both arms of the study (assessed with serial CT coronary angiography) will inform the design and power of a future, multi-centre RCT.

ETHICS AND DISSEMINATION

Ethics approval was granted by South West-Frenchay Research Ethics Committee (reference: 21/SW/0153, 18 January 2022). Study findings will be disseminated via presentations to relevant stakeholders, national and international conferences and open-access peer-reviewed research publications.

TRIAL REGISTRATION NUMBER

ISRCTN14603929.

Dietary Intakes of Choline and Betaine and Incidence of Type 2 Diabetes: Tehran Lipid and Glucose Study

Background: Our knowledge for the possible link between choline and betaine and the risk of type 2 diabetes (T2D) is very limited and contradictory. This study aimed to investigate the prospective association of dietary choline and betaine intakes with the risk of T2D in a group of Tehranian adults. Methods: In this prospective study, 6022 eligible subjects aged ≥18 years were chosen from the participants of the Tehran Lipid and Glucose Study in a secondary analysis. Diet was assessed based on a valid and reliable semiquantitative food frequency questionnaire. At baseline and follow-up examinations, biochemical and anthropometric variables were assessed. Multivariable Cox proportional hazard regression models was used to estimate the new onset of T2D concerning choline and betaine intake. Results: The mean age ± SD of 2707 men and 3315 women were, respectively, 41.4 ± 14.2 and 39.1 ± 13.1. During a median follow-up of 6.63 years, 528 cases of T2D incidence were diagnosed. Participants with a higher intake of choline had a higher intake of protein, fiber, and B12 and a lower intake of energy and carbohydrates. After controlling of confounders a significant positive association was observed between choline intake and the hazard ratio (HR) of T2D across quartiles of choline intake [HR (CI) in the fourth quartile: 1.25 (1.14-1.38), P trend = 0.01], but this significant finding was not reported for betaine intake. For every 100 milligram increase in choline consumption, the HR of T2D increased significantly in all age, sex, and BMI subgroups. Conclusions: Choline consumption increased the risk of T2D in total population and subgroups. No statistically significant association was found between dietary betaine intake and the risk of T2D in total population and subgroups.

Effects of a low carbohydrate diet on heart failure symptoms and quality of life in patients with diabetic cardiomyopathy: A randomised controlled trial pilot study

BACKGROUND AND AIMS

Heart failure, insulin resistance and/or type 2 diabetes mellitus coexist in the syndrome that is diabetic cardiomyopathy. Patients with diabetic cardiomyopathy experience high symptom burden and poor quality of life. We tested the hypothesis that a low carbohydrate diet improves heart failure symptoms and quality of life in patients with diabetic cardiomyopathy.

METHODS AND RESULTS

We conducted a 16-week randomised controlled pilot trial comparing the effects of a low carbohydrate diet (LC) to usual care (UC) in 17 adult patients with diabetic cardiomyopathy. New York Heart Association classification, weight, thirst distress and quality of life scores as well as blood pressure and biochemical data were assessed at baseline and at 16 weeks. Thirteen (n = 8 LC; n = 5 UC) patients completed the trial. The low carbohydrate diet induced significant weight loss in completers (p = 0.004). There was a large between-group difference in systolic blood pressure at the end of the study (Hedges's g 0.99[-014,2.08]). There were no significant differences in thirst or quality of life between groups.

CONCLUSION

This is the first clinical trial utilising the low carbohydrate dietary approach in patients with diabetic cardiomyopathy in an outpatient setting. A low carbohydrate diet can lead to significant weight loss in patients with diabetic cardiomyopathy. Future clinical trials with larger samples and that focus on fluid and sodium requirements of patients with diabetic cardiomyopathy who engage in a low carbohydrate diet are warranted.

CLINICAL TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trial Registry (ANZCTR): ACTRN12620001278921.

DATE OF REGISTRATION

26th November 2020.

Use of herbal medicines for the management of type 2 diabetes: A systematic review of qualitative studies

BACKGROUND

Many people with Type 2 Diabetes Mellitus (T2DM) use herbal medicines, some of which can improve glycaemic control. Providing evidence-based advice on herbal medicines could be an effective intervention to improve control of diabetes, if it is designed to address key needs and concerns of T2DM patients.

AIM

To understand the views and experiences of patients and health professionals on herbal treatments for self-management of T2DM.

METHOD

MEDLINE, EMBASE, CINAHL, SOCIOFILE and Google Scholar were searched for qualitative studies in T2DM patients about their views on herbal medicines. Included papers were analysed using thematic synthesis.

RESULTS

Thirty-one papers (about 30 studies) were included: 20 from low-and-middle income countries, 10 from high income countries, and 1 internet-based study. Almost all studies from high income countries focussed on ethnic minorities. Many people with T2DM wanted a "cure", and often took advice from friends and family, but also traditional healers and mass media. However, they were reluctant to discuss herbal medicines with health professionals, whom they perceived as "closed-minded". They based their treatment decisions on personal experience (from "trial-and-error"), availability, cost and convenience of both herbal and conventional medicines. Most health professionals were reluctant to discuss herbal medicines, or recommended against their use, because of lack of knowledge and concerns about their quality, efficacy and potential interactions.

CONCLUSION

Evidence-based information could help to overcome the current lack of communication about herbal medicines between people with T2DM and health professionals.

Remission effect of Canagliflozin in patients with newly diagnosed type 2 diabetes mellitus: a protocol for a multicenter, parallel-group, randomized, controlled, open-label trial

BACKGROUND

Studies reporting the effects of metabolic surgery, lifestyle intervention, and intensive insulin therapy for the remission of type 2 diabetes (T2DM) has been increasing, with fruitful results better conducted and yielded. However, there are only a few studies on the remission of T2DM using oral hypoglycemic drugs. Therefore, this study aims to investigate the remission effect of canagliflozin and metformin on participants with newly diagnosed T2DM and its possible underlying mechanism(s) through which these two medications elicit diabetes remission.

METHOD

To this end, we performed a multicenter, parallel-group, randomized, controlled, and open-label trial. A total of 184 participants with a ≤ 3-year course of T2DM will be enrolled and randomly assigned to the canagliflozin or metformin treatment group in a ratio of 1:1. Participants in each group will maintain their medication for 3 months after achieving the target blood glucose level and then stop it. These participants will be followed up for one year to determine remission rates in both groups.

DISCUSSION

In this study, we will establish that whether canagliflozin is superior to metformin in terms of remission rate in participants with newly diagnosed T2DM. The results of this trial may provide robust evidence regarding the efficacy and mechanisms of the action of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in T2DM remission.

TRIAL REGISTRATION

ChiCTR2100043770(February 28, 2021).

Acute Glycemic Control in Prediabetes Individuals Favorably Alters Serum NLRP3 Inflammasome and Related Interleukins

Hyperglycemia associated with prediabetes (PD) alters NLRP3 inflammasome activity and related interleukins, yet no study has evaluated the expression of the NLRP3 inflammasome complex and related interleukins in individuals with a PD condition that did or did not develop type 2 diabetes mellitus (T2DM). This study investigated the effect of 6 months of lifestyle modification on the expression of the NLRP3 inflammasome and related interleukins (1α, 1β, 18, 33 and 37) in the sera of individuals with a PD condition that did or did not develop T2DM. This interventional study included 67 Saudi adults (mean age = 41.9 ± 8.0 years, mean BMI = 33.2 ± 5.5 kg/m2). Overnight-fasting serum samples were collected at baseline and at the 6-month follow-up. Serum levels of NLRP3, capsase-1 and related ILs were analyzed at both visits using commercially available immunoassay kits. Results showed that IL-1α increased in the PD group that developed T2DM (p = 0.046), IL-33 decreased in the PD group that reverted to normal (p < 0.001) and NLRP3 decreased in the PD group that remained PD (p = 0.01). Results also showed a positive over-time correlation between NLRP3 and both IL-1α and IL-33 (p < 0.001 and p = 0.028, respectively). In conclusion, glycemic control favorably altered NLRP3 inflammasome complex activity, and lifestyle modification in PD individuals is crucial in reversing harmful metabolic and inflammatory phenotypes.

The burden of type 2 diabetes mellitus in states of the European Union and United Kingdom at the national and subnational levels: A systematic review

Type 2 diabetes mellitus (T2D) is a highly prevalent disease worldwide, with an equally increased expenditure associated with it. We aimed to longitudinally evaluate the epidemiologic and economic burden of T2D in the current member states of the European Union and the United Kingdom (EU-28). The present systematic review is registered on PROSPERO (CRD42020219894), and it followed the PRISMA guidelines. Eligibility criteria comprised original observational studies in English reporting economic and epidemiological data for T2D in member states of the EU-28. Methodological assessment was performed with the Joanna Briggs Institute (JBI) Critical Appraisal Tools. The search retrieved 2253 titles and abstracts. After study selection, 41 studies were included in the epidemiologic analysis and 25 in the economic analysis. Economic and epidemiologic studies covered only 15 member states with reported data between 1970 and 2017, resulting in an incomplete picture. For children in particular, limited information is available. The prevalence, incidence, mortality, and expenditure of the T2D population have increased across the decades in member states. Therefore, policies should aim to prevent or reduce the burden of T2D in the EU and consequently mitigate the expenditure on T2D.

Therapeutic Carbohydrate Restriction as a Metabolic Modality for the Prevention and Treatment of Abnormal Uterine Bleeding

Therapeutic carbohydrate restriction diets have been becoming increasingly popular over the years, resulting in dramatic weight loss and an improvement in metabolic disorders. Obesity, insulin resistance, and diabetes are the risk factors for many gynecologic morbidities such as uterine leiomyoma, endometrial polyps, and polycystic ovarian syndrome. There is evidence suggesting that the pathogenesis of cardiovascular disease is similar to that seen in many causes of abnormal uterine bleeding. We aim to explain how cardiovascular disease risk factor reduction with the use of therapeutic carbohydrate restriction may prevent and potentially treat these gynecologic disorders.

Effect of an Intermittent Calorie-restricted Diet on Type 2 Diabetes Remission: A Randomized Controlled Trial

CONTEXT

The 2021 consensus report on the definition and interpretation of remission of type 2 diabetes (T2D) has been released. Although intermittent fasting diets (IF) are becoming very popular, no studies have investigated their benefit in diabetes remission.

OBJECTIVE

The present study examined the effectiveness of IF in diabetes remission and potential remission durability.

METHODS

Participants between ages 38 and 72 years with a duration of T2D of 1 to 11 years, a body mass index (BMI) of 19.1 to 30.4, 66.7% male, and antidiabetic agent use and/or insulin injection were randomly allocated at a ratio of 1:1 to the Chinese Medical Nutrition Therapy (CMNT) or control group. The primary outcome was diabetes remission, defined as a stable glycated hemoglobin A1c (HbA1c) level of less than 48 mmol/mol (< 6.5%) for at least 3 months after discontinuing all antidiabetic medications. The secondary outcomes included HbA1c level, fasting blood glucose level, blood pressure, weight, quality of life, and medication costs. We conducted a 12-month follow-up to assess the continuation of remission.

RESULTS

On completing the 3-month intervention plus 3-month follow-up, 47.2% (17/36) of participants achieved diabetes remission in the CMNT group, whereas only 2.8% (1/36) of individuals achieved remission in the control group (odds ratio 31.32; 95% CI, 2.39-121.07; P < 0.0001). The mean body weight of participants in the CMNT group was reduced by 5.93 kg (SD 2.47) compared to 0.27 kg (1.43) in the control group. After the 12-month follow-up, 44.4% (16/36) of the participants achieved sustained remission, with an HbA1c level of 6.33% (SD 0.87). The medication costs of the CMNT group were 77.22% lower than those of the control group (60.4/month vs 265.1/month).

CONCLUSION

This study demonstrated the clinical efficacy of CMNT in achieving diabetes remission for at least 1 year.

Automated Diet Capture Using Voice Alerts and Speech Recognition on Smartphones: Pilot Usability and Acceptability Study

BACKGROUND

Effective monitoring of dietary habits is critical for promoting healthy lifestyles and preventing or delaying the onset and progression of diet-related diseases, such as type 2 diabetes. Recent advances in speech recognition technologies and natural language processing present new possibilities for automated diet capture; however, further exploration is necessary to assess the usability and acceptability of such technologies for diet logging.

OBJECTIVE

This study explores the usability and acceptability of speech recognition technologies and natural language processing for automated diet logging.

METHODS

We designed and developed base2Diet-an iOS smartphone application that prompts users to log their food intake using voice or text. To compare the effectiveness of the 2 diet logging modes, we conducted a 28-day pilot study with 2 arms and 2 phases. A total of 18 participants were included in the study, with 9 participants in each arm (text: n=9, voice: n=9). During phase I of the study, all 18 participants received reminders for breakfast, lunch, and dinner at preselected times. At the beginning of phase II, all participants were given the option to choose 3 times during the day to receive 3 times daily reminders to log their food intake for the remainder of the phase, with the ability to modify the selected times at any point before the end of the study.

RESULTS

The total number of distinct diet logging events per participant was 1.7 times higher in the voice arm than in the text arm (P=.03, unpaired t test). Similarly, the total number of active days per participant was 1.5 times higher in the voice arm than in the text arm (P=.04, unpaired t test). Furthermore, the text arm had a higher attrition rate than the voice arm, with only 1 participant dropping out of the study in the voice arm, while 5 participants dropped out in the text arm.

CONCLUSIONS

The results of this pilot study demonstrate the potential of voice technologies in automated diet capturing using smartphones. Our findings suggest that voice-based diet logging is more effective and better received by users compared to traditional text-based methods, underscoring the need for further research in this area. These insights carry significant implications for the development of more effective and accessible tools for monitoring dietary habits and promoting healthy lifestyle choices.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42022300875).

Remission with an Intervention: Is Metabolic Surgery the Ultimate Solution?

Long-term remission of type 2 diabetes following lifestyle intervention or pharmacotherapy, even in patients with mild disease, is rare. Long-term remission following metabolic surgery however, is common and occurs in 23% to 98% depending on disease severity and type of surgery. Remission after surgery is associated with excellent glycemic control without reliance on pharmacotherapy, improvements in quality of life, and major reductions in microvascular and macrovascular complications. For patients with type 2 diabetes, early intervention with metabolic surgery, when beta cell function still remains intact, provides the greatest probability of long-term remission as high as 90% or more.

Metabolic Improvements and Remission of Prediabetes and Type 2 Diabetes: Results From a Multidomain Lifestyle Intervention Clinic

OBJECTIVES

Although lifestyle interventions are first-line treatment for individuals living with prediabetes and type 2 diabetes (T2D), they are rarely implemented effectively in routine clinical care.

METHODS

We present a retrospective analysis of a 12-month, single-centre, structured multidomain lifestyle intervention clinic offered to individuals living with prediabetes and type 2 diabetes. The intervention consisted of expert-guided educational and nutritional counselling combined with a personalized physical exercise prescription, with the main goal of improving metabolic health and reaching remission. Anthropometric parameters, glucose, basal insulin, glycated hemoglobin (A1C), and lipid levels were measured at baseline and at 3, 6, and 12 months after the lifestyle intervention initiation. Remission of prediabetes and T2D were defined as a return of A1C at 6 months to <6.5% (or <5.7% for prediabetes) and persisting for at least 3 months in the absence of glucose-lowering pharmacotherapy.

RESULTS

After a multidomain, expert-guided lifestyle intervention, 117 individuals living with prediabetes and T2D had significantly improved metabolic profiles: Mean weight change at 12 months was -4.9 kg (95% confidence interval [CI], -4.0 to -5.7; p<0.001), and mean change in A1C at 12 months was -0.6% (95% CI, -0.4 to -0.7; p<0.001). A substantial proportion of individuals reached the criteria for remission (20% among participants with prediabetes and 12% among those with T2D).

CONCLUSIONS

The results of this study suggest that prioritizing lifestyle changes in a multifaceted, progressive, 12-month intervention in this population improves anthropometric and insulin resistance measures, and has the potential to normalize metabolic values, even to the point of reaching the criteria of remission.

Metabolic surgery versus usual care effects on diabetes remission: a systematic review and meta-analysis

BACKGROUND

Bariatric surgery is superior to usual care for diabetes remission. Previous meta-analyses were limited by pooling observational and randomized trials, using various definitions of diabetes remission, and not controlling for various diabetes medications. The current meta-analysis aimed to compare bariatric surgery and usual care regarding the same.

METHODS

We searched PubMed MEDLINE, Web of Science, SCOPUS, and Cochrane Library for relevant articles from the date of the first inception up to February 2023. The keywords diabetes remission, Bariatric surgery, metabolic surgery, lifestyles, usual care, GLIP-1 agonists, insulin use, gastric banding, biliopancreatic diversion, sleeve gastrectomy, and Roux-en-Y gastric bypass, were used. A datasheet was used to extract the relevant data.

RESULTS

Diabetes remission (complete and prolonged) was higher among bariatric surgeries compared to usual care, odd ratio, 0.06, 95 CI, 0.02-0.25 and 0.12, 95 CI, 0.02-0.72, respectively. bariatric surgery patients were younger, had higher HbA1c, odd ratio, - 3.13, 95 CI, - 3.71 to 2.54, and 0.25, 95 CI, 0.02-0.48, respectively, insulin use was higher, and glucagon-like peptide agonists use was lower among bariatric surgery patients, odd ratio, 0.49, 95% CI, 0.24-0.97, and 3.06, 95% CI, 1.44-6.53, respectively.

CONCLUSION

Bariatric surgery was better than usual care in diabetes remission. Bariatric surgery patients were younger, had higher HbA1c, and received more insulin and lower GLP-1 agonists. No differences were evident regarding body mass index and the duration of diabetes. Further trials comparing the new anti-diabetic medications and different forms of bariatric surgery and controlling for the level of exercise and diet are recommended.

Effective Handling of Missing Values in Datasets for Classification Using Machine Learning Methods

The existence of missing values reduces the amount of knowledge learned by the machine learning models in the training stage thus affecting the classification accuracy negatively. To address this challenge, we introduce the use of Support Vector Machine (SVM) regression for imputing the missing values. Additionally, we propose a two-level classification process to reduce the number of false classifications. Our evaluation of the proposed method was conducted using the PIMA Indian dataset for diabetes classification. We compared the performance of five different machine learning models: Naive Bayes (NB), Support Vector Machine (SVM), k-Nearest Neighbours (KNN), Random Forest (RF), and Linear Regression (LR). The results of our experiments show that the SVM classifier achieved the highest accuracy of 94.89%. The RF classifier had the highest precision (98.80%) and the SVM classifier had the highest recall (85.48%). The NB model had the highest F1-Score (95.59%). Our proposed method provides a promising solution for detecting diabetes at an early stage by addressing the issue of missing values in the dataset. Our results show that the use of SVM regression and a two-level classification process can notably improve the performance of machine learning models for diabetes classification. This work provides a valuable contribution to the field of diabetes research and highlights the importance of addressing missing values in machine learning applications.

Time-restricted eating did not alter insulin sensitivity or β-cell function in adults with obesity: A randomized pilot study

OBJECTIVE

Decreased insulin sensitivity and impairment of β-cell function predate and predict development of type 2 diabetes mellitus. Time-restricted eating (TRE) might have a benefit for these parameters. The objective of this pilot study was to investigate this possibility.

METHODS

Secondary analysis of a randomized controlled trial comparing 12 weeks of TRE (8-hour eating window) to unrestricted eating (non-TRE) was performed. Participants were adults with overweight or obesity and without diabetes. Two-hour oral glucose tolerance testing was performed at baseline and end-intervention. Glucose tolerance test-derived measures of insulin sensitivity, insulin secretion, and β-cell function were compared between groups.

RESULTS

Participants (17 women/3 men with mean [SD] age 45.5 [12.1] years and BMI 34.1 [7.5] kg/m2 ) with a prolonged eating window (15.4 [0.9] hours) were randomized to TRE (n = 11) or non-TRE (n = 9). The quantitative insulin sensitivity check index (QUICKI), Stumvoll index, Avignon index, insulinogenic index, insulin area under the curve/glucose area under the curve, and oral disposition index did not differ between the TRE and non-TRE groups at end-intervention.

CONCLUSIONS

In adults with overweight or obesity and without diabetes, TRE did not significantly alter insulin sensitivity, insulin secretion, or β-cell function over a 12-week intervention. Whether TRE is beneficial in adults with prediabetes or type 2 diabetes mellitus warrants further investigation.

A personalized multi-interventional approach focusing on customized nutrition, progressive fitness, and lifestyle modification resulted in the reduction of HbA1c, fasting blood sugar and weight in type 2 diabetes: a retrospective study

BACKGROUND

Type 2 diabetes (T2D) is a chronic, progressive lifestyle disease and the most rapidly growing health challenge of the twenty-first century. The American Diabetes Association recommends that T2D reversal can be achieved through an organized, and systematic approach focusing on nutrition, fitness, and lifestyle management.

AIM

This study aimed to evaluate the effectiveness of a comprehensive and multi-interventional diabetes care program called Sugar. Fit Diabetes Reversal Programme (SDRP) on glycosylated haemoglobin (HbA1c), fasting blood sugar (FBS), and body weight for T2D reversal.

METHODOLOGY

SDRP is a personalized intervention study that uses technology-enabled medical management, dedicated coach-led diabetes, and nutrition experts. The study involved 150 patients living with type 2 diabetes in the age group of 20 to 80 years and having HbA1c of > 6.5%. In SDRP, the participants were assigned personal medical doctors specializing in diabetes, along with health coaches for providing customized nutrition, personalized fitness routines, relevant lifestyle modifications to holistically reverse type 2 diabetes. The HbA1c level, fasting blood sugar, and weight of the participants were measured at baseline and the end of the study (90th day). The effectiveness of SDRP was analyzed by comparing it with a control group that involved 110 individuals with type 2 diabetes managed by conventional pharmacotherapy and regular dietary advice but not participating in the SDRP.

RESULTS

All 150 participants adhered to the program for 90 days. The analysis was performed on participants and represented as mean ± standard deviation (mean ± SD). At the end of SDRP, a significant reduction in HbA1c level, FBS, and weight was observed as compared to the control group. The results showed that Hba1c levels dropped from 9.0 ± 1.5% to 7.1 ± 1.3% with a mean change of 1.9 ± 1.5%; FBS levels decreased from 178.3 ± 57.1 mg/dL to 116.1 ± 24.2 mg/dL with a mean loss of 62.2 ± 51.8 mg/dL, and the weight decreased from 76.7 ± 12.7 kg to 73.8 ± 11.8 kg with a mean weight loss of 2.8 ± 1.6 kg. The results also showed that participants between 20 to 35 years showed the highest drop in HbA1c, FBS, and weight.

CONCLUSION

The findings indicate that a comprehensive and multi-interventional diabetes care program involving personalized nutrition, fitness, and lifestyle modification such as SDRP, help in significant and sustained improvements in HbA1c level, glycaemic control, and weight loss in adults with type 2 diabetes.

Low-Carbohydrate High-Fat Diet: A SWOC Analysis

Insulin resistance (IR) plays a role in the pathogenesis of many diseases, such as type 2 diabetes mellitus, cardiovascular disease, non-alcoholic fatty liver disease, obesity, and neurodegenerative diseases, including Alzheimer's disease. The ketogenic diet (KD) is a low-carbohydrate/high-fat diet that arose in the 1920s as an effective treatment for seizure control. Since then, the KD has been studied as a therapeutic approach for various IR-related disorders with successful results. To date, the use of the KD is still debatable regarding its safety. Some studies have acknowledged its usefulness, while others do not recommend its long-term implementation. In this review, we applied a SWOC (Strengths, Weaknesses, Opportunities, and Challenges) analysis that revealed the positive, constructive strengths of the KD, its potential complications, different conditions that can make used for it, and the challenges faced by both physicians and subjects throughout a KD. This SWOC analysis showed that the KD works on the pathophysiological mechanism of IR-related disorders such as chronic inflammation, oxidative stress and mitochondrial stress. Furthermore, the implementation of the KD as a potential adjuvant therapy for many diseases, including cancer, neurodegenerative disorders, polycystic ovary syndrome, and pain management was proven. On the other hand, the short and long-term possible undesirable KD-related effects, including nutritional deficiencies, growth retardation and nephrolithiasis, should be considered and strictly monitored. Conclusively, this review provides a context for decision-makers, physicians, researchers, and the general population to focus on this dietary intervention in preventing and treating diseases. Moreover, it draws the attention of scientists and physicians towards the opportunities and challenges associated with the KD that requires attention before KD initiation.

'Daily 2-only meals and exercise' lifestyle modification for remission of type 2 diabetes mellitus: A therapeutic approach

This case series has documented five patients diagnosed with type 2 diabetes (T2D), referred to the various Diabetes Reversal Centers of the 'World free of obesity and diabetes' campaign in Maharashtra, India. It demonstrates the therapeutic effects of lifestyle modification for remission of diabetes along with weight reduction and reversal of insulin resistance. This resulted in reduction of their glycated haemoglobin level, which signified the long-term effects of this lifestyle modification. Diabetes reversal by lifestyle modification is a healthier option and must be encouraged in all the patients in the pre-diabetes group (HbA1c- 5.7-6.4%) and those with newly diagnosed type 2 diabetes mellitus (HbA1c- >6.5%) without any complications, thus promoting good health seeking behaviour. There are pieces of evidence of complete diabetes reversal of the patients with HbA1c ranging from 8 to 15% by just lifestyle modification and also without any complications among the patients registered under the 'World free of obesity and diabetes' campaign. India is a low-middle-income country with prevalence of T2D on rise. It is thus necessary to provide the community with a cost-effective and sustainable solution for primary and secondary prevention of this lifestyle disease.

Investigating the experiences of low-carbohydrate diets for people living with Type 2 Diabetes: A thematic analysis

Low-Carbohydrate Diets (LCDs) are becoming increasingly popular to manage Type 2 diabetes mellitus (T2DM). However, there is a need to identify people with T2DM’s understanding of LCDs, their reasons for engaging in such a diet, how they sustain it and any challenges they face. This study aimed to assess the experience of adhering to a LCD within a sample of individuals with T2DM. Ten participants with T2DM were recruited using a self-selecting sampling method from an online diabetes community that promotes LCDs. Participants completed one-to-one digitally recorded semi-structured interviews, which were later transcribed verbatim and data subjected to Thematic Analysis. Five core themes and twelve subthemes were developed during the analysis: (1) Lack of professional guidance; (2) Fear of complications & long-term medication use; (3) Dietary control as motivation; (4) Positive health outcomes; and (5) Social support. The findings are discussed with reference to a psychological model of behaviour, COM-B. Participants reported gaining knowledge and skills to increase their Capability to engage in LCDs, Motivation to manage diabetes outcomes influenced adherence. However, challenges were reported with the Opportunity to engage in behaviour, mainly influenced by social support. Health professionals and significant others may benefit from resources to help build knowledge and understanding and assist with maintaining a LCD long-term.

Optimal control for the complication of Type 2 diabetes: the role of awareness programs by media and treatment

T2 diabetes is a silent killer and serious public health issue across the world, though awareness of diabetes allows understanding of the causes and prevention of the disease. With this inspiration, we formulate a deterministic model by incorporating awareness and saturated treatment function of the T2 diabetes model to study the dynamics of the disease. We have carried out thoroughly analysis of the model system, including positivity of solutions, boundedness, equilibrium, and stability analysis. Again, we consider the deterministic model system as an optimal control problem by taking awareness (M) and treatment (u) as time-depended control parameters. The sufficient conditions for optimal control for T2 diabetes are obtained utilizing the Pontryagin’s maximum principle in time-dependent controls to find optimal strategies for disease control. We intended to assess the efficacy and costs of several strategies to determine which is the best cost-effective strategy with the limited resources for treatment. The parameters incident rate (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\beta $$\end{document}β), awareness coefficient (p), media (M), and treatment (u) highly influence the dynamics of T2 diabetes. Numerical simulations suggest that both awareness and treatment controls have a significant impact on the optimal system and are economically feasible to reduce the prevalence of T2 diabetes.

Reversal and Remission of T2DM - An Update for Practitioners

Over the past 50 years, many countries around the world have faced an unchecked pandemic of obesity and type 2 diabetes (T2DM). As best practice treatment of T2DM has done very little to check its growth, the pandemic of diabesity now threatens to make health-care systems economically more difficult for governments and individuals to manage within their budgets. The conventional view has been that T2DM is irreversible and progressive. However, in 2016, the World Health Organization (WHO) global report on diabetes added for the first time a section on diabetes reversal and acknowledged that it could be achieved through a number of therapeutic approaches. Many studies indicate that diabetes reversal, and possibly even long-term remission, is achievable, belying the conventional view. However, T2DM reversal is not yet a standardized area of practice and some questions remain about long-term outcomes. Diabetes reversal through diet is not articulated or discussed as a first-line target (or even goal) of treatment by any internationally recognized guidelines, which are mostly silent on the topic beyond encouraging lifestyle interventions in general. This review paper examines all the sustainable, practical, and scalable approaches to T2DM reversal, highlighting the evidence base, and serves as an interim update for practitioners looking to fill the practical knowledge gap on this topic in conventional diabetes guidelines.

Diabetes reversal: Update on current knowledge and proposal of prediction score parameters for diabetes remission

BACKGROUND AND AIM

The field of diabetes reversal is continuously evolving. Strategies for implementing diabetes care towards diabetes reversal are still being worked out. We aim to analyse data from available literature to ascertain factors allowing patient centric dietary approach to achieve diabetes reversal in clinical practice.

METHODS

In this exploratory review, an update on current knowledge is presented to delineate factors driving diabetes remission in an individual based on major studies in the field. This knowledge is then applied to subtypes of type 2 diabetes to optimise dietary approach for reversal of diabetes.

RESULTS AND CONCLUSION

Shorter duration of diabetes, lesser number of medicines needed to achieve euglycemia and 15 kg weight loss are common factors favouring diabetes remission in all major studies. A patient centric approach to diabetes reversal taking into account the recently described diabetes subtypes is being proposed to improve the proportion of patients achieving remission. We also propose the parameters of a novel diabetes remission prediction score, based on patient motivation, interaction with the care-team, level of diabetes self-care and the intent of the care-team.

Genetically-Guided Medical Nutrition Therapy in Type 2 Diabetes Mellitus and Pre-diabetes: A Series of n-of-1 Superiority Trials

Type 2 diabetes mellitus (T2DM) is a heterogeneous metabolic disorder of multifactorial etiology that includes genetic and dietary influences. By addressing the latter, medical nutrition therapy (MNT) contributes to the management of T2DM or pre-diabetes toward achieving glycaemic control and improved insulin sensitivity. However, the clinical outcomes of MNT vary and may further benefit from personalized nutritional plans that take into consideration genetic variations associated with individual responses to macronutrients. The aim of the present series of n-of-1 trials was to assess the effects of genetically-guided vs. conventional MNT on patients with pre-diabetes or T2DM. A quasi-experimental, cross-over design was adopted in three Caucasian adult men with either diagnosis. Complete diet, bioclinical and anthropometric assessment was performed and a conventional MNT, based on the clinical practice guidelines was applied for 8 weeks. After a week of “wash-out,” a precision MNT was prescribed for an additional 8-week period, based on the genetic characteristics of each patient. Outcomes of interest included changes in body weight (BW), fasting plasma glucose (FPG), and blood pressure (BP). Collectively, the trials indicated improvements in BW, FPG, BP, and glycosylated hemoglobin (HbA1c) following the genetically-guided precision MNT intervention. Moreover, both patients with pre-diabetes experienced remission of the condition. We conclude that improved BW loss and glycemic control can be achieved in patients with pre-diabetes/T2DM, by coupling MNT to their genetic makeup, guiding optimal diet, macronutrient composition, exercise and oral nutrient supplementation in a personalized manner.

Emerging Glycation-Based Therapeutics-Glyoxalase 1 Inducers and Glyoxalase 1 Inhibitors

The abnormal accumulation of methylglyoxal (MG) leading to increased glycation of protein and DNA has emerged as an important metabolic stress, dicarbonyl stress, linked to aging, and disease. Increased MG glycation produces inactivation and misfolding of proteins, cell dysfunction, activation of the unfolded protein response, and related low-grade inflammation. Glycation of DNA and the spliceosome contribute to an antiproliferative and apoptotic response of high, cytotoxic levels of MG. Glyoxalase 1 (Glo1) of the glyoxalase system has a major role in the metabolism of MG. Small molecule inducers of Glo1, Glo1 inducers, have been developed to alleviate dicarbonyl stress as a prospective treatment for the prevention and early-stage reversal of type 2 diabetes and prevention of vascular complications of diabetes. The first clinical trial with the Glo1 inducer, trans-resveratrol and hesperetin combination (tRES-HESP)-a randomized, double-blind, placebo-controlled crossover phase 2A study for correction of insulin resistance in overweight and obese subjects, was completed successfully. tRES-HESP corrected insulin resistance, improved dysglycemia, and low-grade inflammation. Cell permeable Glo1 inhibitor prodrugs have been developed to induce severe dicarbonyl stress as a prospective treatment for cancer-particularly for high Glo1 expressing-related multidrug-resistant tumors. The prototype Glo1 inhibitor is prodrug S-p-bromobenzylglutathione cyclopentyl diester (BBGD). It has antitumor activity in vitro and in tumor-bearing mice in vivo. In the National Cancer Institute human tumor cell line screen, BBGD was most active against the glioblastoma SNB-19 cell line. Recently, potent antitumor activity was found in glioblastoma multiforme tumor-bearing mice. High Glo1 expression is a negative survival factor in chemotherapy of breast cancer where adjunct therapy with a Glo1 inhibitor may improve treatment outcomes. BBGD has not yet been evaluated clinically. Glycation by MG now appears to be a pathogenic process that may be pharmacologically manipulated for therapeutic outcomes of potentially important clinical impact.

Polycystic Ovary Syndrome: An Evolutionary Adaptation to Lifestyle and the Environment

Polycystic ovary syndrome (PCOS) is increasingly recognized as a complex metabolic disorder that manifests in genetically susceptible women following a range of negative exposures to nutritional and environmental factors related to contemporary lifestyle. The hypothesis that PCOS phenotypes are derived from a mismatch between ancient genetic survival mechanisms and modern lifestyle practices is supported by a diversity of research findings. The proposed evolutionary model of the pathogenesis of PCOS incorporates evidence related to evolutionary theory, genetic studies, in utero developmental epigenetic programming, transgenerational inheritance, metabolic features including insulin resistance, obesity and the apparent paradox of lean phenotypes, reproductive effects and subfertility, the impact of the microbiome and dysbiosis, endocrine-disrupting chemical exposure, and the influence of lifestyle factors such as poor-quality diet and physical inactivity. Based on these premises, the diverse lines of research are synthesized into a composite evolutionary model of the pathogenesis of PCOS. It is hoped that this model will assist clinicians and patients to understand the importance of lifestyle interventions in the prevention and management of PCOS and provide a conceptual framework for future research. It is appreciated that this theory represents a synthesis of the current evidence and that it is expected to evolve and change over time.

A comparative study of the effect of two procedures of classic Roux-en-Y and omega bariatric surgery on the control and management of diabetes

Background:

Patient management after bariatric surgery is important in controlling patients’ diabetes and recurrence prevention. This study aimed to meet the medical managements of patients with diabetes 6 months after the bariatric surgery.

Materials and Methods:

This cross-sectional study was performed on 77 type 2 diabetes patients’ candidates for bariatric surgery (Roux-en-Y [RYGP] and Omega). Postoperative implementation protocol was one-third of insulin for patients taking long-term insulin and the discontinuation of medications for patients of oral antidiabetic agents. Blood glucose (BG) level was checked regularly by the patients at home and the necessary medical management was applied. The weight, BG and HbA1C levels, and use of oral antidiabetic agents and insulin were assessed and recorded before 1, 3, and 6 months after the surgery.

Results:

BG levels and HbA1C percentage in the 1^st, 3^rd, and 6^th months after the intervention in Omega group were significantly lower than RYGB group (P value < 0.05). At 1 and 3 months after surgery, the mean insulin dose received by the Omega and RYGB groups was reduced to <30 units/day and 10 units/day, respectively, following the management protocol in this study. Moreover, 23.1% and 7.7% of patients in RYGB group and 12.1% and 3% of patients in Omega group took oral antidiabetic agents 1and 3 months after surgery, respectively. Insulin and oral antidiabetic agents were completely discontinued 6 months after the surgery.

Conclusion:

The long-term management and support of the patients by the implementation of a standard protocol after surgery are of great significance in obtaining the optimal outcome after bariatric surgery.

Optimal Type 2 Diabetes Mellitus Management and Active Ageing

Type two diabetes mellitus (T2DM) represents a chronic condition with increasing prevalence worldwide among the older population. The T2DM condition increases the risk of micro and macrovascular complications as well as the risk of geriatric syndromes such as falls, fractures and cognitive impairment. The management of T2DM in the older population represents a challenge for the clinician, and a Comprehensive Geriatric Assessment should always be prioritized, in order to tailor the glycated hemoglobin target according to functional and cognitive status comorbidities, life expectancy and type of therapy. According to the most recent guidelines, older adults with T2DM should be categorized into three groups: healthy patients with good functional status, patients with complications and reduced functionality and patients at the end of life; for each group the target for glycemic control is different, also according to the type of treatment drug. The therapeutic approach should always begin with lifestyle changes; after that, several lines of therapy are available, with different mechanisms of action and potential effects other than glucose level reduction. Particular interest is growing in sodium-glucose cotransporter-2 inhibitors, due to their effect on the cardiovascular system. In this review, we evaluate the therapeutic options available for the treatment of older diabetic patients, to ensure a correct treatment approach.

The association of dietary macronutrients composition with the incidence of type 2 diabetes, using iso-energetic substitution models: Tehran Lipid and Glucose Study

AIMS

There is still controversy on optimal percentage of macronutrient intakes especially carbohydrate on prevention of type 2 diabetes (T2D). The aim of the current study was to evaluate the iso-energetic substitution of dietary macronutrients in relation to incidence of T2D.

METHODS

This prospective study was conducted on 6547 subjects who were followed for 3.0 ± 1.6 years. Dietary intakes were evaluated using a valid and reliable semi-quantitative food frequency questionnaire. Biochemical variables and anthropometrics were evaluated at baseline and follow-up examinations. Multivariate Cox proportional hazard regression models were used to estimate the hazards ratio (HR) of T2D.

RESULTS

A one unit higher proportion of carbohydrate from whole grain at the expense of carbohydrate from non-whole grain (HR = 0.82, 95% CI = 0.71-0.95), protein (HR = 0.75, 95% CI = 0.60-0.94), total fat (HR = 0.79, 95% CI = 0.67-0.93), saturated fatty acid (HR = 0.79, 95% CI = 0.65-0.96), poly-unsaturated fatty acid (HR = 0.81, 95% CI = 0.68-0.96) and mono-unsaturated fatty acid (HR = 0.75, 95% CI = 0.60-0.94) was associated with decreased risk of T2D. The substitution of protein and fats was not associated with diabetes. Risk of T2D increased from quartiles 1-4 for trans-fatty acid (HR: 1.00, 1.27, 0.95, 1.97, P_trend = 0.01).

CONCLUSIONS

A higher proportion of carbohydrate from whole grain in replacement of refined grain, and other macronutrients was associated with decreased risk of T2D. Also our study suggests a positive association between trans-fatty acid intake and risk of T2D.

Type 2 diabetes reversal with digital twin technology-enabled precision nutrition and staging of reversal: a retrospective cohort study

Background

Type 2 diabetes reversal has been viewed in the literature primarily as a dichotomous event (reversed or not reversed), even though this viewpoint may not be optimal for clinicians or patients. This cohort study’s objectives were to define stages of type 2 diabetes reversal and measure changes in reversal stages before and after 90 days of digital twin-enabled precision nutrition therapy.

Methods

This study defines seven stages of diabetes reversal. The study is a retrospective pre/post comparison of changes in reversal stage, hemoglobin A1c (HbA1c), weight, body mass index (BMI), and other metrics measured before and after precision nutrition therapy. Reversal stages were defined as Stage 0: HbA1c < 5.7% without medication for > 1 year, Stage 1: HbA1c < 5.7% without medication for < 1 year, Stage 2: HbA1c < 6.5% without medication, Stage 3: estimated HbA1c (eA1c) between 5.7 and 6.4% without medication, Stage 4: estimated HbA1c (eA1c) between 5.7 and 6.4% with metformin monotherapy, Stage 5: dual oral therapy, Stage 6: > = 3 medications.

Results

Reversal stage information was available for 463 patients at baseline and 90 days. At baseline, the proportions of patients in each reversal stage were Stages 1 and 2: 0%, Stage 3: 1%, Stage 4: 8%, Stage 5: 6%, and Stage 6: 85%. After 90 days, the proportions in each reversal stage were Stage 1: 2%, Stage 2: 9%, Stage 3: 32%, Stage 4: 39%, Stage 5: 7%, and Stage 6: 11%, indicating significant progress. Reversal stage progression rates varied by patient subgroup.

Conclusions

Type 2 diabetes patients reached differing reversal stages during 90 days of precision nutrition therapy. Use of reversal stages may benefit patients during therapy.

Trial registration

This was a retrospective study that was approved by the Medisys Clinisearch Ethical Review Board (without registration number) in 2019.

Quantifying Remission Probability in Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) is a chronic progressive disorder and is associated with significant morbidity and mortality. The concept of T2DM remission and the reversal of diabetic parameters to normal levels has been gaining momentum over the past years. T2DM remission is increasingly being recognized by various global guidelines. Multiple models have been developed and validated for quantifying the extent of remission achieved. Based on favorable clinical evidence, T2DM remission can be considered as the therapeutic goal in diabetes management and, in select cases, as an alternative to expensive treatment options, which can be burdensome as T2DM progresses. This narrative review discusses the available strategies, such as lifestyle interventions, physical activity, bariatric surgery, medical nutrition therapy, and non-insulin glucose-lowering medications, for achieving T2DM remission. Although the concept of T2DM remission has emerged as a real-world option, effective implementation in routine clinical practice may not be feasible until long-term studies prove the efficacy of different approaches in this regard.

Energy-restricted interventions are effective for the remission of newly diagnosed type 2 diabetes: A systematic review of the evidence base

BACKGROUND

Type 2 diabetes (T2D) is a chronic, progressive disease. Caloric restriction and subsequent weight loss have been associated with both improvements and, in some cases, remission of T2D.

AIM

To systematically review the safety and effectiveness of calorie-restricted diets on weight change and the remission of T2D.

METHODS

Electronic databases were searched. Intervention trials including a calorie restriction, published between 2010 and 2020, evaluating the remission of T2D (HbA1c <6.5% without diabetes medication) were selected. Risk of bias was assessed.

RESULTS

Eight trials met inclusion criteria including four randomized controlled and four single-arm trials. Three controlled trials found greater remission in the calorie-restricted arm (p < 0.05). A recent diagnosis of diabetes was associated with higher remission rates (75%-80%) with an inverse association between duration of diabetes and rate of remission (r = -0.94). A higher level of remission was observed with greater calorie restriction in non-new diagnosis studies. Greater weight loss was associated with increasing rates of remission (r = 0.83). No reported adverse events led to withdrawal from trials. There was great heterogeneity in study design.

CONCLUSION

Remission rate of T2D achieved through calorie restriction is high and similar to that reported in the bariatric surgery literature. Remission should be the aim at diagnosis and calorie restriction could be used to achieve this. The target weight loss should be >10% body weight in people with obesity. More research is needed into the optimum level of calorie restriction and the support required for long-term remission. National guidelines should be updated to reflect recent evidence.

On the causal relationships between hyperinsulinaemia, insulin resistance, obesity and dysglycaemia in type 2 diabetes

Hundreds of millions of people are affected by hyperinsulinaemia, insulin resistance, obesity and the dysglycaemia that mark a common progression from metabolic health to type 2 diabetes. Although the relative contribution of these features and the order in which they appear may differ between individuals, the common clustering and seemingly progressive nature of type 2 diabetes aetiology has guided research and clinical practice in this area for decades. At the same time, lively debate around the causal relationships between these features has continued, as new data from human trials and highly controlled animal studies are presented. This 'For debate' article was prompted by the review in Diabetologia by Esser, Utzschneider and Kahn ( https://doi.org/10.1007/s00125-020-05245-x ), with the purpose of reviewing established and emerging data that provide insight into the relative contributions of hyperinsulinaemia and impaired glucose-stimulated insulin secretion in progressive stages between health, obesity and diabetes. It is concluded that these beta cell defects are not mutually exclusive and that they are both important, but at different stages.

Effect of low carbohydrate diets on insulin resistance and the metabolic syndrome

PURPOSE OF REVIEW

This review outlines recent research in the application of low carbohydrate diets (LCD) for insulin resistance (IR) and metabolic syndrome (MetS).

RECENT FINDINGS

Studies included in this review explore how a LCD can be used in the management of patients with IR and MetS. LCDs have been shown to result in Type 2 Diabetes Mellitus (T2DM) remission, improve lipid profiles and dramatically reduce intrahepatic fat.

SUMMARY

The field of nutritional science is notoriously complex. The LCD has a simple narrative, which can easily and safely be applied in clinical practice. Current guidelines recognise and encourage the use of LCD as a valid option for patients with T2DM and obesity. Structured, evidence-based education should be available for all clinicians to increase confidence and ensure consistency and quality control. Further real-world evidence into the application and scalability of a LCD are required. The use of digital health solutions and improved health technology should see significant advances in this field, with dietary habit being driven by patient-derived health data in response to food, and not population-based food guidelines. The narrative around MetS and IR needs to change from progression to remission, with a LCD being a valid option for this.

Plasma N-glycome shows continuous deterioration as the diagnosis of insulin resistance approaches

INTRODUCTION

Prediction of type 2 diabetes mellitus (T2DM) and its preceding factors, such as insulin resistance (IR), is of great importance as it may allow delay or prevention of onset of the disease. Plasma protein N-glycome has emerged as a promising predictive biomarker. In a prospective longitudinal study, we included patients with a first diagnosis of impaired glucose metabolism (IR or T2DM) to investigate the N-glycosylation's predictive value years before diabetes development.

RESEARCH DESIGN AND METHODS

Plasma protein N-glycome was profiled by hydrophilic interaction ultra-performance liquid chromatography in 534 TwinsUK participants free from disease at baseline. This included 89 participants with incident diagnosis of IR or T2DM during the follow-up period (7.14±3.04 years) whose last sample prior to diagnosis was compared using general linear regression with 445 age-matched unrelated controls. Findings were replicated in an independent cohort. Changes in N-glycome have also been presented in connection with time to diagnosis.

RESULTS

Eight groups of plasma N-glycans were different between incident IR or T2DM cases and controls (p<0.05) after adjusting for multiple testing using Benjamini-Hochberg correction. These differences were noticeable up to 10 years prior to diagnosis and are changing continuously as becoming more expressed toward the diagnosis. The prediction model was built using significant glycan traits, displaying a discriminative performance with an area under the receiver operating characteristic curve of 0.77.

CONCLUSIONS

In addition to previous studies, we showed the diagnostic potential of plasma N-glycome in the prediction of both IR and T2DM development years before the clinical manifestation and indicated the continuous deterioration of N-glycome toward the diagnosis.

High-Expenditure Disease in the EU-28: Does Drug Spend Correspond to Clinical and Economic Burden in Oncology, Autoimmune Disease and Diabetes?

BACKGROUND

Drug costs are increasing in Europe, and there is a heightened need to reduce pressure on healthcare systems. In 2017, oncology, autoimmune disease, and diabetes featured as the three highest therapy areas for drug spend in the EU-28. However, the absolute 1-year drug spend growth for diabetes did not feature within the ten fastest growing therapy areas.

OBJECTIVE

This study explores the association between drug spend and disease burden in oncology, autoimmune disease, and diabetes in the EU-28.

METHODS

Oncology, autoimmune disease and diabetes therapeutic areas were investigated using four methodologies. Historical and forecasted drug spend was analysed using the IQVIA MIDAS® drug sales database. Clinical and economic burden was estimated from targeted literature reviews. Trend analyses compared changes in drug spend with clinical burden using the Global Burden of Disease tool as the epidemiological reference. Cost per quality-adjusted life-years (QALYs) from UK health technology assessments were compared to interpret the health economic value.

RESULTS

Oncology had the highest historical drug spend and growth compared with autoimmune disease and diabetes. Total drug spend and growth in oncology is forecasted to exceed diabetes by twofold. Increasing oncology drug spend historically did not correspond with reductions in mortality and morbidity. Diabetes had the lowest drug spend and greatest QALY/€1000 spent benefit.

CONCLUSION

This study indicates that drug spend may not correlate to clinical burden across diseases. Future research could stimulate debate on whether more equitable drug funding may improve disease management.

Effect of liraglutide treatment on body mass index and weight parameters in children and adolescents with type 2 diabetes: Post hoc analysis of the ellipse trial

BACKGROUND

Weight loss in children and adolescents with type 2 diabetes (T2D) is associated with improved glycaemic control.

OBJECTIVES

To assess the effects of liraglutide vs placebo on body mass index (BMI) and weight parameters in children and adolescents with T2D using data from the ellipse trial (NCT01541215).

METHODS

The ellipse trial randomized participants (10-<17 years old, BMI >85th percentile, T2D, glycated haemoglobin [HbA_1c ] 7.0%-11.0% [if diet- and exercise-treated] or 6.5% to 11.0% [if treated with metformin, basal insulin or both]) to liraglutide or placebo. This post-hoc analysis evaluated changes from baseline to weeks 26 and 52 in absolute BMI, percent change in BMI and other weight-related parameters. Changes were assessed by liraglutide overall (all doses) and liraglutide by dose (0.6, 1.2 and 1.8 mg/day) vs placebo using a pattern mixture model of observed data, with missing observations imputed from each treatment group.

RESULTS

In total, 134 participants were included. There were statistically significant differences between groups in certain parameters, including absolute BMI (estimated treatment difference [ETD] -0.89 kg/m² ; 95% confidence interval [CI] -1.71,-0.06) and percent change in BMI (ETD -2.73%; 95% CI -5.15,-0.30) at week 52, but none at week 26. Dose-dependent effects were not observed for liraglutide vs placebo for all BMI/weight parameters.

CONCLUSIONS

Compared with placebo, liraglutide was associated with statistically significant reductions in BMI/weight parameters at week 52, but not week 26, in children and adolescents with T2D.

Retrospective study of glycemic variability, BMI, and blood pressure in diabetes patients in the Digital Twin Precision Treatment Program

The objective of this retrospective observational cohort study was to measure glycemic variability and reductions in body mass index (BMI), blood pressure (BP), and use of antihypertensive medications in type 2 diabetes (T2D) patients participating in the digital twin-enabled Twin Precision Treatment (TPT) Program. Study participants included 19 females and 45 males with T2D who chose to participate in the TPT Program and adhered to program protocols. Nine additional enrollees were excluded due to major program non-adherence. Enrollees were required to have adequate hepatic and renal function, no myocardial infarction, stroke, or angina ≤ 90 days before enrollment, and no history of ketoacidosis or major psychiatric disorders. The TPT program uses Digital Twin technology, machine learning algorithms, and precision nutrition to aid treatment of patients with T2D. Each study participant had ≥ 3 months of follow-up. Outcome measures included glucose percentage coefficient of variation (%CV), low blood glucose index (LBGI), high blood glucose index (HBGI), systolic and diastolic BP, number of antihypertensive medications, and BMI. Sixty-four patients participated in the program. Mean (± standard deviation) %CV, LBGI, and HBGI values were low (17.34 ± 4.35, 1.37 ± 1.37, and 2.13 ± 2.79, respectively) throughout the 90-day program. BMI decreased from 29.23 ± 5.83 at baseline to 27.43 ± 5.25 kg/m². Systolic BP fell from 134.72 ± 17.73 to 124.58 ± 11.62 mm Hg. Diastolic BP decreased from 83.95 ± 10.20 to 80.33 ± 7.04 mm Hg. The percent of patients taking antihypertensive medications decreased from 35.9% at baseline to 4.7% at 90 days. During 90 days of the TPT Program, patients achieved low glycemic variability and significant reductions in BMI and BP. Antihypertensive medication use was eliminated in nearly all patients. Future research will focus on randomized case–control comparisons.

Low Carbohydrate Dietary Approaches for People With Type 2 Diabetes-A Narrative Review

Although carbohydrate restriction is not a new approach for the management of Type 2 diabetes, interest in its safety and efficacy has increased significantly in recent years. The purpose of the current narrative review is to summarise the key relevant research and practical considerations in this area, as well as to explore some of the common concerns expressed in relation to the use of such approaches. There is a strong physiological rationale supporting the role of carbohydrate restriction for the management of Type 2 diabetes, and available evidence suggests that low carbohydrate dietary approaches (LCDs) are as effective as, or superior to, other dietary approaches for its management. Importantly, LCDs appear to be more effective than other dietary approaches for facilitating a reduction in the requirement for certain medications, which leads to their effects on other health markers being underestimated. LCDs have also been demonstrated to be an effective method for achieving remission of Type 2 diabetes for some people. The available evidence does not support concerns that LCDs increase the risk of cardiovascular disease, that such approaches increase the risk of nutrient deficiencies, or that they are more difficult to adhere to than other dietary approaches. A growing number of organisations support the use of LCDs as a suitable choice for individuals with Type 2 diabetes.