The imperative to prevent diabetes complications: a broadening spectrum and an increasing burden despite improved outcomes

Preventing diabetes complications

The key aim of diabetes management is to prevent complications, which are a major cause of morbidity and mortality. At an individual level, people with diabetes are less likely than they were several decades ago to experience classical macrovascular and microvascular complications as a result of improvements in modifiable cardiovascular risk factors and preventive healthcare. However, a significant burden of diabetes complications persists at a population level because of the increasing incidence of diabetes, as well as longer lifetime exposure to diabetes because of younger diagnosis and increased life expectancy. Trials have shown that the most effective strategy for preventing complications of diabetes is a multifactorial approach focussing simultaneously on the management of diet, exercise, glucose levels, blood pressure and lipids. In addition to the cornerstone strategies of addressing diet, exercise and lifestyle measures, the introduction of newer glucose-lowering agents, including sodium-glucose transport protein 2 inhibitors and glucagon-like peptide-1 agonists, have brought about a paradigm shift in preventing the onset and progression of complications of type 2 diabetes, particularly cardiovascular and renal disease. The improvement in rates of classical complications of diabetes over time has been accompanied by a growing awareness of non-traditional complications, including non-alcoholic fatty liver disease. These emerging complications may not respond to a glycaemic-centred approach alone and highlight the importance of foundational strategies centred on lifestyle measures and supported by pharmaceutical therapy to achieve weight loss and reduce metabolic risk in patients living with diabetes.

Stress and human health in diabetes: A report from the 19th Chicago Biomedical Consortium symposium

Stress and diabetes coexist in a vicious cycle. Different types of stress lead to diabetes, while diabetes itself is a major life stressor. This was the focus of the Chicago Biomedical Consortium's 19th annual symposium, "Stress and Human Health: Diabetes," in November 2022. There, researchers primarily from the Chicago area met to explore how different sources of stress - from the cells to the community - impact diabetes outcomes. Presenters discussed the consequences of stress arising from mutant proteins, obesity, sleep disturbances, environmental pollutants, COVID-19, and racial and socioeconomic disparities. This symposium showcased the latest diabetes research and highlighted promising new treatment approaches for mitigating stress in diabetes.

Circulating soluble CD163 as a potential biomarker of diabetes complications

AIMS

To investigate whether soluble CD163 (sCD163) is altered in those with diabetes and various subtypes of complications and non-alcoholic fatty liver disease (NAFLD), and whether it can assess disease complications and severity in people with diabetes.

METHODS

Adults with diabetes (n = 101) were recruited and assessed for the presence of any complications (D^+Comps). Liver steatosis presence was determined by ultrasound and liver stiffness measurement (LSM) by transient elastography. Liver pathology other than non-alcoholic steatohepatitis (NASH) was excluded. Plasma sCD163 was measured by ELISA.

RESULTS

sCD163 was higher in D^+Comps (n = 59) compared to D^-comps (n = 42) in those with microvascular complications (n = 56; 1.3-fold), including a 1.4-fold increase in chronic kidney disease (CKD) (n = 42). sCD163 correlated positively with HbA_1c and urinary albumin-creatinine ratio and negatively with HDL-c in D^+Comps. sCD163 was increased 1.7-fold in those with advanced NASH fibrosis (LSM ≥ 10.3 kPa, n = 19) compared to those without (LSM < 10.3 kPa, n = 80). The AUC-ROC-curve was 0.64 for sCD163 to detect CKD and 0.74 to detect advanced NASH fibrosis.

CONCLUSIONS

In this study, the elevated circulating sCD163 occurred in people with diabetes who had microvascular complications or advanced NASH fibrosis, suggesting sCD163 may have clinical utility as a biomarker in certain diabetes complications and disease severity in NAFLD.

Referral Compliance Following a Diabetes Screening in a Dental Setting: A Scoping Review

With type 2 diabetes prevalence increasing in Australia, and the condition associated with significant morbidity and mortality, screening for dysglycaemia in the dental setting has been proposed to identify asymptomatic individuals. Screening commences with a risk assessment, and individuals identified at elevated risk for having diabetes are then referred to their medical practitioner for confirmation of their glycemic status. Therefore, for screening to be effective, individuals need to adhere to their oral health professionals’ (OHP) advice and attend their medical follow-ups. This review aims to investigate the literature on referral compliance following a risk assessment in the dental setting and identify barriers and facilitators to screened individuals’ referral compliance. A scoping review of the literature was undertaken, selecting studies of diabetes screening in a dental setting that recorded compliance to referral to follow-up, and explored any barriers and facilitators to adherence. Fourteen studies were selected. The referral compliance varied from 25 % to 90%. Six studies reported barriers and facilitators to attending medical follow-ups. Barriers identified included accessibility, cost, knowledge of the condition, and OHP characteristics.

Evaluation of the initial implementation of a nationwide diabetic retinopathy screening programme in primary care: a multimethod study

OBJECTIVES

The Australian Government funded a nationwide diabetic retinopathy screening programme to improve visual outcomes for people with diabetes. This study examined the benefits and barriers of the programme, image interpretation pathways and assessed the characteristics of people who had their fundus photos graded by a telereading service which was available as a part of the programme.

DESIGN

Multimethod: survey and retrospective review of referral forms.

SETTING

Twenty-two primary healthcare facilities from urban, regional, rural and remote areas of Australia, and one telereading service operated by a referral-only eye clinic in metropolitan Sydney, Australia.

PARTICIPANTS

Twenty-seven primary healthcare workers out of 110 contacted completed a survey, and 145 patient referrals were reviewed.

RESULTS

Manifest qualitative content analysis showed that primary healthcare workers reported that the benefits of the screening programme included improved patient outcomes and increased awareness and knowledge of diabetic retinopathy. Barriers related to staffing issues and limited referral pathways. Image grading was performed by a variety of primary healthcare workers, with one responder indicating the utilisation of a diabetic retinopathy reading service. Of the people with fundus photos graded by the reading service, 26.2% were reported to have diabetes. Overall, 12.3% of eyes were diagnosed with diabetic retinopathy. Photo quality was rated as excellent in 46.2% of photos. Referral to an optometrist for diabetic retinopathy was recommended in 4.1% of cases, and to an ophthalmologist in 6.9% of cases.

CONCLUSIONS

This nationwide diabetic retinopathy screening programme was perceived to increase access to diabetic retinopathy screening in regional, rural and remote areas of Australia. The telereading service has diagnosed diabetic retinopathy and other ocular pathologies in images it has received. Key barriers, such as access to ophthalmologists and optometrists, must be overcome to improve visual outcomes.

Metformin as an add-on to insulin improves periodontal response during orthodontic tooth movement in type 1 diabetic rats

BACKGROUND

Type 1 diabetes (T1D) is associated with delayed tissue healing and bone loss. Periodontal tissues during tooth movement (OTM) in T1D and under diabetic treatment are poorly understood. We aimed to study the effect of metformin as an add-on to insulin therapy on periodontal structures during OTM in T1D rats.

METHODS

Rats were divided into normoglycemic (NG, n = 20) and streptozotocin-induced diabetic groups that were untreated (T1D, n = 20), treated with insulin (I-T1D, n = 20), or treated with insulin plus metformin (IM-T1D, n = 20). After 7 days of treatment, the first right upper molar (M1) was moved mesially. At days 0, 3, 7 and 14, the pattern of OTM and the periodontal tissues were analyzed by micro-CT, histomorphometry, and immunohistochemistry for TRAP.

RESULTS

In T1D, major osteoclastogenic activity and bone loss versus other groups were confirmed by a greater TRAP-positive cell number and reabsorption surface on both the pressure and tension sides for 14 days (p < 0.01). Additionally, we observed low bone volume density. Metformin plus insulin resulted in a daily insulin dose reduction and major glycemic control versus I-T1D. Although no significant differences were observed between I-T1D and IM-T1D, the tooth displacement and inclination, periodontal ligament thickness, and alveolar bone density on the pressure side in IM-T1D were similar to that of NG (p > 0.05).

CONCLUSION

Antidiabetic treatment reduces severe periodontal damage during applied orthodontic force in T1D untreated rats. Metformin as an add-on to insulin therapy resulted in glycemic control and a periodontal tissue response to orthodontic forces that was similar to that of normoglycemic rats.

The Role of Negative Affect in the Assessment of Quality of Life among Women with Type 1 Diabetes Mellitus

BACKGROUND

The purpose of this study is to determine the impact of negative affect (defined in terms of lack of optimism, depressogenic attributional style, and hopelessness depression) on the quality of life of women with type 1 diabetes mellitus.

METHODS

Participants (n=177) completed either an online or paper questionnaire made available to members of Australian diabetes support groups. Measures of optimism, attributional style, hopelessness depression, disease-specific data, and diabetes-related quality of life were sought. Bivariate correlations informed the construction of a structural equation model.

RESULTS

Participants were 36.3±11.3 years old, with a disease duration of 18.4±11.2 years. Age and recent glycosylated hemoglobin readings were significant contextual variables in the model. All bivariate associations involving the components of negative affect were as hypothesized. That is, poorer quality of life was associated with a greater depressogenic attributional style, higher hopelessness depression, and lower optimism. The structural equation model demonstrated significant direct effects of depressogenic attributional style and hopelessness depression on quality of life, while (lack of) optimism contributed to quality of life indirectly by way of these variables.

CONCLUSION

The recognition of negative affect presentations among patients, and an understanding of its relevance to diabetes-related quality of life, is a valuable tool for the practitioner.

Regulation and bioactivity of the CCN family of genes and proteins in obesity and diabetes

Across the years the CCNs have been increasingly implicated in the development of obesity, diabetes and its complications. Evidence for this is currently derived from their dysregulation in key metabolic pathological states in humans, animal and in vitro models, and also pre-clinical effects of their bioactivities. CCN2 is the best studied in this disease process and the other CCNs are yet to be better defined. Key steps where CCNs may play a pathogenic metabolic role include: (i) obesity and insulin resistance, where CCN2 inhibits fat cell differentiation in vitro and CCN3 may induce obesity and insulin resistance; (ii) elevated blood glucose levels to diabetes mellitus onset, where CCN2 may contribute to pancreatic beta cell and islet function; and (iii) in diabetes complications, such as nephropathy, retinopathy, liver disease (NAFLD/NASH), CVD and diabetes with heart failure. In contrast, CCN1, CCN2 and possibly CCN3, may have a reparative role in wound healing in diabetes, and CCN2 in islet cell development. In terms of CCN2 regulation by a diabetes metabolic environment and related mechanisms, the author's laboratory and others have progressively shown that advanced glycation-end products, protein kinase C isoforms, saturated fatty acids, reactive oxygen species and haemodynamic factors upregulate CCN2 in relevant cell and animal systems. Recent data has suggested that CCN2, CCN3 and CCN6 may affect energy homeostasis including in regulating glycolysis and mitochondrial function. This paper will address the current data implicating CCNs in diabetes and its complications, focusing on recent aspects with translational clinical relevance and future directions.

Value-Based Payments and Incentives to Improve Care: A Case Study of Patients with Type 2 Diabetes in Medicare Advantage

OBJECTIVES

To estimate the impact of increased glycated hemoglobin (A1C) monitoring and treatment intensification for patients with type 2 diabetes (T2D) on quality measures and reimbursement within the Medicare Advantage Star (MA Star) program.

METHODS

The primary endpoint was the share of patients with T2D with adequate A1C control (A1C ≤ 9%). We conducted a simulation of how increased A1C monitoring and treatment intensification affected this end point using data from the National Health and Nutrition Examination Survey and clinical trials. Using the estimated changes in measured A_1C levels, we calculated corresponding changes in the plan-level A_1C quality measure, overall star rating, and reimbursement.

RESULTS

At baseline, 24.4% of patients with T2D in the average plan had poor A1C control. The share of plans receiving the highest A1C rating increased from 27% at baseline to 49.5% (increased monitoring), 36.2% (intensification), and 57.1% (joint implementation of both interventions). However, overall star ratings increased for only 3.6%, 1.3%, and 4.8% of plans, respectively, by intervention. Projected per-member per-year rebate increases under the MA Star program were $7.71 (monitoring), $2.66 (intensification), and $10.55 (joint implementation).

CONCLUSIONS

The simulation showed that increased monitoring and treatment intensification would improve A1C levels; however, the resulting average increases in reimbursement would be small.

The Research of Improved Grey GM (1, 1) Model to Predict the Postprandial Glucose in Type 2 Diabetes

Diabetes may result in some complications and increase the risk of many serious health problems. The purpose of clinical treatment is to carefully manage the blood glucose concentration. If the blood glucose concentration is predicted, treatments can be taken in advance to reduce the harm to patients. For this purpose, an improved grey GM (1, 1) model is applied to predict blood glucose with a small amount of data, and especially in terms of improved smoothness it can get higher prediction accuracy. The original data of blood glucose of type 2 diabetes is acquired by CGMS. Then the prediction model is established. Finally, 50 cases of blood glucose from the Henan Province People's Hospital are predicted in 5, 10, 15, 20, 25, and 30 minutes, respectively, in advance to verify the prediction model. The prediction result of blood glucose is evaluated by the EGA, MSE, and MAE. Particularly, the prediction results of postprandial blood glucose are presented and analyzed. The result shows that the improved grey GM (1, 1) model has excellent performance in postprandial blood glucose prediction.