Relationship Between Lipohypertrophy, Glycemic Control, and Insulin Dosing: A Systematic Meta-Analysis

Background: Lipohypertrophy is a common complication in patients with diabetes receiving insulin therapy. There is a lack of consensus regarding how much lipohypertrophy affects diabetes management. Our study aimed to assess the potential correlation between lipohypertrophy and glycemic control, as well as insulin dosing in patients with diabetes. Methods: We performed a systematic review followed by a meta-analysis to collect data about glycemic control and insulin dosing in diabetic patients with and without lipohypertrophy. To identify relevant studies published in English, we searched medical databases (MEDLINE/PubMed, Embase, and CENTRAL) from 1990 to January 20, 2023. An additional hand-search of references was performed to retrieve publications not indexed in medical databases. Results of meta-analyses were presented either as prevalence odds ratios (pORs) or mean differences (MDs) with 95% confidence intervals (95% CIs). This study was registered on PROSPERO (CRD42023393103). Results: Of the 5540 records and 240 full-text articles screened, 37 studies fulfilled the prespecified inclusion criteria. Performed meta-analyses showed that patients with lipohypertrophy compared with those without lipohypertrophy were more likely to experience unexplained hypoglycemia (pOR [95% CI] = 6.98 [3.30-14.77]), overall hypoglycemia (pOR [95% CI] = 6.65 [1.37-32.36]), and glycemic variability (pOR [95% CI] = 5.24 [2.68-10.23]). Patients with lipohypertrophy also had higher HbA1c (MD [95% CI] = 0.55 [0.23-0.87] %), and increased daily insulin consumption (MD [95% CI] = 7.68 IU [5.31-10.06]). Conclusions: These results suggest that overall glycemic control is worse in patients with lipohypertrophy than in those without this condition.

Shared genetic architecture between periodontal disease and type 2 diabetes: a large scale genome-wide cross-trait analysis

PURPOSE

To investigate the relationship between abnormal glucose metabolism, type 2 diabetes (T2D), and periodontal disease (PER) independent of Body Mass Index (BMI), we employed a genome-wide cross-trait approach to clarify the association.

METHODS

Our study utilized the most extensive genome-wide association studies conducted for populations of European ancestry, including PER, T2D, fasting glucose, fasting insulin, 2-hour glucose after an oral glucose challenge, HOMA-β, HOMA-IR (unadjusted or adjusted for BMI) and HbA1c.

RESULTS

With this approach, we were able to identify pleiotropic loci, establish expression-trait associations, and quantify global and local genetic correlations. There was a significant positive global genetic correlation between T2D (rg = 0.261, p = 2.65 × 10-13), HbA1c (rg = 0.182, p = 4.14 × 10-6) and PER, as well as for T2D independent of BMI (rg = 0.158, p = 2.34 × 10-6). A significant local genetic correlation was also observed between PER and glycemic traits or T2D. We also identified 62 independent pleiotropic loci that impact both PER and glycemic traits, including T2D. Nine significant pathways were identified between the shared genes between T2D, glycemic traits and PER. Genetically liability of HOMA-βadjBMI was causally associated with the risk of PER.

CONCLUSION

Our research has revealed a genetic link between T2D, glycemic traits, and PER that is influenced by biological pleiotropy. Notably, some of these links are not related to BMI. Our research highlights an underlying link between patients with T2D and PER, regardless of their BMI.

Dietary assessment of type 2 diabetic patients using healthful plant-based diet score in the Eastern Province of Saudi Arabia

BACKGROUND

Diabetes mellitus is a chronic disease characterized by a wide range of metabolic problems. The current study sought to assess nutritional habits of Saudi patients with type 2 diabetes (T2D) and to propose recommendations to improve these patients' dietary habits and delay possible disease complications.

METHODS

Over a period of three years, (2017-2019) 577 patients with T2D attending the outpatient's diabetic clinics at King Fahd Hospital of the University, Al Khobar, Saudi Arabia were invited to participate in this study. Data of dietary intake were collected by trained nurses using a pretested structured validated semi quantitative food frequency questionnaire. The dietary data were collected using 7-day dietary recall questionnaire. A modified score system that associates dietary habits with glycemic control and lipid profile was used.

RESULTS

Overall, a high healthful plant-based diet score was associated with a significant (P = 0.018) reduction in triglycerides (TG) level (mean difference - 3.78%; 95% CI, -0.65% to -6.81%) and a statistically non-significant (P = 0.06) increase in high density lipoprotein (HDL) levels (mean difference 1.87%; 95% CI -0.06-3.84%) in T2D patients from the Eastern Province of Saudi Arabia. Additionally, in our patient group, the prevalence of coronary artery disease, stroke, peripheral artery disease, and chronic kidney disease in T2D patients was 11.3%, 6.2%, 3.3%, and 8.4%, respectively and were higher when compared to the prevalence in the general population.

CONCLUSION

The present study showed that adherence to a healthful plant-based diet, when compared to high glycemic index diet, is associated with a favorable outcome in glycemic control and lipid profile in T2D patients. Prior assessment of total diet quality may be beneficial when giving nutritional advice to T2D patients with the possibility of improving glycemic control and lipid profile.

Predictors of lack of glycemic control in persons with type 2 diabetes

BACKGROUND

Professional guidelines recommend an HbA1c < 7% for most people with diabetes and < 8.5% for those with relaxed glycemic goals. However, many people with type 2 diabetes mellitus (T2DM) are unable to achieve the desired HbA1c goal. This study evaluated factors associated with lack of improvement in HbA1c over 3 years.

METHODS

All patients with T2DM treated within a major academic healthcare system during 2015-2020, who had at least one HbA1c value > 8.5% within 3 years from their last HbA1c were included in analysis. Patients were grouped as improved glycemic control (last HbA1c ≤ 8.5%) or lack of improvement (last HbA1c > 8.5%). Multivariate logistic regression analysis was performed to assess independent predictors of lack of improvement in glycemic control.

RESULTS

Out of 2,232 patients who met the inclusion criteria, 1,383 had an improvement in HbA1c while 849 did not. In the fully adjusted model, independent predictors of lack of improvement included: younger age (odds ratio, 0.89 per 1-SD [12 years]; 95% CI, 0.79-1.00), female gender (1.30, 1.08-1.56), presence of hypertension (1.29, 1.08-1.55), belonging to Black race (1.32, 1.04-1.68, White as reference), living in low income area (1.86,1.28-2.68, high income area as reference), and insurance coverage other than Medicare (1.32, 1.05-1.66). Presence of current smoking was associated with a paradoxical improvement in HbA1c (0.69, 0.47-0.99). In a subgroup analysis, comparing those with all subsequent HbA1c values > 8.5% (N = 444) to those with all subsequent HbA1c values < 8.5% (N = 341), similar factors were associated with lack of improvement, but smoking was no longer significant.

CONCLUSION

We conclude that socioeconomic factors like race, type of insurance coverage and living in low-income areas are associated with lack of improvement in HbA1c over a period of 3-years in people with T2DM. Intervention strategies focused on low-income neighborhoods need to be designed to improve diabetes management.

Influence of Anaerobic Exercise in Type 1 Diabetes Mellitus Biomarkers: A Systematic Review

AIM

Physical exercise is part of the type 1 diabetes mellitus (T1DM) treatment. However, this practice is still neglected due to the wide variety of glycemic responses under the influence of anaerobic exercise. Therefore, this study aimed to investigate the influence of anaerobic exercise on biomarkers of T1DM.

METHODS

The systematic review was conducted on PubMed, Lilacs, and Embase, according to PRISMA. For this purpose, three groups of descriptors were used: adults with T1DM, anaerobic physical exercise, and glycemic control. The search filter was set to human beings older than 18 years of age, longitudinal and cross-sectional studies, with studies published from 2000 to 2023 in English, Spanish, or Portuguese. Titles and abstracts were read independently by two reviewers, and then the articles were selected for this review. The Kappa coefficient was measured to evaluate the selection.

RESULTS

A total of 738 articles were identified, and five were selected to be part of the review after applying the steps of the procedure. Some benefits were observed in fatigue reduction, absence of diabetic ketoacidosis requiring hospitalization, and enhancement of glucose monitoring during exercise. In the anaerobic workouts of the groups with T1DM, glycemic mean values ranged from 124.5-185.0 mg/dl, and glycated hemoglobin records ranged from 6.7-8.1%.

CONCLUSION

Anaerobic exercise improved the biomarkers of T1DM, especially glycemic control, and the reduction of symptomatic hypoglycemic episodes. Anaerobic exercise can be performed by individuals with T1DM, suggesting an individualized training prescription and encouraging its practice associated with aerobic exercise.

Association Between the Magnitude of Glycemic Control and Body Weight Loss With GLP-1 Receptor Agonists and Risk of Atherosclerotic Cardiovascular Disease: A Systematic Review and Meta-analyses of Randomized Diabetes Cardiovascular Outcomes Trials

PURPOSE

Reduction of major atherosclerotic cardiovascular events (MACE) has not been consistent among different glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in patients with type 2 diabetes mellitus (T2DM). The aim of this study was to assess the association between the magnitude of glycemic control, body weight loss, and reductions in systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-C) achieved through GLP-1 RA therapy and MACE.

METHODS

Electronic databases (MEDLINE, CENTRAL, SCOPUS) were searched through March 2023. Studies were eligible if they were cardiovascular outcome trials (CVOTs) comparing GLP-1 RAs versus placebo in T2DM patients. The outcome of interest was 3-point MACE - cardiovascular death, myocardial infarction, or stroke. Random-effects meta-regression analyses evaluated the associations between reductions of HbA1c, body weight, SBP and LDL-C and reduction of MACE.

RESULTS

Overall, 8 CVOTs were included (60079 patients, 30693 with GLP-1 RAs). Reductions of HbA1C were associated with the reduction of 3P-MACE (Log RR -0.290 [95% CI -0.515;-0.064], p = 0.012), with an estimated RR reduction of 25% for each 1% absolute reduction in HbA1C levels. Body weight loss was associated with the reduction of 3P-MACE (Log RR -0.068 [95% CI -0.135;-0.001], p = 0.047), with an estimated RR reduction of 7% for each 1 kg reduction in body weight. Reductions of SBP (Log RR -0.058 [95% CI -0.192;0.076], p = 0.396) and LDL-C (Log RR -0.602 [95% CI -4.157;2.953], p = 0.740) were not associated with the reduction of 3P-MACE.

CONCLUSIONS

In T2DM patients, more potent GLP-1 RAs in reducing HbA1c and body weight were associated with greater reductions of MACE.

Association of glycemic control with hypertension in patients with diabetes: a population-based longitudinal study

BACKGROUND

Diabetes increases the risk of hypertension morbidity, but whether this association is varied with glycemic control remains unknown. We aimed to examine the association of glycemic control with hypertension among individuals with diabetes.

METHODS

Data was from the China Health and Retirement Longitudinal Study (CHARLS) between 2011 and 2018. Participants were categorized as having adequate glycemic control (HbA1c < 7%) and inadequate glycemic uncontrol (HbA1c ≥ 7%) by combining blood glucose tests and physician's diagnoses in 2011. Incident hypertension was ascertained through self-reported physician diagnoses from 2011 to 2018. Cox proportional hazards regression models were used to examine the effect of glycemic control on hypertension.

RESULTS

Among 436 participants with diabetes in this study, 102 met the glycemic control standard, and 334 were insufficient glycemic control. During 7 years of follow-up, 141 individuals developed hypertension. Compared with adequate glycemic control, the hazard ratio of inadequate glycemic control on hypertension was 1.54 (95% CI, 1.07-2.21) in the multivariate model. Additionally, the influence of glycemic control on hypertension varied based on educational attainment and the presence of depressive symptoms (P for interaction < 0.05).

CONCLUSIONS

Insufficient glycemic control was associated with a higher risk of hypertension among individuals with diabetes. Notably, the effect of glycemic control on hypertension was more pronounced among those with lower educational attainment and those exhibiting depressive symptoms. These findings underscore the significance of vigilant glycemic monitoring, educational background considerations, and mental health assessments in managing diabetic individuals.

Glycated haemoglobin trajectories and one-year risk of potentially avoidable hospitalisations among adult type 2 diabetes patients seeking care at specialist outpatient clinics of a tertiary hospital: a cohort study

AIM

To evaluate the association between trajectories of glycated haemoglobin (HbA1c) and potentially avoidable hospitalisations (PAH).

METHODS

We performed a cohort study in a tertiary hospital in Singapore among adult type 2 diabetes patients with ≥3HbA1c tests over two years. Then, we followed up for one year after the last HbA1c reading. Glycaemic control was analysed by (1)HbA1c trajectories through group-based trajectory modelling, and (2)mean HbA1c. PAH was defined using the Agency of Healthcare Research and Quality criteria, categorising as overall, acute, chronic, diabetes-composites.

RESULTS

A total of 14923 patients (mean age:62.9±12.8 years;55.2% men)were included. Four HbA1c trajectories were observed; low-stable(n=9854,66.0%), moderate-stable(n=3125,20.9%), high-decrease(n=1017,6.8%) and high-persistent(n=927,6.2%). Compared to the low-stable trajectory, one-year risk ratio(RR) and 95%CI, respectively for moderate-stable, high-decrease and high-persistent trajectories were as follows:(1)overall PAH:1.15(1.00-1.31),1.53(1.31-1.80),1.96(1.58-2.43);(2)diabetes PAH:1.30(1.04-1.64),1.98(1.55-2.53),2.24(1.59-3.15);(3)acute PAH:1.14(0.90-1.44),1.29(0.95-1.77),1.75(1.17-2.62); and (4)chronic PAH:1.21(1.02-1.43),1.62(1.34-1.97),2.14(1.67-2.75). Mean HbA1c was significantly associated with overall and chronic-composites of PAH whilst evidence of a non-linear relationship with diabetes-composite of PAH was noted.

CONCLUSION

Patients with high-decrease trajectory had a risk lower than those with persistently-high HbA1c, highlighting that a greater risk of hospitalisation conferred by poor glycaemic control is potentially reversible. Determining HbA1c trajectories could help to identify the high-risk individuals for targeted and intensive management to improve care and reduce hospitalisations.

Diabetic neuropathy: Past, present, and future

Background

A sedentary lifestyle and an unhealthy diet have considerably increased the incidence of diabetes mellitus worldwide in recent decades, which has generated a high rate of associated chronic complications.

Methods

A narrative review was performed in MEDLINE, EMBASES and SciELO databases, including 162 articles.

Results

Diabetic neuropathy (DN) is the most common of these complications, mainly producing two types of involvement: sensorimotor neuropathy, whose most common form is symmetric distal polyneuropathy, and autonomic neuropathies, affecting the cardiovascular, gastrointestinal, and urogenital system. Although hyperglycemia is the main metabolic alteration involved in its genesis, the presents of obesity, dyslipidemia, arterial hypertension, and smoking, play an additional role in its appearance. In the pathophysiology, three main phenomena stand out: oxidative stress, the formation of advanced glycosylation end-products, and microvasculature damage. Diagnosis is clinical, and it is recommended to use a 10 g monofilament and a 128 Hz tuning fork as screening tools. Glycemic control and non-pharmacological interventions constitute the mainstay of DN treatment, although there are currently investigations in antioxidant therapies, in addition to pain management.

Conclusions

Diabetes mellitus causes damage to peripheral nerves, being the most common form of this, distal symmetric polyneuropathy. Control of glycemia and comorbidities contribute to prevent, postpone, and reduce its severity. Pharmacological interventions are intended to relieve pain.

Diabetes with poor-control HbA1c is cardiovascular disease 'risk equivalent' for mortality: UK Biobank and Hong Kong population-based cohort study

INTRODUCTION

Type 2 diabetes mellitus (T2DM) has traditionally been considered a coronary heart disease 'risk equivalent' for future mortality, but significant heterogeneity exists across people with T2DM. This study aims to determine the risk of all-cause mortality of patients with cardiovascular disease (CVD) and T2DM in UK and Hong Kong, with stratifications for hemoglobin A1 (HbA1c) concentrations, compared with those without CVD and diabetes mellitus.

RESEARCH DESIGN AND METHODS

This is a retrospective cohort study of 3 839 391 adults from Hong Kong and a prospective cohort study of 497 779 adults from the UK Biobank. Individuals were divided into seven disease groups: (1) no T2DM and CVD, (2) T2DM only with HbA1c <7%, (3) T2DM only with HbA1c 7%-7.9%, (4) T2DM only with HbA1c 8%-8.9%, (5) T2DM only with HbA1c ≥9%, (6) CVD only, and (7) T2DM and CVD. Differences in all-cause mortality between groups were examined using Cox regression.

RESULTS

After around 10 years of median follow-up, 423 818 and 19 844 deaths were identified in the Hong Kong cohort and UK Biobank, respectively. Compared with individuals without T2DM and CVD, the adjusted HR for all-cause mortality in the other six disease groups for the Hong Kong cohort was 1.25 (95% CI 1.23 to 1.27) for T2DM only with HbA1c <7%, 1.21 (95% CI 1.19 to 1.23) for T2DM only with HbA1c 7%-7.9%, 1.36 (95% CI 1.33 to 1.39) for T2DM only with HbA1c 8%-8.9%, 1.82 (95% CI 1.78 to 1.85) for T2DM only with HbA1c ≥9%, 1.37 (95% CI 1.36 to 1.38) for CVD only, and 1.83 (95% CI 1.81 to 1.85) for T2DM and CVD, and for the UK Biobank the HR was 1.45 (95% CI 1.33 to 1.58), 1.50 (95% CI 1.32 to 1.70), 1.72 (95% CI 1.43 to 2.08), 2.51 (95% CI 2.05 to 3.08), 1.67 (95% CI 1.59 to 1.75) and 2.62 (95% CI 2.42 to 2.83), respectively. This indicates that patients with T2DM had an increased risk of mortality compared with those without T2DM and CVD, and in those with HbA1c ≥9% an even higher risk than people with CVD.

CONCLUSIONS

Patients with T2DM with poor HbA1c control (8%-8.9% and ≥9%) were associated with similar and higher risk of mortality compared with patients with CVD, respectively. Optimal HbA1c, controlled for risk reduction and prevention of mortality and complications in diabetes management, remains important.

Long-Term Changes in HbA1c According to Blood Glucose Control Status During the First 3 Months After Visiting a Tertiary University Hospital

BACKGROUND

We evaluated patients visiting a tertiary university hospital due to a diagnosis of diabetes with a goal of achieving blood glucose control and evaluated blood glucose persistence over 7 years according to the change in blood glucose evident at 3 months after the first visit.

METHODS

Patients treated from 2009 to 2013 were categorized into four groups according to the change in HbA1c levels during the first 3 months of follow-up (Best_group, ≥ 1.6% decrease; Better_group, 0.5-1.5% decrease; Neutral_group, maintained at -0.4% to +0.4%; Worse_group, ≥ 0.5% increase). Each patient's blood glucose control status was then monitored for 7 years. The incidence of stroke and acute coronary syndrome during this period was confirmed.

RESULTS

Overall, 9,776 patients were included. HbA1c values were lower in the Best_group than in the other groups at all time points (all P < 0.001). The rate of reaching targets of < 6.5% or < 7.0% HbA1c decreased over time; the rate at which the estimated glomerular filtration rate decreased to < 30 or < 60 mL/min/1.73m² increased over time (all trends, P < 0.01).

CONCLUSION

Blood glucose control status in the first 3 months after initiating hospital care enabled estimation of the patient's glycemic control status for the next 7 years. In cases with poor initial blood glucose control, a new or more active method of blood glucose control should be sought.

Better TIR, HbA1c, and less hypoglycemia in closed-loop insulin system in patients with type 1 diabetes: a meta-analysis

The study aimed to evaluate the effectiveness and safety of long-term use of closed-loop insulin system (CLS) in non-pregnant patients with type 1 diabetes mellitus (T1DM) using systematic review and meta-analysis. A literature search was performed using MEDLINE, EMBASE, and the Cochrane Library. Randomized controlled trials (RCTs) on long-term use (not less than 8 weeks) of CLS in patients with T1DM were selected. Meta-analysis was performed with RevMan V.5.3.5 to compare CLS with controls (continuous subcutaneous insulin infusion with blinded continuous glucose monitoring or unblinded sensor-augmented pump therapy or multiple daily injections or predictive low-glucose suspend system) in adults and children with type 1 diabetes. Research quality evaluation was conducted using the Cochrane risk of bias tool. Eleven RCTs (817 patients) that satisfied the eligibility criteria were included in the meta-analysis. Compared with controls, the CLS group had a favorable effect on the proportion of time with sensor glucose level in 3.9-10 mmol/L (10.32%, 8.70% to 11.95%), above 10 mmol/L (-8.89%, -10.57% to -7.22%), or below 3.9 mmol/L (-1.09%, -1.54% to -0.64%) over 24 hours. The CLS group also had lower glycated hemoglobin levels (-0.30%, -0.41% to -0.19%), and glucose variability, coefficient of variation of glucose, and SD were lower by 1.41 (-2.38 to -0.44, p=0.004) and 6.37 mg/dL (-9.19 mg/dL to -3.55 mg/dL, p<0.00001). There were no significant differences between the CLS and the control group in terms of daily insulin dose, quality of life assessment, and satisfaction with diabetes treatment. CLS is a better solution than control treatment in optimizing blood glucose management in patients with T1DM. CLS could become a common means of treating T1DM in clinical practice.

Nutrition Management in Patients With Traumatic Brain Injury: A Narrative Review

Traumatic brain injury (TBI) is a major cause of long-term physical and psychological disability and death. In patients with TBI, undernutrition is associated with an increased mortality rate, more infectious complications, and worse neurologic outcomes. Therefore, timely and effective nutritional therapy is particularly crucial in the management of TBI to improve patients' prognoses. This narrative review summarizes the issues encountered in clinical practice for patients with neurotrauma who receive acute and post-acute in-patient rehabilitation services, and it comprehensively incorporates a wide range of studies, including recent clinical practice guidelines (CPGs), with the aim of better understanding the current evidence for optimal nutritional therapy focused on TBI patients. Recent CPGs were reviewed for 6 topics: 1) hypermetabolism and variation in energy expenditure in patients with TBI, 2) delayed gastric emptying and intolerance to enteral nutrition, 3) decision-making on the route and timing of access in patients with TBI who are unable to maintain volitional intake (enteral nutrition versus parenteral nutrition), 4) decision-making on the enteral formula (standard or immune-modulating formulas), 5) glycemic control, and 6) protein support. We also identified areas that need further research in the future.

Diabetic Striatopathy: A New Challenge in Type 1 Pediatric Diabetic Patients

Diabetic striatopathy is a neurological condition in patients with diabetes characterized by hemichorea-hemiballismus due to vascular and metabolic derangements in basal ganglia. This is a known entity in type 2 diabetic adult patients; however, seen rarely in pediatric patients with type 1 diabetes. Diabetic striatopathy develops in patients with poor glycemic control in the absence of ketosis. The patient tolerates hyperglycemia for a long time, which results in metabolic injury.

Predictors of the effectiveness of insulin pumps in patients with type 1 diabetes mellitus

PURPOSE

Insulin pump therapy has become the preferential treatment for type 1 diabetes (T1D) as it mimics the physiological secretion of insulin better than multiple daily injections. However, not all patients improve with insulin pump therapy. This study aims to determine the predictors of the effectiveness of insulin pumps in T1D.

METHODS

We conducted a retrospective observational study of patients who started insulin pumps. Data from four timepoints (before, at 6, 12, and 36 months) were evaluated for outcomes of glycemic control and safety. The association of baseline predictors with outcomes was analyzed using linear and logistic regression models.

RESULTS

We evaluated 136 patients (57.4% females, age 36 ± 12 years, duration of T1D 14 ± 9 years). During the follow-up, there was a mean decrease of HbA1c of 0.9 ± 1.2%. The improvement in HbA1c was independent of sex, age, and duration of T1D. Higher baseline HbA1c, family history of diabetes, and not being treated with statins were predictors of improvement in HbA1c. Not being treated with statins and higher baseline HbA1c predicted improvement in HbA1c without worsening hypoglycemia. History of hypoglycemia was a predictor of severe hypoglycemia. Family history, higher baseline HbA1c, and psychological/psychiatric disorders were predictors of ketoacidosis.

CONCLUSION

Benefits of insulin pump were independent of sex, age, and duration of T1D. Baseline HbA1c, family history of diabetes, treatment with statins, history of hypoglycemia, and psychological/psychiatric disorders were predictors of outcomes, and may allow the identification of patients who benefit most from insulin pump therapy or who are at increased risk of complications.

Impact of Coronavirus Disease 2019 Outbreak on Children and Adolescents with Type 1 Diabetes Mellitus

BACKGROUND

This study aimed to investigate the impact of the Coronavirus Disease 2019 (COVID-19) pandemic on daily routines and health of patients with type 1 diabetes mellitus (T1DM).

STUDY DESIGN

A cross-sectional study.

METHODS

This study included 98 children and adolescents with type 1 diabetes who were regularly followed up in the Endocrinology outpatient clinic of Besat Hospital, Hamadan, Iran, in 2020. The primary measurements included body mass index, glycemic control, number of hypoglycemic events, number of hospitalizations, as well as bedtime and availability of insulin six months pre and post COVID-19 outbreak. The obtained data were analyzed in SPSS software (version 16). A p-value less than 0.05 was considered statistically significant.

RESULTS

Out of 98 participants (mean±SD age: 13.5±49), 51% of the cases were male, and %81.6 of the patients were urban residents. Furthermore, most participants (43.9%) were in the age group of 11-15 years, and the mean±SD duration of diabetes was 4.64±3.31 years. In addition, 2.04% of the participants developed COVID-19. There was a statistically significant difference among average duration of night sleep (P<0.001), bedtime (P<0.001), time of waking up (P<0.001), amount of insulin intake (P=0.003), daily exercise (P<0.001), and availability of the insulin (P<0.001) before and during COVID-19 crisis. The frequencies of hospitalizations and hypoglycemic events were lower after the COVID-19 outbreak (P=0.005 and P=0.034, respectively). Morning insulin dose was omitted in 22.2% of participants. No differences were found between hemoglobin A1c and daytime sleep pre and post COVID-19 outbreak.

CONCLUSIONS

The key challenges due to COVID-19 pandemic restrictions for Iranian T1DM patients were the need to take more insulin, lower physical activity, non-availability of insulin, and missed morning insulin dose. However, it is worth mentioning that the patients' blood glucose control did not worsen in this period.

Effects of Mobile Phone-based Telemedicine Management in Patients with Type 2 Diabetes Mellitus: A Randomized Clinical Trial

BACKGROUND

This study aims to explore the effect of mobile phone-based telemedicine management of glycemic control of type 2 diabetes mellitus (T2DM).

METHODS

Patients with T2DM were followed up in Chongqing Jiulongpo District Yuzhoulu Community Health Center, and randomly divided into the telemedicine group (n=47) and the control group (n=50). The control group received regularly routine intervention. The telemedicine management group used the mobile phone to manage their health condition remotely.

RESULTS

Both groups had similar baseline characteristics. After a follow-up period of 12 months intervention, the weight, body mass index, waist circumference, systolic blood pressure, body fat percentage, body fat mass, body water and muscle mass, fasting blood glucose, glycosylated hemoglobin, total costs of diabetes treatment for 1 month and the quality-of-life score were significantly improved in the telemedicine group (P<0.05). And compared with the control group, body fat composition, fasting blood glucose, glycosylated hemoglobin and the cost of change shows a significant improvement (P<0.05). Positive correlation was detected between fasting blood glucose and body composition parameters, such as body fat percentage, lean body mass and body fat mass in the telemedicine group (r=0.56, P<0.05; r=0.37, P<0.05; r=0.56, P<0.05).

CONCLUSIONS

Compared with conventional intervention, the mobile phone-based telemedicine management can help patients with diabetes to improve glycemic level and quality of life.

Oral semaglutide in the management of type 2 DM: Clinical status and comparative analysis

BACKGROUND

In the incretin system, Glucagon-like peptide-1 (GLP-1) is a hormone that inhibits the release of glucagon and regulates glucose-dependent insulin secretion. In type 2 diabetes, correcting the impaired incretin system using GLP-1 agonist is a well-defined therapeutic strategy.

OBJECTIVES

This review article aims to discuss the mechanism of action, key regulatory events, clinical trials for glycaemic control and comparative analysis of semaglutide with the second-line antidiabetic drugs.

DESCRIPTION

Semaglutide is a glucagon-like peptide 1 (GLP 1) receptor agonist with enhanced glycaemic control in diabetes patients. In 2019, USFDA approved the first oral GLP-1 receptor agonist, semaglutide to be administered as a once-daily tablet. Further, recent studies highlight the ability of semaglutide to improve the glycaemic control in obese patients with a reduction in body weight. Still, in clinical practice, in type 2 DM treatment paradigm the impact of oral semaglutide remains unidentified. This review article discusses the mechanism of action, pharmacodynamics, key regulatory events, and clinical trials regarding glycaemic control.

CONCLUSION

The review highlights the comparative analysis of semaglutide with the existing second-line drugs for the management of type 2 diabetes mellitus by stressing on its benefits and adverse events.

[Anthropometric indicators and poor glycemic control in type 2 diabetes with kidney disease]

BACKGROUND

The relationship of anthropometric and body composition indicators with the evolution of kidney disease in patients with type 2 diabetes, is still inconsistent.

OBJECTIVE

To identify the association of indicators of kidney disease with indicators of metabolic and anthropometric control in patients with type 2 diabetes.

MATERIAL AND METHODS

An analytical cross-sectional study was carried out in 395 patients of the first level of care. The glucose, glycosylated hemoglobin (HbA1c), creatinine and lipid profile were measured. The kidney disease (CKD) was made when urinary albumin excretion (UAE) > 30 mg/g and with a reduction in the level of glomerular filtration rate < 60 mL/min/1.73 m2, using the CKD-formula. Weight and waist circumference were measured, as well as the body composition through bioimpedance.

RESULTS

Seventeen percent of the population has a diagnosed with CKD with alteration of the UAE and 6.6% had a reduced GFR. A longer time of diagnosis of the diabetes, higher HbA1c level and body fat were associated with an UAE > 30 mg/g, (p < 0.05). The decline in GFR (< 60 mL/min/1.73 m2) was associated with older age, being a woman, greater waist circumference, and a higher percentage of body fat (p < 0.05).

CONCLUSIONS

A higher level of waist circumference and a lower percentage of body fat are associated with a greater evolution of chronic kidney disease in patients with type 2 diabetes. Glycemic uncontrol is identified in patients with high urinary albumin excretion.

Impact of pharmacist-led care on glycaemic control of patients with uncontrolled type 2 diabetes: a randomised controlled trial in Nigeria

BACKGROUND

Diabetes mellitus is a chronic, degenerative disease, requiring a multi-dimensional, multi-professional care by healthcare providers and substantial self-care by the patients, to achieve treatment goals.

OBJECTIVE

To evaluate the impact of pharmacist-led care on glycaemic control in patients with uncontrolled Type 2 Diabetes.

METHODS

In a parallel group, single-blind randomised controlled study; type 2 diabetic patients, with greater than 7% glycated haemoglobin (A1C) were randomised into intervention and usual care groups and followed for six months. Glycated haemoglobin analyzer, lipid analyzer and blood pressure monitor/apparatus were used to measure patients' laboratory parameters at baseline and six months. Intervention group patients received pharmacist-structured care, made up of patient education and phone calls, in addition to usual care. In an intention to treat analysis, Mann-Whitney U test was used to compare median change at six months in the primary (A1C) and secondary outcome measures. Effect size was computed and proportion of patients that reached target laboratory parameters were compared in both arms.

RESULTS

All enrolled participants (108) completed the study, 54 in each arm. Mean age was 51 (SD 11.75) and majority were females (68.5%). Participants in the intervention group had significant reduction in A1C of -0.75%, compared with an increase of 0.15% in the usual care group (p<0.001; eta-square= 0.144). The proportion of those that achieved target A1C of <7% at 6 months in the intervention and usual care group was 42.6% vs 20.8% (p=0.02). Furthermore, intervention patients were about 3 times more likely to have better glucose control; A1C<7% (aOR 2.72, 95% CI: 1.14-6.46) compared to usual care group, adjusted for sex, age, and duration of diabetes.

CONCLUSIONS

Pharmacist-led care significantly improved glycaemic control in patients with uncontrolled T2DM.

An analysis of Medtronic MiniMed 670G insulin pump use in clinical practice and the impact on glycemic control, quality of life, and compliance

AIMS

This study evaluated the use of the Medtronic MiniMed 670G system in adults with type 1 diabetes mellitus from a large endocrinology practice and its impact on glycemic control, quality of life (QoL), compliance and safety.

METHODS

84 participants completed one site visit for data collection. Percentage of time in range (TIR: 70-180 mg/dL), hyperglycemia or time above range (TAB) (>180 mg/dL), hypoglycemia or time below range (TBR) (<70 mg/dL), HbA1c, average blood glucose (ABG), and other metrics were evaluated at the last visit using the system (LVMM) and compared between the last visit on previous insulin therapy (LVPT).

RESULTS

The mean percentage of TIR at the LVMM was 74.0 ± 12.1%, with an increase of 27.1% (p < 0.001) in TIR from the LVPT. The mean percentage of TAR was 22.9 ± 11.8% and the mean percentage of TBR was 3.2 ± 5.1%.

CONCLUSIONS

The use of the Medtronic MiniMed 670G system in our practice resulted in a TIR above the recommended target with a high degree of treatment satisfaction and compliance in adults with type 1 diabetes. Furthermore, the system may be a reasonable choice for patients struggling with significant amounts of hypoglycemia.

Evaluation of home medication review for patients with type 2 diabetes mellitus by community pharmacists: a randomised controlled trial

BACKGROUND

Successful diabetes treatment requires commitment and understanding of disease management by the patients.

OBJECTIVE

This trial aimed to evaluate the programme effectiveness of home medication review by community pharmacists (HMR-CP) in optimising diabetes care and reducing medication wastage.

METHODS

A randomised controlled trial was conducted on 166 patients with Type 2 Diabetes Mellitus (T2DM) who were randomly assigned to the intervention or control groups. The intervention group received HMR-CP at 0-month, 3-month, and 6-month. The primary outcome was haemoglobin A1c (HbA1c) while clinical outcomes, anthropometric data, and humanistic outcomes were the secondary outcomes. For the intervention group, drug-related problems (DRP) were classified according to the Pharmaceutical Care Network Europe Foundation (PCNE). Medication adherence was determined based on the Pill Counting Adherence Ratio (PCAR). The cost of medication wastage was calculated based on the total missed dose by the T2DM patients multiplied by the cost of medication. General linear model and generalised estimating equations were used to compare data across the different time-points within and between the groups, respectively.

RESULTS

No significant difference was observed in the demographic and anthropometric data at baseline between the two groups except for fasting blood glucose (FBG). There was a significant reduction in the HbA1c (-0.91%) and FBG (-1.62mmol/L) over the study period (p<0.05). A similar observation was noted in diastolic blood pressure (DBP) and total cholesterol (TC) but not in high-density lipoprotein (HDL), and anthropometric parameters. Both utility value and Michigan Diabetes Knowledge Test (MDKT) scores increased significantly over time. As for the intervention group, significant changes in PCAR (p<0.001) and the number of DRP (p<0.001) were noted.

CONCLUSIONS

HMR-CP significantly improved the glycaemic control, QoL, medication adherence, and knowledge of T2DM patients as well as reduced the number of DRP and cost of medication wastage. However, the impact of HMR-CP on certain clinical and anthropometric parameters remains inconclusive and further investigation is warranted.

Self-management Education Program: The Case of Glycemic Control of Type 2 Diabetes

Objectives

Self-management education (SME) is recognized globally as a tool that enables patients to achieve optimal glucose control. While factors influencing the effectiveness of self-management interventions have been studied extensively, the impact of program length on clinical endpoints of patients diagnosed with diabetes is underdeveloped. This paper synthesized information from the existing literature to understand the effect of program length on glycated hemoglobin (HbA_1C) in adults with type 2 diabetes mellitus.

Methods

We searched Web of Science, PubMed, Scopus, MEDLINE, EMBASE, PsychINFO, and the Cochrane Central Register of Controlled Trials to identify relevant English language publications on diabetes self-management education published between January 2000 and April 2019.

Results

The review included 25 randomized controlled trials, with 64.0% reporting significant changes in HbA_1C. The studies classified as long-term (lasting one year and above) were associated with the greatest number of interventions achieving statistically significant (87.5% significant vs. 12.5% non-significant) differences in changes in HbA_1C between the intervention and the control subjects, recording an overall between-group HbA_1C mean difference of 0.6±0.3% (range = 0.2–1.2).

Conclusions

Our findings suggest that program length may change the effectiveness of educational interventions. Achieving sustained improvements in patients’ HbA_1C levels will require long-term, ongoing SME, and support.

Electronic medical records-based comparison of glycemic control efficacy between sulfonylureas and dipeptidyl peptidase-4 inhibitors added on to metformin monotherapy in patients with type 2 diabetes

Sulfonylurea (SU) and dipeptidyl peptidase-4 (DPP-4) inhibitors are most common secondary agents that are added to metformin monotherapy. Real-world studies have become increasingly important in providing evidence of treatment effectiveness in clinical practice and real-world data could help appropriate therapeutic information. Therefore, this study aims to compare the glycemic effectiveness of SU and DPP-4 inhibitors, which are added to metformin monotherapy in real clinical practice using electronic medical record (EMR) data. EMR data of type 2 diabetes patients treated at Seoul National University Hospital from December 2002 to December 2012 were retrieved and analyzed. The patients were divided into three groups: patients who maintained metformin monotherapy (M), and patients who added SU (MS) or DPP-4 inhibitors (MD) to metformin monotherapy. The mean change in HbA1c level, the proportion of patients achieving the HbA1c target < 7.0%, proportion of patients with treatment failure, and probability of treatment failure occurrence and changes in prescription were evaluated to compare glycemic control efficacy between SU and DPP-4 inhibitors. The MS showed significantly greater reduction in the Hb1Ac level than MD. The proportion of patients achieving HbA1c < 7.0% is higher in MD, whereas the proportion of patients with treatment failure was greater in MS. The probability of the treatment failure and probability of changes in the prescription were lower in MD than MS with hazard ratio of 0.499 and 0.579, respectively. In conclusion, this real-world study suggested that DPP-4 inhibitors are expected to show more durable glycemic control efficacy than SU in long-term use.

Association of Evening Chronotype with Poor Control of Type 2 Diabetes: Roles of Sleep Duration and Insomnia Level

BACKGROUND

Evening chronotype is usually associated with insomnia and short sleep duration.

OBJECTIVES

To investigate the independent association of chronotype with diabetes control.

METHODS

In this cross-sectional study, 140 patients with type 2 diabetes were studied. The insomnia score was examined by a 7-item questionnaire. Also, chronotype was assessed by a 19-item questionnaire, and using the questionnaire, the patients were divided into three groups of morning, intermediate, and evening. This questionnaire has been developed for evaluating the preference for performing mental and physical activities at a special time of day. The Multivariate hierarchical analysis was applied for investigating the independent association of chronotype and glycated hemoglobin (HbA1c).

RESULTS

The fasting blood glucose and HbA1c levels were significantly different across all the three chronotype groups such that it had the highest value in the evening group and the lowest value in the morning group (FBS = 164.5 ± 34.1 mg/dL and HbA1c = 8.7% ± 1.7, in the evening group, and FBS = 132.7 ± 23.1 mg/dL and HbA1c = 6.9% ± 0.4 in the morning group, P < 0.001). The morning group had longer sleep duration and less insomnia than other groups. Results of the hierarchical regression analysis showed that the chronotype explained 28.4% of the variance of HbA1c. Results of the final model demonstrated that the chronotype had a relationship with HbA1c, independent of body mass index (BMI), time of going to bed, and insomnia score.

CONCLUSIONS

Evening chronotype is associated with poorer control of diabetes, independent of BMI and sleep variables.

Sleep Quality and Blood Lipid Composition Among Patients with Diabetes

BACKGROUND

Recent literature has mentioned that people with sleep disorder, experience insulin sensitivity reduction and accordingly higher levels of blood glucose.

OBJECTIVES

This study aimed to investigate the relationship between sleep quality and blood lipid composition in patients with diabetes referring to Minoodar health center in Qazvin, Iran in 2017.

METHODS

Sleep duration and quality were assessed in 347 patients with diabetes using the Pittsburgh sleep quality index (PSQI). The glycosylated hemoglobin A1c (HbA1c) test was used to measure the glycemic control and total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), and high-density lipoprotein cholesterol (HDL-C) were used to determine blood lipid composition of the patients. Multiple regression analyses were applied to examine the associations between sleep measures and HbA1c and lipid parameters using SPSS version 20.

RESULTS

The patients in the poor sleep quality group had higher levels of fasting blood sugar (FBS) (146.07 ± 57.06 versus 132.8 ± 53.3 mg/dL, P = 0.02), body mass index (BMI) (29.1 ± 3.9 versus 27.6 ± 4.2 kg/m², P = 0.005) and total cholesterol (209.9 ± 53.4 versus 193.4 ± 45.8, P = 0.02). Furthermore, the patients with short sleep duration had higher total cholesterol level compared with long sleep and medium sleep duration group (202.3 ± 50.2 versus 196.6 ± 47.7 and 195.7 ± 47.4, respectively, P = 0.05). Among different PSQI measures, subjective sleep quality was associated with lower TC and TG in unadjusted models (β = -0.0.1, P = 0.05). Furthermore, greater sleep disturbance was positively linked with higher levels of TC and TG (β = 0.1, P = 0.01 and β = 0.02, P = 0.05).

CONCLUSIONS

In an Iranian population with diabetes living in Qazvin city, sleep disorder is common and as study findings revealed sleep quality was recognized as an influencing factor on some of the lipid profiles, including TC and TG. Thus sleep assessment of patients with type 2 diabetes to find the early recognition of their sleep disorder should be considered an important part of the patients' treatment.

Impact of food security on glycemic control among low-income primarily Hispanic/Latino children in Los Angeles, California: A cross-sectional study

Studies examining the impact of food insecurity on metabolic markers are limited, specifically in Hispanic youth. This study was a cross-sectional analysis of 218 3^rd-5^th grade students (83% Hispanic and 49% male). Anthropometrics, blood glucose, insulin, and lipids via fasting blood draw, dietary intake via Block screener, and a 5-item food security scale were collected. HOMA-Insulin Resistance was calculated. Multivariate analyses of covariance were used to examine differences in glucose and insulin indices, adiposity, metabolic and dietary intake variables between categories of food security. Food secure children had greater glycemic control and decreased insulin resistance compared to food insecure children.

Glycemic Status and Prognosis of Patients with Squamous Cell Carcinoma of the Esophagus

BACKGROUND

The impact of glycemic status on esophageal squamous cell carcinoma (ESCC) prognosis is unclear.

METHODS

A total of 623 patients who underwent curative subtotal esophagectomy for ESCC were evaluated. Diabetes was defined as a prior diagnosis of diabetes under treatment or newly diagnosed diabetes based on preoperative glycosylated hemoglobin (HbA1c) levels. Poor glycemic control was defined as HbA1c ≥ 7.0%, whereas good glycemic control was defined as HbA1c < 7.0%. The impact of glycemic status on long-term survival after esophagectomy was evaluated.

RESULTS

Among the 623 patients, 64 (10.3%) had diabetes including 30 (4.8%) with poor glycemic control. Although diabetes did not influence patient survival, patients with poor glycemic control had worse overall and disease-specific survival compared with those with good glycemic control (P = 0.011 and 0.039, respectively). Comparing poor glycemic control with good glycemic control, the hazard ratios (HRs) for overall and disease-specific mortality were 1.91 (1.15-3.18) and 1.89 (1.02-3.49) in univariate analysis. After multivariate adjustment, poor glycemic control also had increased risk of overall and disease-specific mortality [HR 1.72 (95% CI 1.02-2.88) and 1.65 (95% CI 0.89-3.08), respectively]. Poor glycemic control did not increase the risk of overall or disease-specific mortality in patients with stages 0-II disease but significantly increased this risk in those with stages III-IV disease [HR 2.05 (1.14-3.69) and 1.95 (1.01-3.80), respectively].

CONCLUSIONS

Poor glycemic control is an independent risk factor for overall and disease-specific mortality after esophagectomy for advanced-stage ESCC.

Impact of Distress Reduction on Behavioral Correlates and A1C in African American Women with Uncontrolled Type 2 Diabetes: Results from EMPOWER

OBJECTIVE

Symptoms of emotional distress related to diabetes have been associated with inadequate self-care behaviors, medication non-adherence, and poor glycemic control that may predispose patients to premature death. African American women, in whom diabetes is more common and social support is often insufficient, may be at particularly high risk. The objective of this study was to examine the impact of lowering diabetes-related emotional distress on glycemic control and associated behavioral correlates in rural African American women with uncontrolled type 2 diabetes (T2D).

DESIGN

Post-hoc analysis of prospective, randomized, controlled trial.

SETTING

Rural communities in the southeastern United States.

PATIENTS

129 rural middle-aged African American women with uncontrolled type 2 diabetes (T2D)(A1C ≥ 7.0).

PRIMARY INDEPENDENT VARIABLE

Diabetes-related distress.

MAIN OUTCOME MEASURES

Changes from baseline to 12-month follow-up in diabetes-related distress, and associated changes in medication adherence, self-care activities, self-efficacy, and glycemic control (A1C).

RESULTS

Patients with a reduction in diabetes-related distress (n=79) had significantly greater improvement in A1C, medication adherence, self-care activities, and self-efficacy compared with those in whom diabetes distress worsened or was unchanged (n=50). Changes in distress were also significantly and inversely correlated with improvements in medication adherence, self-care activities, and self-efficacy.

CONCLUSIONS

Among rural African American women, reductions in diabetes-related distress may be associated with lower A1C and improvements in self-efficacy, self-care behaviors, and medication adherence.

Insulin Detemir in Combination with Oral Antidiabetic Drugs Improves Glycemic Control in Persons with Type 2 Diabetes in Near East Countries: Results from the Lebanese Subgroup

OBJECTIVE

To evaluate the effectiveness and safety of insulin detemir treatment as add-on therapy in a real-world setting of Lebanese insulin naïve persons, with type 2 diabetes poorly controlled on oral antidiabetic drugs (OADs).

METHODS

Our study was a prospective, observational study representing the Lebanese arm of the multinational prospective and observational study involving 2,155 persons across Near East countries, Lebanon, Pakistan, Israel and Jordan. Effectiveness endpoints were changes in HbA1c, fasting and post-prandial glucose (FPG, PPG) after 24 weeks of treatment with insulin detemir in eligible persons. Safety endpoints were number of hypoglycemic events, incidence of adverse drug reactions (ADRs), serious ADRs, adverse events, and body weight change between baseline and end of treatment.

RESULTS

868 persons were included (mean age: 59.5 ± 10.4 years, men: 55.3%). Glycemic control improved with significant reduction in mean HbA1c from 9.7 ± 1.6% to 7.2 ± 1% (P<.0001). The percentage of persons who achieved the target of HbA1c<7% increased from .7% at baseline to 39% at week 24. Mean FPG decreased significantly from 213.7 ± 60.1 mg/dL to 120.3 ± 25.7 mg/dL (P<.001), and mean PPG from 271 ± 65.3 mg/dL to 158.1 ± 36.4 mg/dL (P<.0001). The rate of major hypoglycemic episodes decreased from .1498 at baseline to .0448 at week 24. Three adverse events but no ADR or serious ADR were reported. Body weight decreased from 80.4±13.2 Kg to 79.9±12.5 Kg (P<.0001).

CONCLUSIONS

Initiating insulin detemir in a clinical health care setting among Lebanese with type 2 diabetes mellitus on OADs improves glycemic control with no increase in hypoglycemia, adverse events or weight compared with baseline.

Higher health literacy is associated with better glycemic control in adults with type 1 diabetes: a cohort study among 1399 Danes

AIM

Self-management of diabetes is influenced by a range of factors including the ability to access, understand, appraise, and use of health information in everyday life, which can collectively be called health literacy. We investigated associations between nine domains of health literacy and HbA1c level in people with type 1 diabetes.

METHODS

A cross-sectional study was conducted with 1399 people with type 1 diabetes attending a Danish specialist diabetes clinic. Health literacy was assessed using the nine-domain Health Literacy Questionnaire. The association between health literacy and HbA1c was analyzed using linear regression with adjustment for age, sex, educational attainment and diabetes duration.

RESULTS

Of the 1399 participants, 50% were women, mean age was 54 years, and mean HbA1c was 61 mmol/mol (7.8%). Higher health literacy scores were associated with lower HbA1c levels across eight of nine health literacy domains. This association remained significant after adjusting for educational attainment. Among the domains, 'Actively managing my health' had the strongest impact on HbA1c. This was in turn predicted by 'Appraising health information', 'Having sufficient information to manage health', and 'Social support for health'.

CONCLUSIONS

Higher health literacy levels are associated with lower HbA1c regardless of educational background. This study highlights the importance of healthcare provision to respond to the health literacy levels of people with diabetes and to the possible need to provide program designed to enhance health literacy.

Systematic review and meta-analysis of dietary carbohydrate restriction in patients with type 2 diabetes

OBJECTIVE

Nutrition therapy is an integral part of self-management education in patients with type 2 diabetes. Carbohydrates with a low glycemic index are recommended, but the ideal amount of carbohydrate in the diet is unclear. We performed a meta-analysis comparing diets containing low to moderate amounts of carbohydrate (LCD) (energy percentage below 45%) to diets containing high amounts of carbohydrate (HCD) in subjects with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We systematically reviewed Cochrane library databases, EMBASE, and MEDLINE in the period 2004-2014 for guidelines, meta-analyses, and randomized trials assessing the outcomes HbA1c, BMI, weight, LDL cholesterol, quality of life (QoL), and attrition.

RESULTS

We identified 10 randomized trials comprising 1376 participants in total. In the first year of intervention, LCD was followed by a 0.34% lower HbA1c (3.7 mmol/mol) compared with HCD (95% CI 0.06 (0.7 mmol/mol), 0.63 (6.9 mmol/mol)). The greater the carbohydrate restriction, the greater the glucose-lowering effect (R=-0.85, p<0.01). At 1 year or later, however, HbA1c was similar in the 2 diet groups. The effect of the 2 types of diet on BMI/body weight, LDL cholesterol, QoL, and attrition rate was similar throughout interventions.

LIMITATIONS

Glucose-lowering medication, the nutrition therapy, the amount of carbohydrate in the diet, glycemic index, fat and protein intake, baseline HbA1c, and adherence to the prescribed diets could all have affected the outcomes.

CONCLUSIONS

Low to moderate carbohydrate diets have greater effect on glycemic control in type 2 diabetes compared with high-carbohydrate diets in the first year of intervention. The greater the carbohydrate restriction, the greater glucose lowering, a relationship that has not been demonstrated earlier. Apart from this lowering of HbA1c over the short term, there is no superiority of low-carbohydrate diets in terms of glycemic control, weight, or LDL cholesterol.

Medication usage, treatment intensification, and medical cost in patients with type 2 diabetes: a retrospective database study

OBJECTIVE

The goal of this study was to describe medication usage patterns in patients with type 2 diabetes mellitus (T2DM) initiating treatment with non-insulin antidiabetic drugs (NIADs), basal insulin, or prandial/mixed insulin using real-world data.

RESEARCH DESIGN AND METHODS

A retrospective analysis using the Truven Health MarketScan Research Databases was conducted to identify adults (≥18 years) with T2DM from 2006 to 2012. Patients were categorized into four cohorts based on diabetes treatment. Cohort 1 (n=597 664) consisted of newly diagnosed patients who did not receive any treatment, cohort 2 (n=342 511) included NIAD initiators, cohort 3 (n=99 578) included basal insulin initiators, and cohort 4 (n=62 876) included prandial/mixed insulin initiators. Patients transitioned out of a cohort once they met the criteria for the next one.

RESULTS

Patients in cohort 2 were younger (56.2 years, SD±12.1) than patients in cohorts 1, 3, and 4 (58 years, SD±0.75). Metformin was the most commonly prescribed drug in cohort 2 patients. Basal insulin usage decreased from 71% in year 1 to 47% in year 4, in cohort 3 patients. Approximately one-third of these patients switched to prandial/mixed insulin each year. In cohort 4, the usage of prandial/mixed insulin decreased to 61% by year 4. Use of basal insulin and NIAD remained common in this group. Mean glycosylated hemoglobin (HbA1c) values decreased by ∼1% for each of the treatment cohorts following treatment initiation and remained stable during follow-up. All-cause and diabetes-related medical costs were highest for patients in cohorts 3 and 4.

CONCLUSIONS

Overall, our findings demonstrate that treatment intensification was low in all study cohorts despite elevated HbA1c levels during preindex and follow-up period.

Prediction of protective sensory loss, neuropathy and foot ulceration in type 2 diabetes

OBJECTIVES

To prospectively determine clinical and biochemical characteristics associated with the development of peripheral neuropathy, loss of protective sensation, and foot ulceration in persons with type 2 diabetes mellitus (DM) over 7 years.

RESEARCH DESIGN AND METHODS

Graded monofilament (MF) testing, vibration perception threshold, and neuropathy symptom questionnaires were undertaken in 206 participants with type 2 DM without peripheral vascular disease or history of foot ulceration and 71 healthy participants without DM at baseline and after 7 years. 6 monthly glycosylated hemoglobin (HbA1c) levels and annual serum lipid profiles were measured during follow-up of those with DM. Incident foot ulceration was recorded at follow-up.

RESULTS

Taller stature and higher quartiles of serum triglyceride and HbA1c levels were associated with neuropathy at follow-up (p=0.008). Remission of baseline neuropathy was observed in 7 participants at follow-up. 9 participants with type 2 DM developed foot ulcers by the end of the study, only 1 at low risk. Mean HbA1c levels were higher in those who developed foot ulceration (p<0.0001). 1 participant with neuropathy throughout developed a Charcot foot. Failure to perceive 2 or more 2, 4 and 6 g MF stimuli at baseline predicted loss of protective sensation at follow-up.

CONCLUSIONS

Tall stature and worse metabolic control were associated with progression to neuropathy. Mean HbA1c levels were higher in those who developed foot ulcers. Graded MF testing may enrich recruitment to clinical trials and assignation of high risk for foot ulceration.

Effect of tighter glycemic control on cardiac function, exercise capacity, and muscle strength in heart failure patients with type 2 diabetes: a randomized study

OBJECTIVES

In patients with type 2 diabetes (T2D) and heart failure (HF), the optimal glycemic target is uncertain, and evidence-based data are lacking. Therefore, we performed a randomized study on the effect of optimized glycemic control on left ventricular function, exercise capacity, muscle strength, and body composition.

DESIGN AND METHODS

40 patients with T2D and HF (left ventricular ejection fraction (LVEF) 35±12% and hemoglobin A1c (HbA1c) 8.4±0.7% (68±0.8 mmol/mol)) were randomized to either 4-month optimization (OPT group) or non-optimization (non-OPT group) of glycemic control. Patients underwent dobutamine stress echocardiography, cardiopulmonary exercise test, 6 min hall-walk test (6-MWT), muscle strength examination, and dual X-ray absorptiometry scanning at baseline and at follow-up.

RESULTS

39 patients completed the study. HbA1c decreased in the OPT versus the non-OPT group (8.4±0.8% (68±9 mmol/mol) to 7.6±0.7% (60±7 mmol/mol) vs 8.3±0.7% (67±10 mmol/mol) to 8.4±1.0% (68±11 mmol/mol); p<0.001). There was no difference between the groups with respect to changes in myocardial contractile reserve (LVEF (p=0.18)), oxygen consumption (p=0.55), exercise capacity (p=0.12), and 6-MWT (p=0.84). Muscle strength decreased in the non-OPT compared with the OPT group (37.2±8.1 to 34.8±8.3 kg vs 34.9±10.2 to 35.4±10.7 kg; p=0.01), in line with a non-significant decrease in lean (p=0.07) and fat (p=0.07) tissue mass in the non-OPT group. Hypoglycemia and fluid retention did not differ between groups.

CONCLUSIONS

4 months of optimization of glycemic control was associated with preserved muscle strength and lean body mass in patients with T2D and HF compared with lenient control, and had no deleterious effect on left ventricular contractile function and seemed to be safe.

TRIAL REGISTRATION NUMBER

NCT01213784; pre-results.

Diabetes as an increasingly common comorbidity among patient hospitalizations for tuberculosis in the USA

OBJECTIVE

Diabetes is a risk factor for active tuberculosis (TB). The purpose of this paper was to estimate the risk of hospitalization for TB with and without a secondary diagnosis of diabetes in groups with different ethnic backgrounds.

RESEARCH DESIGN AND METHODS

We used the Nationwide Inpatient Sample from 1998 to 2011, identifying all patients with a primary diagnosis of TB and/or a secondary diagnosis of diabetes (type 1 or type 2) or HIV. Next, we performed logistic regression to investigate the association of diabetes status, HIV status, and race (and the interaction of diabetes and race) with the risk of hospitalization with a primary diagnosis of TB. We also included a time covariate, to determine whether potential risk factors changed during the study period.

RESULTS

Controlling for HIV status, diabetes did not increase the odds of TB in white and black patients. However, in Hispanic and Asian/Pacific Islander patients, diabetes increased the odds of TB by a factor of 1.7 (95% CI 1.51 to 1.83). Asian/Pacific Islanders who had diabetes but not HIV experienced 26.4 (95% CI 23.1 to 30.1) times the odds of TB relative to the white males without diabetes or HIV. In addition, the percent of TB cases that belong to these high-risk groups (Asian/Pacific Islander/Hispanic diabetics) has more than doubled from 4.6% in 1998 to 9.6% in 2011.

CONCLUSIONS

In specific demographic groups, diabetes was a strong risk factor for hospital admissions for TB.

Study of Adiponectin Level in Diabetic Adolescent Girls in Relation to Glycemic Control and Complication of Diabetes

AIM:

To study the relation between adiponectin level with glycemic control and complication of diabetes.

PATIENTS AND METHODS:

The study included 40 female adolescent type 1 diabetic patients and 40 healthy volunteers of the same age and sex. Blood sample was taken for assessment of glycosylated hemoglobin, lipid profile and adiponectine. Urine sample was taken for assessment of albumin/creatinine ratio.

RESULTS:

Diabetic patients had a significantly higher diastolic blood pressure, triglyceride, total cholesterol, LDL and adiponectin than controls. Patients with diabetes complication had a significant lower BMI and HDL. On the other hand, they had higher disease duration, total cholesterol, HbA1, albumin/creatinine ratio and adiponectin. Patients with microalbuminuria had a lower BMI, higher disease duration, diastolic blood pressure and adiponectin. Patients with diabetic retinopathy had higher disease duration, insulin dose, HbA1, microalbuminuria and adiponectin. Adiponectin in diabetic patients had a significant negative correlation with BMI and positive correlation with systolic blood pressure and microlabuminuria.

CONCLUSION:

Serum adiponectin level is high in adolescent type 1 diabetic girls. It can be used as a predictor of diabetes complications rather than a sensitive biochemical marker for glycemic control.

Effect of Fresh Royal Jelly Ingestion on Glycemic Response in Patients With Type 2 Diabetes

BACKGROUND

Type 2 diabetes is the fourth major public health problem worldwide. Royal Jelly (RJ) insulin-like activity and blood glucose modulating properties have been reported in animal and healthy volunteers.

OBJECTIVES

This study aimed to investigate the effect of a single dose of fresh RJ as a complementary therapy on glycemic response in patients with type 2 diabetes.

PATIENTS AND METHODS

In this randomized clinical trial, 40 patients with type 2 diabetes were assigned into the RJ (n = 20) and placebo (n = 20) groups and received either 10 g fresh RJ or placebo after overnight fasting. Serum glucose, insulin and C-peptide concentrations were determined at 0, 60, 120 minutes after the intervention. Independent t-tests and repeated measures ANOVA were used to analyze data.

RESULTS

The mean serum glucose levels were significantly decreased in RJ and placebo groups; however, mean serum level was different but not statistically. (P = 0.77). One hour after RJ ingestion the mean serum insulin concentrations were increased and after 2 hours it was decreased insignificantly (P = 0.54, P = 0.20). The mean C-peptide concentrations were significantly increased after 1 and 2 hours of RJ ingestion; however, in the placebo group we observed a slight but insignificant reduction at the time of 1 and 2 hours in the mean C-peptide serum levels (P = 0.40). Moreover, there was no significant difference in none of the glycemic control parameters between both studied groups (P > 0.05).

CONCLUSIONS

It seems that RJ does not appear to have significant immediate effects on glycemic factors in patients with type 2 diabetes. However, further studies with larger sample sizes and different doses of RJ are needed to achieve more precise results.

Delayed Gastric Emptying Is Associated With Early and Long-term Hyperglycemia in Type 1 Diabetes Mellitus

BACKGROUND & AIMS

After the Diabetes Control and Complications Trial (DCCT), the Epidemiology of Diabetes Interventions and Complications (EDIC) study continued to show persistent benefit of prior intensive therapy on neuropathy, retinopathy, and nephropathy in type 1 diabetes mellitus (DM). The relationship between control of glycemia and gastric emptying (GE) is unclear.

METHODS

We assessed GE with a (13)C-spirulina breath test and symptoms in 78 participants with type 1 diabetes at year 20 of EDIC. The relationship between delayed GE and glycated hemoglobin (HbA1c), complications of DM, and gastrointestinal symptoms were evaluated.

RESULTS

GE was normal (37 participants; 50%), delayed (35 participants; 47%), or rapid (2 participants; 3%). The latest mean HbA1c was 7.7%. In univariate analyses, delayed GE was associated with greater DCCT baseline HbA1c and duration of DM before DCCT (P ≤ .04), greater mean HbA1c over an average of 27 years of follow-up evaluation (during DCCT-EDIC, P = .01), lower R-R variability during deep breathing (P = .03) and severe nephropathy (P = .05), and a greater composite upper gastrointestinal symptom score (P < .05). In multivariate models, retinopathy was the only complication of DM associated with delayed GE. Separately, DCCT baseline HbA1c (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.3) and duration of DM (OR, 1.2; 95% CI, 1.01-1.3) before DCCT entry and mean HbA1c during DCCT-EDIC (OR, 2.2; 95% CI, 1.04-4.5) were associated independently with delayed GE.

CONCLUSIONS

In the DCCT/EDIC study, delayed GE was remarkably common and associated with gastrointestinal symptoms and with measures of early and long-term hyperglycemia. ClinicalTrials.gov numbers NCT00360815 and NCT00360893.

Potential mechanism for osseointegration of dental implants in Zucker diabetic fatty rats

Our aim was to investigate the impact of diabetes mellitus and different durations of glycaemic control on early osseointegration of dental implants, and to explore possible mechanisms by measuring the expression of integrin α5β1 and fibronectin in bone around the implant. We divided 33 male Zucker diabetic fatty (ZDF) rats aged 3 months into 3 groups. The first group comprised diabetic rats with dental implants (controls); the second group was treated with insulin and implants were placed simultaneously (exenatide alone group); and the third group was treated with insulin until the serum glucose was at a constant concentration (< 16 mmol/L), and implants were then inserted (exenatide+normal glucose group). Rats were killed 7, 14, 30, and 60 days after implants had been inserted. The expression of integrin α5β1 and fibronectin in bone around the implants was detected by immunohistochemical analysis in each group. The expression in the exenatide+normal glucose group was stronger than in the other 2 groups. Fourteen days after implantation, expression of integrin α5β1 in the exenatide alone group was significantly stronger than that in the control group (p=0.027), and 60 days after implantation the expression of fibronectin in the exenatide alone group was also significantly stronger than that among the controls (p=0.001). Both fibronectin and integrin α5β1 participate in the adhesion of osteoblasts and act as signals at the bone/implant interface. Diabetes interferes with the osseointegration of implants by deferring expression of fibronectin and integrin α5β1.

Bacterial infections in patients with type 1 diabetes: a 14-year follow-up study

OBJECTIVE

This study explored the annual occurrence/incidence of bacterial infections, and their association with chronic hyperglycemia and diabetic nephropathy, in patients with type 1 diabetes.

DESIGN

In a register-based follow-up study, we investigated the frequency of bacterial infections in patients with type 1 diabetes (n=4748) and age-matched and sex-matched non-diabetic control (NDC) subjects (n=12 954) using nationwide register data on antibiotic drug prescription purchases and hospital discharge diagnoses, collected between 1996 and 2009. Diabetic nephropathy was classified based on the urinary albumin excretion rate (AER).

RESULTS

The hospitalization rate due to bacterial infections was higher in patients with diabetes compared with NDCs (rate ratio (RR) 2.30 (95% CI 2.11 to 2.51)). The rate correlated with the severity of diabetic nephropathy: RR for microalbuminuria was 1.23 (0.94 to 1.60), 1.97 (1.49 to 2.61) for macroalbuminuria, 11.2 (8.1 to 15.5) for dialysis, and 6.72 (4.92 to 9.18) for kidney transplant as compared to patients with diabetes and normal AER. The annual number of antibiotic purchases was higher in patients with diabetes (1.00 (1.00 to 1.01)) as compared with NDCs (0.47 (0.46 to 0.47)), RR=1.71 (1.65 to 1.77). Annual antibiotic purchases were 1.18-fold more frequent in patients with microalbuminuria, 1.29-fold with macroalbuminuria, 2.43-fold with dialysis, and 2.74-fold with kidney transplant as compared to patients with normal AER. Each unit of increase in glycated hemoglobin was associated with a 6-10% increase in the number of annual antibiotic purchases.

CONCLUSIONS

The incidence of bacterial infections was significantly higher in patients with type 1 diabetes compared with age-matched and sex-matched NDC subjects, and correlated with the severity of diabetic nephropathy in inpatient and outpatient settings.

Initiation of human regular U-500 insulin use is associated with improved glycemic control: a real-world US cohort study

AIM

Describe the characteristics of patients initiating human regular U-500 insulin (U-500R) and their subsequent glycemic control in a real-world setting.

METHODS

US Humedica electronic health record system data (July 2007-September 2011) were used to identify patients with diabetes aged ≥18 years with ≥1 records for U-500R prescriptions, 6 months of preindex data, 12 months following first use of U-500R, and at least one glycated hemoglobin (HbA1c) value in both preindex and postindex periods. Paired t tests were used to measure the change in HbA1c from preindex to postindex periods (last or most recent values) and hypoglycemia.

RESULTS

Among patients initiating U-500R (N=445), 96.9% had type 2 diabetes with mean age 57 years and mean body mass index 40.4 kg/m(2). Postindex prescriptions were written for U-500R alone (47.0%, group A) and concomitant U-500R/U-100 insulins (53.0%, group B). Concomitant oral antihyperglycemic agents (AHAs) and non-insulin injectable AHAs were used by 43.4% and 14.6% of patients, respectively. Following initiation of U-500R, mean HbA1c improved 0.68% in all patients (p<0.0001 compared with baseline), but the decrease in HbA1c did not differ significantly between groups (A: 0.78%; B: 0.60%). Overall, hypoglycemic events, largely captured in the outpatient setting, increased in incidence from 6.7% to 11.9% (p≤0.0001) and from 0.23 to 0.39 events/patient/year, an increase of 0.16 (p=0.003), from preindex to postindex.

CONCLUSIONS

This real-world outcomes analysis demonstrates that U-500R initiation is associated with a clinically meaningful improvement in glycemic control over the subsequent 12-month period with modest increase in incidence and rate of hypoglycemia.

Functional health literacy and glycaemic control in older adults with type 2 diabetes: a cross-sectional study

OBJECTIVES

To investigate the relationship between functional health literacy and glycaemic control in a sample of older patients with type 2 diabetes.

DESIGN

Cross-sectional study.

SETTING

A government-financed outpatient geriatric clinic in São Paulo, Brazil.

PARTICIPANTS

129 older patients with type 2 diabetes, a mean (SD) age of 75.9 (6.2) years, a mean glycosylated haemoglobin (HbA1c) of 7.2% (1.4), of which 14.7% had no formal education and 82.9% had less than a high-school diploma.

MEASURES

HbA1c was used as a measure of glycaemic control. Functional health literacy was assessed with the 18-item Short Assessment of Health Literacy for Portuguese-speaking Adults (SAHLPA-18), a validated instrument to evaluate pronunciation and comprehension of commonly used medical terms. Regression models were controlled for demographic data, depressive symptoms, diabetes duration, treatment regimen, diabetes knowledge and assistance for taking medications.

RESULTS

Functional health literacy below adequate was encountered in 56.6% of the sample. After controlling for potential confounding factors, patients with inadequate functional health literacy were more likely than patients with adequate functional health literacy to present poor glycaemic control (OR=4.76; 95% CI 1.36 to 16.63). In a fully adjusted linear regression model, lower functional health literacy (β=-0.42; p<0.001), longer diabetes duration (β=0.24; p=0.012) and lack of assistance for taking medications (β=0.23; p=0.014) were associated with higher levels of HbA1c. Contrary to our expectations, illiterate patients did not have poorer outcomes when compared with patients with adequate functional health literacy, raising the hypothesis that illiterate individuals are more likely to have their difficulties recognised and compensated. However, the small subsample of illiterate patients provided limited power to reject differences with small magnitude.

CONCLUSIONS

Patients with inadequate functional health literacy presented with higher odds of poor glycaemic control. These findings reinforce the importance of addressing limited functional health literacy in clinical practice.

Age at diagnosis predicts deterioration in glycaemic control among children and adolescents with type 1 diabetes

BACKGROUND

Poor glycemic control early in the course of type 1 diabetes mellitus (T1DM) increases the risk for microvascular complications. However, predictors of deteriorating control after diagnosis have not been described, making it difficult to identify high-risk patients and proactively provide aggressive interventions.

OBJECTIVE

We examined whether diagnostic age, gender, and race were associated with deteriorating glycemic control during the first 5 years after diagnosis.

PARTICIPANTS

2218 pediatric patients with T1DM.

METHODS

We conducted a longitudinal cohort study of pediatric patients with T1DM from the Midwest USA, 1993-2009, evaluating within-patient glycated hemoglobin (HbA1c) trajectories constructed from all available HbA1c values within 5 years of diagnosis.

RESULTS

52.6% of patients were male; 86.1% were non-Hispanic Caucasian. The mean diagnostic age was 9.0±4.1 years. The mean number of HbA1c values/year/participant was 2.4±0.9. HbA1c trajectories differed markedly across age groups, with older patients experiencing greater deterioration than their younger counterparts (p<0.001). HbA1c trajectories, stratified by age, varied markedly by race (p for race×diagnostic age <0.001). Non-Hispanic African-American patients experienced higher initial HbA1c (8.7% vs 7.6% (71.6 vs 59.6 mmol/mol); p<0.001), and greater deterioration in HbA1c than non-Hispanic Caucasian patients across diagnostic ages (rise of 2.04% vs 0.99% per year (22.3 vs 10.8 mmol/mol/year); p<0.0001).

CONCLUSIONS

Older diagnostic age and black race are major risk factors for deterioration in glycemic control early in the course of T1DM. These findings can inform efforts to explore the reasons behind these differences and develop preventive interventions for high-risk patients.

Female sex as a risk factor for glycemic control and complications in Iranian patients with type one diabetes mellitus

OBJECTIVE

The aim of this study was to evaluate the influence of sex on glycemic control, diabetes complications and associated abnormalities in patients with type one diabetes mellitus.

METHODS

In a cross-sectional study in 309 patients (156 females and 153 males within the age range of 3-16 years) with type one diabetes mellitus referred to endocrinology clinic in Children's Medical Center in Tehran from March 2005 to March 2007 gender differences in diabetes control were analyzed.

FINDINGS

Mean glycosylated hemoglobin (HbA1c), was significantly higher in females (9.25 vs. 8.01). Insulin dose per kilogram of body weight was significantly more in girls (0.91±0.31 vs. 0.74±0.37, P<0.001) self monitoring of blood glucose was performed significantly more in boys. Frequency of Diabetic ketoacidosis, height growth problems and dyslipidemia were significantly higher in girls. 1.20±0.86 vs. 0.93±0.55, P=0.004), (-0.05±1.20 vs. -0.41±1.17, P=0.015), (134.60±44.43 vs. 110.56±20.72, P=<0.001) respectively.

CONCLUSION

Female sex is a risk factor in glycemic control and complications of diabetes type I and females should be managed more seriously regarding self monitoring of blood glucose, nutritional and psychological factors and puberty issues.

Personality characteristics, environmental factors and glycemic control in adolescents with diabetes

Metabolic control in adolescents with diabetes is difficult to achieve and seems to depend in part on personality and the family environment. We tried to identify relevant characteristics in this study. We administered the Children's Manifest Anxiety Scale, a Self-Competence scale, a Locus of Control Scale, and a structured interview, to 40 adolescent diabetics and 39 healthy controls, and the Rotter Locus of Control Scale to mothers. There were indications of more depressive thoughts and feelings (P=0.036) and slightly more anxiety (P=0.065) in the diabetics than in the controls. The diabetics who put in more effort at school had better metabolic control. Also, the diabetics who worried about their illness (P=0.021) and the ones who belonged to lower social class (P=0.011) had poorer metabolic control than others. The diabetics did not differ in locus of control and self-competence from controls. Locus of control, self-competence and anxiety were not correlated to HbA_1c values.