Association Between Gut Microbiota and Insulin Therapy in Women With Gestational Diabetes Mellitus

OBJECTIVES

At the time of diagnosis, the blood glucose of women with gestational diabetes mellitus (GDM) who require subsequent insulin treatment does not differ from that of women with adequate diet control. Hence, in this study, we aimed to determine the role of maternal gut microbiota as a marker of insulin necessity in GDM and to identify the effect of insulin therapy on gut microbiota composition in mothers with GDM and their newborns.

METHODS

Seventy-one pregnant women were enrolled into the study, including 38 GDM and 33 non-GDM participants. During the follow-up period, 8 of the 38 GDM subjects required insulin therapy (GDM-I group), whereas 30 of the 38 GDM cases with sufficient glycemic control by diet alone (GDM-D group). Maternal blood and feces were obtained at the time of GDM diagnosis (pretreatment; 24 to 28 weeks of gestation) and before delivery (posttreatment; ≥37 weeks of gestation). Meconium and first feces of the newborns were also collected.

RESULTS

Pretreatment, the glycemic profile did not differ between the GDM-D and GDM-I groups. However, the proportions of Clostridiales, Lactobacillus and Bacteroidetes were higher in the GDM-I group than in the non-GDM and GDM-D groups. After treatment, gut microbiota composition showed no difference between non-GDM and GDM-I groups. Interestingly, a higher Firmicutes/Bacteroidetes (F/B) ratio was displayed in GDM-D mothers at posttreatment, and this was also observed in both meconium and first feces of GDM-D newborns.

CONCLUSION

Insulin therapy changed maternal gut microbiota composition, which could be transferable to the mothers' newborns.

Efficacy of Carbohydrate Supplementation Compared With Bolus Insulin Dose Reduction Around Exercise in Adults With Type 1 Diabetes: A Retrospective, Controlled Analysis

OBJECTIVES

Individuals with type 1 diabetes try to manage the risk of exercise-induced hypoglycemia by either pre-exercise/pre-meal bolus insulin dose reductions and/or consuming additional carbohydrates during exercise. Both strategies have proven to be effective in offsetting hypoglycemia, but it remains unclear which one is more beneficial. The aim of this study was to assess the efficacy of carbohydrate supplementation vs bolus insulin dose reduction in prevention of hypoglycemia during moderate-intensity exercise in those with type 1 diabetes.

METHODS

This investigation was a retrospective, controlled analysis of 2 independent clinical trials. All participants performed continuous, moderate-intensity cycle ergometer exercise for ∼45 minutes. Two therapy management groups and a control group were compared. Group A was supplemented with 15 to 30 g carbohydrates at a glycemic threshold of 7.0 mmol/L during exercise, group B reduced their individual bolus insulin dose by 50% with their last meal before exercise and group C served as a control.

RESULTS

No hypoglycemic events occurred in group A, whereas 4 events were recorded in groups B (p=0.02) and C (p=0.02).

CONCLUSIONS

Carbohydrate supplementation was superior to bolus insulin reduction for prevention of hypoglycemia during exercise in people with type 1 diabetes.

Evaluation of a Province-Wide Type 1 Diabetes Care Plan for Children in the School Setting

OBJECTIVES

The aim of this study was to identify perceptions of safety and effectiveness of a provincial type 1 diabetes school care plan, and to best inform future improvements in school care to accommodate the shifting needs of families, best clinical practices and new medical technologies.

METHODS

A cross-sectional satisfaction and feedback questionnaire to inform quality improvement was offered to both families of children with type 1 diabetes who receive care at school through a Delegated Diabetes Care Plan and to their program coordinators during the 2017‒2018 school year.

RESULTS

The response rate was 29.8% (160 of 537) for families and 68.2% (45 of 66) for coordinators. The majority of parents and coordinators reported that the care plan is meeting both safety and diabetes management needs. On a 7-point Likert scale, the safety score, expressed as mean (standard deviation), was 6.0 (1.2) by families and 5.7 (1.3) by coordinators, with higher scores reflecting greater satisfaction. Diabetes management was rated 5.6 (1.2) out of 7 by families, and 5.4 (0.8) out of 7 by coordinators. Families and coordinators expressed the need for individualization of care, and suggested modifications to how information is presented. There was near-unanimous support for future integration of continuous glucose-monitoring devices into the school setting.

CONCLUSIONS

British Columbia's provision of diabetes care in the school setting is overall perceived to be safe and is generally well received by families and coordinators. In this study, we provide valuable information to improve the care of children with type 1 diabetes in schools, including support for further individualization of care and future integration of diabetes technology into the school setting.

Qualitative Evaluation of the Barriers and Facilitators Influencing the Use of an Electronic Basal Bolus Insulin Therapy Protocol to Improve the Care of Adult Inpatients With Diabetes

OBJECTIVES

A qualitative evaluation of the perceived impact of a new evidence-informed electronic basal bolus insulin therapy order set on clinical workflow and practice, and exploration of potential barriers and facilitators to electronic basal bolus insulin order set uptake and use in acute care facilities for various acute care team members.

METHODS

We conducted 9 semistructured focus groups with multidisciplinary nursing staff (n=22), resident trainees (n=24) and attending physicians (n=23) involved in the delivery of inpatient diabetes care at 3 adult acute care facilities. The domains of inquiry included impact on workload, perceived impact on patient care and discipline-specific barriers and facilitators to use, including care-providers' needs, comfort and competencies, contributions from the clinical environment and efficacy of communication. The interviews were transcribed and analyzed using a content analysis approach.

RESULTS

Several major themes emerged from the focus group discussions, including impact of education, information technology/user interface, workflow, organizational issues and practices, and perceived outcomes. Barriers and facilitators were identified relating to each theme.

CONCLUSIONS

The outcomes highlight the complex interplay between educational, organizational and technical themes and the significance of employing a systemic approach to support the implementation of electronic inpatient glycemic-management protocols within complex social organizations.

[The artificial pancreas, a dream on the point of becoming reality]

Almost 45 000 patients with type 1 diabetes are concerned in France by outpatient insulin pump therapy. The first systems of insulin pump therapy guided by glycaemia have evolved driven by the work carried out by multi-disciplinary research teams. Today, the outpatient treatment of type 1 diabetes by an artificial pancreas is on the point of becoming reality.

[Insulin therapy in type 2 diabetes: a review of "when" over "how" up to "why"]

Type 2 Diabetes is characterized by its progressive character. An intensification of the therapy is necessary in most cases over the years and insulin is typically used as an add-on agent when oral antidiabetic regimes are judged to be no longer sufficient. However, insulin can also be used in the initial phase of the disease directly after diagnosis of diabetes. Intermittent worsening of glycemic control (e.g. due to infectious diseases or corticosteroids) may be additional indications for an insulin treatment at an earlier stage. Noticeably, insulin can often be stopped if the triggering event or treatment is reversible, thereby countering the widely spread fear of dependency on insulin. We recommend a rather cautious starting dose of insulin and individual adaptations thereafter. Well-informed patients can also perform such adaptations themselves.

Impact of insulin treatment in diabetic macular edema therapy in type 2 diabetes

OBJECTIVE

To evaluate the impact of insulin therapy on the outcomes of diabetic macular edema (DME) treatment with vascular endothelial growth factor (VEGF) inhibitors in people with type 2 diabetes.

METHODS

A retrospective consecutive case series of 95 patients with type 2 diabetes and DME who were treated with anti-VEGF therapy. We examined 2 cohorts: patients taking only oral antidiabetic agents and patients on insulin therapy. The main outcome measures were change in visual acuity and change in central subfield macular thickness measured by spectral-domain optical coherence tomography. The additional variables analyzed included glycated hemoglobin (A1C), creatinine, blood pressure and body mass index and their correlations with clinical findings.

RESULTS

Both groups had a statistically significant improvement in visual acuity (oral antidiabetic agents group: 20/61 to 20/49, p=0.003; insulin therapy group: 20/76 to 20/56, p=0.005). There was no difference between groups at initial or 12-month examination (p=0.239 and p=0.489, respectively). From an anatomic standpoint, central subfield macular thickness also improved significantly in both groups: from 454.7 μm to 354.9 μm (p<0.001) in the oral antidiabetic agents group and from 471.5 μm to 368.4 μm (p<0.001) in the insulin therapy group. Again, there was no significant difference between groups at initial or 12-month follow-up examinations (p=0.586 and p=0.591, respectively). Mean A1C levels remained relatively stable during the follow up in both groups.

CONCLUSION

Anti-VEGF therapy is a useful treatment for DME. This study suggests that chronic insulin therapy, compared with oral antidiabetic agents, does not modify the anatomic or functional effectiveness of DME treatment.