Prevalence of Therapeutic Inertia in the Management of Overweight and Obesity in Patients With a Diagnosis of Type 2 Diabetes Who Are Followed up by Primary Care Physicians.

There is growing interest in understanding and addressing factors that govern the decision-making process in multiple sclerosis (MS) care. Therapeutic inertia (TI) is the failure to escalate therapy when goals are unmet. Limited data are available on the prevalence of TI and factors affecting therapeutic decisions in the management of patients with MS worldwide. To compare TI across 4 countries (Canada, Argentina, Chile, and Spain) and to identify factors contributing to TI. Prospective cohort study conducted between July 10, 2017, and May 4, 2018. Participants were exposed to behavioral experiments in which instruments were used to assess their risk preferences (eg, aversion to ambiguity) and therapeutic decisions in 10 simulated MS case scenarios. Mixed-effects linear and logistic regression analyses were performed to determine the association between the participants' baseline characteristics and TI. The association of unmeasured confounders was assessed by the E-value and a bootstrapping analysis. This multicenter study included neurologists practicing at academic and community centers in Canada, Argentina, Chile, and Spain who make therapeutic decisions for patients with MS. The primary outcome was the prevalence of TI. The TI score was calculated by dividing the number of case scenarios in which participants showed TI by the number of case scenarios that measured TI. Higher TI scores indicated greater degrees of TI. The secondary outcome was the identification of factors that contributed to TI. Of 300 neurologists with expertise in MS care who were invited to be part of the study, 226 (75.3%) agreed to participate. Among those who initially showed interest in participating, 195 physicians (86.3%) completed the study, while 31 did not. The mean (SD) age of participants was 43.3 (11.2) years; 52.3% were male. Therapeutic inertia was present in 72.8% (142 of 195) of participants, leading to suboptimal decisions in 20.4% (318 of 1560) of case scenarios. The prevalence of TI among the Canadian group was the lowest compared with the other 3 countries (60.0% [33 of 55] vs 77.9% [109 of 140]; P = .01). For the primary outcome, the TI score in the Canadian group (mean [SD], 0.98 [1.15]) was significantly lower compared with groups from other countries (mean [SD], 1.70 [1.43] for Argentina, 2.24 [1.54] for Chile, and 2.56 [1.64] for Spain) (P = .001). The mixed-effects linear models revealed that participants from Argentina, Chile, and Spain (combined) had higher TI scores compared with their Canadian counterparts (β coefficient, 0.90; 95% CI, 0.52-1.28; P < .001). A higher number of patients with MS per week (OR, 0.44; 95% CI, 0.22-0.88), years of practice (OR, 0.93; 95% CI, 0.86-0.99), and participation from Canada (OR, 0.47; 95% CI, 0.23-0.96) were associated with a lower likelihood of TI. Aversion to ambiguity was associated with a 2-fold higher likelihood of TI (OR, 2.25; 95% CI, 1.02-5.00). All 95% CIs of the β coefficients of covariates were lower than the E-value of 2.35, making it unlikely for the results to be due to the association of unmeasured confounders. This study showed that Canadian participants had the lowest prevalence and magnitude of TI. Higher TI scores were associated with a lower expertise in MS care and with a greater tendency for aversion to ambiguity.

Type 2 treatments for type 1 diabetes.

Obesity and chronic kidney disease (CKD) are highly prevalent worldwide and result in substantial health care costs. Obesity is a predictor of incident CKD and progression to kidney failure. Whether weight loss interventions are safe and effective to impact on disease progression and clinical outcomes, such as death remains unclear. This review aimed to evaluate the safety and efficacy of intentional weight loss interventions in overweight and obese adults with CKD; including those with end-stage kidney disease (ESKD) being treated with dialysis, kidney transplantation, or supportive care. We searched the Cochrane Kidney and Transplant Register of Studies up to 14 December 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Randomised controlled trials (RCTs) and quasi-RCTs of more than four weeks duration, reporting on intentional weight loss interventions, in individuals with any stage of CKD, designed to promote weight loss as one of their primary stated goals, in any health care setting. Two authors independently assessed study eligibility and extracted data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess the certainty of evidence. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised mean difference (SMD) for continuous outcomes or in descriptive format when meta-analysis was not possible. We included 17 RCTs enrolling 988 overweight or obese adults with CKD. The weight loss interventions and comparators across studies varied. We categorised comparisons into three groups: any weight loss intervention versus usual care or control; any weight loss intervention versus dietary intervention; and surgical intervention versus non-surgical intervention. Methodological quality was varied, with many studies providing insufficient information to accurately judge the risk of bias. Death (any cause), cardiovascular events, successful kidney transplantation, nutritional status, cost effectiveness and economic analysis were not measured in any of the included studies. Across all 17 studies many clinical parameters, patient-centred outcomes, and adverse events were not measured limiting comparisons for these outcomes. In studies comparing any weight loss intervention to usual care or control, weight loss interventions may lead to weight loss or reduction in body weight post intervention (6 studies, 180 participants: MD -3.69 kg, 95% CI -5.82 to -1.57; follow-up: 5 weeks to 12 months, very low-certainty evidence). In very low certainty evidence any weight loss intervention had uncertain effects on body mass index (BMI) (4 studies, 100 participants: MD -2.18 kg/m², 95% CI -4.90 to 0.54), waist circumference (2 studies, 53 participants: MD 0.68 cm, 95% CI -7.6 to 6.24), proteinuria (4 studies, 84 participants: 0.29 g/day, 95% CI -0.76 to 0.18), systolic (4 studies, 139 participants: -3.45 mmHg, 95% CI -9.99 to 3.09) and diastolic blood pressure (4 studies, 139 participants: -2.02 mmHg, 95% CI -3.79 to 0.24). Any weight loss intervention made little or no difference to total cholesterol, high density lipoprotein cholesterol, and inflammation, but may lower low density lipoprotein cholesterol. There was little or no difference between any weight loss interventions (lifestyle or pharmacological) compared to dietary-only weight loss interventions for weight loss, BMI, waist circumference, proteinuria, and systolic blood pressure, however diastolic blood pressure was probably reduced. Furthermore, studies comparing the efficacy of different types of dietary interventions failed to find a specific dietary intervention to be superior for weight loss or a reduction in BMI. Surgical interventions probably reduced body weight (1 study, 11 participants: MD -29.50 kg, 95% CI -36.4 to -23.35), BMI (2 studies, 17 participants: MD -10.43 kg/m², 95% CI -13.58 to -7.29), and waist circumference (MD -30.00 cm, 95% CI -39.93 to -20.07) when compared to non-surgical weight loss interventions after 12 months of follow-up. Proteinuria and blood pressure were not reported. All results across all comparators should be interpreted with caution due to the small number of studies, very low quality of evidence and heterogeneity across interventions and comparators. All types of weight loss interventions had uncertain effects on death and cardiovascular events among overweight and obese adults with CKD as no studies reported these outcome measures. Non-surgical weight loss interventions (predominately lifestyle) appear to be an effective treatment to reduce body weight, and LDL cholesterol. Surgical interventions probably reduce body weight, waist circumference, and fat mass. The current evidence is limited by the small number of included studies, as well as the significant heterogeneity and a high risk of bias in most studies.

Background Obesity and chronic kidney disease (CKD) are highly prevalent worldwide and result in substantial health care costs. Obesity is a predictor of incident CKD and progression to kidney failure. Whether weight loss interventions are safe and effective to impact on disease progression and clinical outcomes, such as death remains unclear. Objectives This review aimed to evaluate the safety and efficacy of intentional weight loss interventions in overweight and obese adults with CKD; including those with end-stage kidney disease (ESKD) being treated with dialysis, kidney transplantation, or supportive care. Search methods We searched the Cochrane Kidney and Transplant Register of Studies up to 14 December 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi-RCTs of more than four weeks duration, reporting on intentional weight loss interventions, in individuals with any stage of CKD, designed to promote weight loss as one of their primary stated goals, in any health care setting. Data collection and analysis Two authors independently assessed study eligibility and extracted data. We applied the Cochrane 'Risk of Bias' tool and used the GRADE process to assess the certainty of evidence. We estimated treatment effects using random-effects meta-analysis. Results were expressed as risk ratios (RR) for dichotomous outcomes together with 95% confidence intervals (CI) or mean differences (MD) or standardised mean difference (SMD) for continuous outcomes or in descriptive format when meta-analysis was not possible. Main results We included 17 RCTs enrolling 988 overweight or obese adults with CKD. The weight loss interventions and comparators across studies varied. We categorised comparisons into three groups: any weight loss intervention versus usual care or control; any weight loss intervention versus dietary intervention; and surgical intervention versus non-surgical intervention. Methodological quality was varied, with many studies providing insufficient information to accurately judge the risk of bias. Death (any cause), cardiovascular events, successful kidney transplantation, nutritional status, cost effectiveness and economic analysis were not measured in any of the included studies. Across all 17 studies many clinical parameters, patient-centred outcomes, and adverse events were not measured limiting comparisons for these outcomes. In studies comparing any weight loss intervention to usual care or control, weight loss interventions may lead to weight loss or reduction in body weight post intervention (6 studies, 180 participants: MD -3.69 kg, 95% CI -5.82 to -1.57; follow-up: 5 weeks to 12 months, very low-certainty evidence). In very low certainty evidence any weight loss intervention had uncertain effects on body mass index (BMI) (4 studies, 100 participants: MD -2.18 kg/m², 95% CI -4.90 to 0.54), waist circumference (2 studies, 53 participants: MD 0.68 cm, 95% CI -7.6 to 6.24), proteinuria (4 studies, 84 participants: 0.29 g/day, 95% CI -0.76 to 0.18), systolic (4 studies, 139 participants: -3.45 mmHg, 95% CI -9.99 to 3.09) and diastolic blood pressure (4 studies, 139 participants: -2.02 mmHg, 95% CI -3.79 to 0.24). Any weight loss intervention made little or no difference to total cholesterol, high density lipoprotein cholesterol, and inflammation, but may lower low density lipoprotein cholesterol. There was little or no difference between any weight loss interventions (lifestyle or pharmacological) compared to dietary-only weight loss interventions for weight loss, BMI, waist circumference, proteinuria, and systolic blood pressure, however diastolic blood pressure was probably reduced. Furthermore, studies comparing the efficacy of different types of dietary interventions failed to find a specific dietary intervention to be superior for weight loss or a reduction in BMI. Surgical interventions probably reduced body weight (1 study, 11 participants: MD -29.50 kg, 95% CI -36.4 to -23.35), BMI (2 studies, 17 participants: MD -10.43 kg/m², 95% CI -13.58 to -7.29), and waist circumference (MD -30.00 cm, 95% CI -39.93 to -20.07) when compared to non-surgical weight loss interventions after 12 months of follow-up. Proteinuria and blood pressure were not reported. All results across all comparators should be interpreted with caution due to the small number of studies, very low quality of evidence and heterogeneity across interventions and comparators. Authors' conclusions All types of weight loss interventions had uncertain effects on death and cardiovascular events among overweight and obese adults with CKD as no studies reported these outcome measures. Non-surgical weight loss interventions (predominately lifestyle) appear to be an effective treatment to reduce body weight, and LDL cholesterol. Surgical interventions probably reduce body weight, waist circumference, and fat mass. The current evidence is limited by the small number of included studies, as well as the significant heterogeneity and a high risk of bias in most studies.

The Diabetes UK Professional Conference, held in London in March, included presentations focusing on what's new in dietary advice, foods for glycaemic control and cardiovascular disease prevention, and the management of liver disease. Felix David here reports on key factors for diabetes care. The prevalence of diagnosed diabetes is significantly higher among most ethnic minorities than in the general population. In her presentation, Dr Louise Goff, Senior Lecturer in Nutrition and Dietetics at King's College London, explained how culturally tailored prevention programmes are vital to help engage with ethnic minorities at high risk of developing diabetes. Across all age ranges, Afro-Caribbeans and South Asians have a significantly higher risk than white Europeans of developing type 2 diabetes (T2D) in the overweight and normal weight categories.1 A 2004 Health Survey2 showed 10.4% of black Caribbean men and 8.4% of black Caribbean women were diagnosed with diabetes, compared to 4.3% of men and 3.4% of women in the host population. This disparity was also significant among men and women from Indian (10% and 5.9%, respectively), Pakistani (7.3% and 8.6%) and Bangladeshi (8.2% and 5.2%) ethnic groups.2 Numerous environmental, genetic, socio-economic and cultural factors help account for this disparity in diabetes risk. ‘Language barriers, poor health literacy and low socio-economic position also all contribute to poor health care access and engagement among ethnic minorities,’ said Dr Goff, ‘which results in poor glycaemic control and higher levels of medical complications.’ Ramadan, for example, is associated with a seven-fold higher incidence of severe hypoglycaemia in patients with T2D – yet evidence shows that structured education plans given in the weeks before Ramadan can reduce acute complications.3 ‘There are numerous ways in which we can tailor the treatment of ethnic minority patients with type 2 diabetes,’ said Dr Goff. ‘These include: greater community engagement; consideration of a patient's socio-economic status and language barriers; the delivery of education information in the appropriate language; along with visual aids for low-literacy needs and providing practical advice on cultural foods and cooking methods.’ Utilising communal centres of faith, such as mosques and churches, was also demonstrated as a useful way to target high-risk minority groups that are less likely to use conventional routes to engage with the health care system. ‘The good news is that culturally tailored education programmes do seem to work,’ said Dr Goff. A Cochrane review4 of 33 trials demonstrated significant improvements in glycaemic control in participants with T2D that were given culturally tailored education. Glycaemic improvements were maintained at six, 12 and 24 months, with a significant reduction in HbA1c at three months (-0.39% [-1.19, -0.30], p=0.003) and at 12 months (-0.19% [-0.34, -0.04], p=0.02).4 At six months, the study also found significant improvement in diabetes knowledge among participants given culturally tailored education (0.50 [0.33, 0.68), p<0.001).4 However, only four of the 33 trials used in the Cochrane study were based on a UK ethnic minority (each South Asian), while 27 of the trials were from US ethnic minority groups (14 Hispanic, 12 African-American and one American Samoan). ‘As the US clearly has an ethnic minority demographic different from the UK, for example by having a sizeable Hispanic population, the trial data from this study cannot simply be translated to UK minorities who have their own cultural and environmental differences. The difficulty is that there is a paucity of UK studies into diabetes prevention programmes,’ said Dr Goff. In order to successfully create a culturally tailored intervention programme ‘it is vital to work with the community to produce it’, said Dr Goff. From the available data, reductions in HbA1c in ethnic minority groups are best achieved when face-to-face interventions are used instead of telecommunication, along with a combination of group and individual education sessions and the involvement of a peer educator. Selecting which diet is best is highly controversial among the general public, as well as in health care. In his presentation, Dr Duane Mellor, Senior Lecturer in Human Nutrition at Coventry University, aimed to help clinicians negotiate the calorie minefield in the treatment of their diabetic patients. ‘So what's new in food-based recommendations?’ asked Dr Mellor. ‘Mainly, there is an increasing move away from nutrient-based recommendations to describe food and dietary patterns. People don't eat in terms of nutrients, they eat food – so telling them to consume the ideal proportion of macronutrients from carbohydrates is not helpful.’ But what does this mean in practice? In terms of dietary education for patients with type 1 diabetes, the recommendations have been simplified into two points to optimise carbohydrate intake for good glycaemic control: to adjust insulin-to- carbohydrate intake in patients using an insulin pump or multiple daily injections; and to aim for a consistent daily carbohydrate intake for patients on fixed insulin regimens.5 In patients with T2D the emphasis away from energy advice to information on dietary patterns is noticeable. There is a continued focus on weight management – and in overweight or obese individuals a sustained weight loss of at least 5% should be prioritised while also aiming for ≥150 minutes of physical exercise per week. With regard to diet, a Mediterranean-style or similar diet should be recommended in combination with individualised education informing patients how to use the low glycaemic index to monitor and (if necessary) reduce their carbohydrate intake. Close monitoring is important as weight management in patients with T2D is vital to improve treatment outcomes. Results from a recent meta-analysis showed weight loss of ≥5% in patients with T2D is needed to significantly improve glycaemic control, with longitudinal studies showing that weight loss in people with T2D was a significant predictor in being able to achieve HbA1c targets.5 In people with newly-diagnosed T2D, one study found that 86% of those who lost >15kg achieved remission of their T2D;6 while in bariatric surgery weight loss was not sustained post-surgery in the majority of patients.7 ‘However, in terms of what diet we should be recommending to achieve treatment targets, the evidence is conflicting,’ said Dr Mellor. ‘Terms like Mediterranean-style diet and Nordic-style diet are bandied around, but we don't really know what they include.’ A meta-analysis did show the Mediterranean diet can reduce HbA1c by up to 5mmol/mol (0.47%) when compared to a standard care or low fat diet;8 however, ‘diets like the Mediterranean-style one may not be suitable for all cultures and they may not always be realistic for people on the low economic spectrum to afford,’ said Dr Mellor. Similar confusion surrounds carbohydrate diets, despite the importance of carbohydrate in glycaemic control. A recent clinical trial found similar reductions in weight and HbA1c in patients with T2D who were placed on either low or high carbohydrate diets, though an increased reduction in diabetes medication was also seen in the low carbohydrate group.9 Generally though, ‘there is a lack of long-term studies on the effect of carbohydrate diets and a lack of clarity on what constitutes the definition of low carbohydrate,’ said Dr Mellor. ‘What we do know is that reducing saturated fats and replacing with good fats reduces the risk of cardiovascular disease, and there is good evidence that refined carbohydrates and saturated fats are bad.’ Rather than focusing on the superiority of a single diet in the long-term glycaemic management of T2D, it is better to combine a range of diets based on their nutritional quality and patient preference. If long-term adherence is to be realistically expected from patients, then diet plans need to be tailored to that individual. ‘We really need to start having conversations about how people can follow these diets and still enjoy food, rather than giving them as an all or nothing battle,’ concluded Dr Mellor. Type 2 diabetes is a leading cause of liver disease and its progression. In his presentation, Professor Quentin Anstee, Professor of Experimental Hepatology and Honorary Consultant Hepatologist at Newcastle University, informed the audience why it is vital that they look out for fatty liver disease in their diabetic patients. In the UK, liver disease stands out among chronic disorders such as heart disease, stroke and most cancers, as the only condition that has seen a significant increase in mortality over the last 30 years. This trend is peculiar to the UK, which has had a significantly higher increase in liver disease incidence than in other Western European countries – with a mortality rate that has increased by 400% since 1970.10 Liver disease is now the third most common cause of premature death in the UK, with a noticeable increase in the younger generation (the mortality of liver disease increased by five times in people aged <65 years since 1970).10 One of the reasons for this shift is that ‘we are all getting fatter,’ said Professor Anstee. ‘We are seeing an increase in cases of liver cancer that are not related to alcohol, with non-alcoholic fatty liver deposits rapidly becoming the underlying aetiology of liver disease.’ Non-alcoholic fatty liver disease (NALFD) is the broad term used to define the accumulation of abnormal fats in the liver in cases when alcohol consumption is <20/30g per day and when other causes for liver dysfunction, such as hepatotoxins, have also been excluded. The main histological features of NALFD are steatosis, Mallory-Denk bodies, ballooning hepatocyte degeneration and megamitochondria; with non- alcoholic steatohepatitis (NASH) a progressive subtype of NAFLD. Risk factors associated with NALFD and its progression are insulin resistance, obesity, cardiovascular disease, dyslipdaemia, and metabolic syndrome, ‘but the single biggest cause of liver disease progression is type 2 diabetes and this is key to understand the pathophysiology of this disease,’ said Professor Anstee. Estimates on the prevalence of NALFD in the general population vary, but one European study found it present in 94% of obese patients (BMI >30) and in 67% of overweight patients (BMI >25).11 ‘Even in organ donors, who we presume to be healthy, we find that 3–15% have fatty liver disease,’ said Professor Anstee. ‘In patients with NALFD, screening for diabetes is mandatory, and the EASD-EASL-EASO clinical guidelines recommend that we need to also be testing all patients with [type 2] diabetes for fatty liver deposits even if they do not present with liver problems.’ Thankfully, for patients with T2D, when asked if a liver biopsy is always necessary Professor Anstee responded ‘the answer is a resounding NO’. Liver disease is often asymptomatic and the majority of cases are discovered by chance, commonly in annual reviews in diabetes and hypertension clinics, or through statin monitoring. If liver disease is suspected, then the first steps are to gather a patient's history regarding alcohol intake (<14/21 units/week), and, if there is any pre-existing liver disease, followed by investigation into their liver biochemistry, primarily aspartate transaminase and alanine transaminase; and ultrasound imaging to detect steatosis and the level of fat deposit. ‘The use of biomarkers such as NFS or FIB4 in combination with a non-invasive test, for example FibroScan or an MR elastography, can help rule out patients unlikely to have significant disease,’ concluded Professor Anstee. References are available online at www.practicaldiabetes.com.

The Health Risks of Obesity Have Been Exaggerated.

This study compares the views of psychiatry residency training directors about psychiatry and mental health training in the primary care programs in their institutions with those of the primary care residency training directors. A 16-item questionnaire surveying specific areas of training and perceived adequacy of current teaching was distributed to 1,544 U.S. primary care and psychiatry program directors. The response rate was 53%. Among psychiatry training directors, 85% responded that psychiatry training in their primary care programs was minimal to suboptimal, while 68% of family practice training directors responded that their psychiatry training was optimal to extensive. Among psychiatry training directors, 89% were dissatisfied with the psychiatry training in their primary care programs, and only 8% were satisfied. In contrast, almost half of primary care training directors were satisfied. However, within the primary care programs, there was a marked difference between family practice (majority satisfied) and the rest (internal medicine, obstetrics and gynecology, pediatrics, mostly unsatisfied). All primary care and psychiatry training directors agreed that most basic psychiatric skills and diagnoses were taught in the primary care programs. For all skills and syndromes examined, psychiatry training directors consistently and significantly rated the training to be less adequate than did primary care training directors. There was general agreement that primary care physicians should be able to treat most uncomplicated cases in patients with psychiatric disorders, and some but not other psychiatric conditions. Psychiatry and primary care training directors, except in family practice, generally agree that psychiatry training in primary care programs is inadequate and should be significantly enhanced. There should be more communication between psychiatry and primary care training programs for optimal curriculum development.

The prevalence of obesity in the United States and the world has risen to epidemic/pandemic proportions. This increase has occurred despite efforts by healthcare providers and consumers alike to improve the health-related behaviors of the population and a tremendous push from the scientific community to better understand the pathophysiology of obesity. This epidemic is all the more concerning given the clear association between excess adiposity and adverse health consequences such as cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). These risks associated with overweight/obesity are primarily related to the deposition of excess adiposity or body fatness. Weight loss, specifically loss of body fat, is associated with benefits in all of the obesity-related comorbidities, but, unfortunately, most weight loss interventions are associated with weight regain and are therefore not successful in the long term. It is for these reasons that efforts to prevent weight gain and overweight/obesity are necessary. This is especially important when one considers younger individuals, who have even more to lose as a consequence of a longer duration of excess adiposity. After a brief review of the epidemiology of obesity, this statement will make the case for the importance of weight gain prevention. This argument will first include a review of the complications of overweight and obesity in both adults and children, including the future CVD risks of obesity in early life. Energy balance dysregulation and adaptations to the weight-reduced state, favoring weight regain, will then be reviewed as further argument for the need for obesity prevention. This will be followed by a discussion on the goals and strategies for accomplishing the difficult task of the prevention of weight gain and obesity. ### Classification of Overweight and Obesity The body mass index (BMI) is the most widely used and accepted method for the assessment and classification of excess adiposity or body fatness. Overweight …

Reprint: 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults.

IntroductionThe objective of this subgroup analysis is to investigate the effectiveness of liraglutide in people with type 2 diabetes (T2D) treated within the primary care physician (PCP) and specialist care settings.MethodsEVIDENCE is a prospective, observational study of 3152 adults with T2D recently starting or about to start liraglutide treatment in France. We followed patients in the PCP and specialist settings for 2 years to evaluate the effectiveness of liraglutide in glycemic control and body weight reduction. Furthermore, we evaluated the changes in combined antihyperglycemic treatments, the reasons for prescribing liraglutide, patient satisfaction, and safety of liraglutide in these two treatment settings.ResultsAfter 2 years of follow-up, 477 out of 1209 (39.0%) of PCP and 297 out of 1398 (21.2%) of specialist-treated patients still used liraglutide and maintained the glycated hemoglobin (HbA1c) target of <7.0%. Significant reductions from baseline were observed in both PCP- and specialist-treated cohorts in mean HbA1c (−1.22% and −0.8%, respectively), fasting plasma glucose (FPG) concentration (−39 and −23 mg/dL), body weight (−4.4 and −3.8 kg), and body mass index (BMI) (−1.5 and −1.4 kg/m2), all p < 0.0001. Reductions in HbA1c and FPG were significantly greater among PCP- compared with specialist-treated patients, p < 0.0001 for both. Patient treatment satisfaction was also significantly increased in both cohorts. Reported gastrointestinal adverse events were less frequent among PCP-treated patients compared with specialist-treated patients (4.5% vs. 16.1%).ConclusionDespite differences in demography and clinical characteristics of patients treated for T2D in PCP and specialty care, greater reduction in HbA1c and increased glycemic control durability were observed with liraglutide in primary care, compared with specialist care. These data suggest that liraglutide treatment could benefit patients in primary care by delaying the need for further treatment intensification.Trial RegistrationClinicalTrials.gov identifier, NCT01226966.FundingNovo Nordisk A/S.Electronic supplementary materialThe online version of this article (doi:10.1007/s12325-017-0476-0) contains supplementary material, which is available to authorized users.

Therapeutic inertia (TI) in blood pressure (BP) control has been traditionally defined as failure to initiate or intensify therapy when treatment goals are not met. The fallacy with this definition is that TI may be overestimated because it includes hypertensive patients deliberately uncontrolled. This is a retrospective chart review study that evaluated physicians' response to an uncontrolled clinic BP reading in a population of patients with stage 3 to 5 chronic kidney disease (CKD) and hypertension. Of 429 patients screened, 166 had controlled BP and 263 did not. Of these 263 patients, 115 patients had no clear reason documented for the absence of changes in medication regimen. This population was defined as cases with true TI. In the remaining 148 patients, the medication regimen was changed in 81 patients. In the rest of the patients, there was a reason documented for not changing the medication regimen. The prevalence of true TI rate (defined as percentage of uncontrolled hypertension as a result of physician inaccountability) in our study was 44% as compared with 69% if the traditional TI definition is applied. Thus, we conclude that the prevalence of TI in the literature overestimates the rate of true TI as it does not account for physician decision making. The current definition of TI in BP control needs to be revised, as it underestimates a provider's care to improve BP control and is misleading. The TI definition should include some mechanism to account for interventions beyond medication titration.

Aim. The mainstays for the treatment of non-alcoholic fatty liver disease (NAFLD) are lifestyle intervention with the aim of significant weight loss alongside aggressive cardiovascular risk reduction. NAFLD is tightly associated with both obesity and type 2 diabetes (T2D). In people with T2D, glucose lowering agents that promote weight loss have shown a beneficial impact on NAFLD based on histological features. However, it remains unclear as to whether glucose lowering can improve NALFD in patients with T2D, independent of weight loss. Methods. In a consecutively recruited population of 637 patients with T2D with HbA1c levels above treatment targets, DPP-IV inhibition, GLP-1RA therapy or SGLT2 inhibition was initiated, alongside lifestyle education with maintenance of exiting background glucose lowering treatment. We examined the longitudinal impact of the optimization of glycaemic control on fatty liver index (FLI) and Fibrosis score 4 (Fib-4) adjusting for changes in BMI and choice of glucose lowering regimen over a 12-month period. Results. Change in HbA1c and change in FLI correlated significantly in a linear regression analysis after adjustment for change in BMI, age, sex, and drug class (R=0.467, p=0.031). The greatest reduction in FLI was observed in patients with the largest reduction in HbA1c (p&lt;0.0001). The probability of improvements in FLI with optimization of glycaemic control was similar with all 3 glucose lowering agents, despite differences in weight reduction. Similar relationships were observed examining the changes in glycaemic control and Fib-4. Conclusions. Significant reductions of HbA1c are associated with improvement in NAFLD independently from weight loss. These results suggest a prominent role for the optimization of glucose control in the management of coexistent NAFLD and T2D, especially in the ‘lean’ NAFLD and where significant weight loss may not be achieved.

Clinical inertia -failing to start or intensify therapy when appropriate -can undermine glycaemic control and increase the risk of diabetic complications. The multitude and diversity of contributing factors mean that clinical inertia poses a particularly difficult conundrum. As Mark Greener reports, however, potential solutions are beginning to emerge.

Prediabetes, marked by elevated blood glucose levels below the type 2 diabetes mellitus (T2DM) threshold, is a growing public health concern due to its rising prevalence and risk of progression to diabetes and cardiovascular issues. Structured weight loss programs in primary care show promise for improving glycemic control, yet their impact on HbA1c remains underexplored. This systematic review evaluates their effectiveness in reducing HbA1c in adults with prediabetes. Following PRISMA 2020 and SWiM guidelines, we searched six databases (PubMed, EMBASE, Cochrane CENTRAL, Scopus, CINAHL, Web of Science) through July 10, 2025, for studies evaluating structured weight-loss interventions delivered in primary care. Eligible studies included adults (≥18 years) with prediabetes and used randomized trials, cohort designs, or pilot interventions reporting HbA1c as a primary outcome. Risk of bias was assessed using the original Cochrane RoB tool for randomized studies. Narrative synthesis was conducted due to substantial heterogeneity in design, intervention intensity, and analytical approaches. Six studies (n = 45-2818) showed HbA1c reductions, with high-intensity (frequent behavioral sessions) and digital interventions (low-carbohydrate apps) yielding the largest effects. Weight loss (up to 4.08 kg), BMI, and lipid profiles also improved. Adherence and intervention intensity were key factors, though inconsistent reporting limited comparisons. Structured weight loss programs in primary care are associated with modest-to-moderate HbA1c reductions. However, study heterogeneity, analytical methods and inconsistent adherence reporting limit definitive conclusions. Future research should prioritize standardized reporting, long-term outcomes, and diverse populations to enhance generalizability.

Real-world data of 12-month adjunct sodium-glucose co-transporter-2 inhibitor treatment in type 1 diabetes from the German/Austrian DPV registry: Improved HbA1c without diabetic ketoacidosis.