Changes In Blood Glucose Control Research Articles

IDF21-0101 Blood Glucose Control using a Mobile Health Application in Asia – A Retrospective Real-World Data Analysis

Background: Mobile health (mHealth) solutions have the potential to reduce the clinical and psychological burden of diabetes and enhance patient self-management. Previous real world data analyses showed significant improvement in blood glucose (BG) control with the use of a mHealth application for people with diabetes after 6 months. However, there is under-representation of Asian data while user behaviours and outcomes remain little known. Aim: We aimed to investigate the potential impact of mySugr Logbook app usage on parameters of BG control in Asia – Singapore, Philippines and Hong Kong. Method: We analysed changes in BG control [mean BG, tests in range (TeIR), estimated HbA1c (eHbA1c)] in a sample of highly engaged users, defined as ≥2 logs on at least 14 out of 30 days, over a 6-month period. We also analysed measures of glycaemic variability [high blood glucose index (HBGI) and Low blood glucose index (LBGI)]. Data from the first month (t0) of use was compared to month 6 (t1) using paired t-tests in individuals who logged continuously for 6 months. Subgroup analysis was performed on those with suboptimal glycaemic control (eHbA1c >7.0%). Results: A total of 1761 users satisfying criteria above have been using mySugr app over a 6-month period. Of this, 63.7% had Type 2 diabetes (T2D), 14.4% had Type 1 diabetes (T1D), 21.9% was others/unknown. Baseline eHBA1c and mean BG were 6.6% and 142.6 ± 36.4 mg/dl respectively. In 357 individuals who logged continuously, t0 eHbA1c 6.7±0.9% fell 0.2% (p<0.01) at t1. In those with eHbA1c>7% (n=107) at baseline, mean t0 eHbA1c 8.1 ± 1.4%, reduced by 0.5% (p<0.01) with TeIR improving by 10.9% (p<0.01) at t1. Likewise, HBGI decreased from 11 (high risk) to 9 (moderate risk) (p<0.01) whilst the LBGI did not significantly change and remained at low risk level (<2.5) (p=0.300). Discussion: This real-world data shows improvements in BG control in those with higher eHbA1c at baseline over a 6-month period in highly engaged users. A clinically relevant decrease in eHbA1c by 0.5% for those with baseline eHbA1c>7% at 6 months of mHealth application usage was shown to be statistically significant. Although mySugr app supports manual logging of BG data, it was previously observed that users who manually logged data had lower retention rates compared to those who used connected BG meters that enable automatic transfer of data. This preliminary work suggests a positive impact of connected BG meters and mobile health applications in supporting diabetes self-management.

Personalised exercise as medicine for type 2 diabetes: finding the ‘sweet spot’ for glycaemic control

Introduction: Exercise is an effective strategy for the prevention and management of type 2 diabetes (T2D), however, there is contention regarding the relative benefits of moderate intensity continuous training (MICT) and high intensity interval training (HIIT). Moreover, there is significant inter-individual variability in glycaemic response to a given dose of exercise. Therefore, ‘personalised’ approaches to exercise prescription are required to ensure that all people with T2D gain health benefits. This study aims to determine whether glycaemic responses to an acute bout of exercise are associated with long-term adaptations in glycaemic control, and whether these associations are intensity dependent. We hypothesise that acute exercise-induced changes in blood glucose control will be strongly associated with the training response at the same intensity.

953-P: Sustainable Improvement in Quality of Blood Glucose Control in Users of mySugr’s Integrated Diabetes Management Solution

Objective: The mySugr App is the most widespread mobile health application in the diabetes industry, reaching 1.5M patients in 62 countries. mySugr’s Integrated Diabetes Management solution, the mySugr bundle, introduces unlimited test strip delivery and Certified Diabetes Educator-led coaching. In a previous retrospective study we looked at real world changes in blood glucose (BG) in a U.S. population of mySugr Bundle users. In this follow-up study we extended the observation period of intervention to further analyse the course of effect seen before. Method: We analyzed changes in BG control (mean±SD, tests in range (TIR), estimated A1c (eA1c)) and frequency of testing. Participants monitored BG ≥3 times/day during the observation period. Data from the first 2 weeks of use (t0), 8 weeks before (t1), 8 weeks after (t2) and 8 to 16 weeks after (t3) initiation of Bundle usage were aggregated and statistically compared using two-sided t-tests. Results: Study participants were 61 users; 59% with type 1 diabetes, 32.8% with type 2 diabetes, 6.6% with LADA and 1.6% with unreported diabetes type. Baseline BG was 152.0±56.0 mg/dl, eA1c 6.9% and TIR 65%. Significant (p&amp;lt;0.05) improvements were observed in mean BG (-11,8 mg/dl), standard deviation (-5,48 mg/dl), TIR (+6.8%), readings above target (-7.2%) and eA1c (-0.41%) between t0 and t3. A significant improvement was also observed in monitoring frequency (+21.4%) between t1 and t3. Conclusion: Our previous study suggested use of the mySugr Bundle triggered positive changes of glucose control at 8 weeks post intervention. We were now able to show a sustainable improvement in BG control over an extended time period of 16 weeks, indicating the potential benefits of mobile interventions that combine complementary treatment strategies for therapy adherence over longer time periods. Given that improvements were observed in well-controlled patients, findings support further studies in a wider study population range. Disclosure H. Mayer: Employee; Self; mySugr. R.P. Bankosegger: Employee; Self; mySugr. J. Kober: Employee; Self; mySugr.

Sources of Inter-individual Variability in the Therapeutic Response of Blood Glucose Control to Exercise in Type 2 Diabetes: Going Beyond Exercise Dose.

In the context of type 2 diabetes, inter-individual variability in the therapeutic response of blood glucose control to exercise exists to the extent that some individuals, occasionally referred to as “non-responders,” may not experience therapeutic benefit to their blood glucose control. This narrative review examines the evidence and, more importantly, identifies the sources of such inter-individual variability. In doing so, this review highlights that no randomized controlled trial of exercise has yet prospectively measured inter-individual variability in blood glucose control in individuals with prediabetes or type 2 diabetes. Of the identified sources of inter-individual variability, neither has a prospective randomized controlled trial yet quantified the impact of exercise dose, exercise frequency, exercise type, behavioral/environmental barriers, exercise-meal timing, or anti-hyperglycemic drugs on changes in blood glucose control, in individuals with prediabetes or type 2 diabetes. In addition, there is also an urgent need for prospective trials to identify molecular or physiological predictors of inter-individual variability in the changes in blood glucose control following exercise. Therefore, the narrative identifies critical science gaps that must be filled if exercise scientists are to succeed in optimizing health care policy recommendations for type 2 diabetes, so that the therapeutic benefit of exercise may be maximized for all individuals with, or at risk of, diabetes.

The Value of Glycated Albumin for Monitoring Graft Function in the Non-Human Primate Porcine Islet Transplantation Model

Background The development of a precise and simple-to-use monitoring tool for islet graft function is important in clarifying the causes of graft loss, identifying appropriate therapy, and ensuring graft survival in the nonhuman primate (NHP) model of porcine islet transplantation (PITx). Glycated albumin (GA) is an indicator of intermediate-term changes in blood glucose control and is useful in clinical diabetes management. The validity of GA for monitoring graft function in NHP recipients of PITx was evaluated using a retrospective analysis of cohort samples. Methods Data from a total of 23 PITxs performed in 20 recipients (3 were re-transplanted) were included in this study. Islet clusters purified from adult wild-type pigs were transplanted via the intraportal route into streptozotocin-induced diabetic rhesus monkeys with immune suppression. Blood samples were obtained once per week from the recipients until they lost insulin-independence (Ins-Ind). Blood was also obtained from 69 non-diabetic monkeys that served as a control group. The levels of GA and albumin in stored plasma aliquots were measured using each enzymatic method, and the GA result was expressed as the percentage of GA level to the total albumin level. Results The median level of GA in the recipients on the day of PITx (median 18.6%, 95% confidence interval [CI] 16.7-20.4%) was significantly higher than that of healthy controls (median 9.14%, 95% CI 9.0-9.3%, P < 0.0001). However, the level decreased after PITx and remained low or increased depending on the extent of residual graft function. The GA level at a nadir (median 11.6%, 95% CI 10.8-13.0%) and the time to reach a nadir (median 43 days, 95% CI 21.7-69.3 days) correlated with Ins-Ind duration (rho [ρ] = -0.605, P = 0.0028 and ρ = 0.662, P = 0.0008, respectively]. The GA level strongly correlated with KG, the glucose disappearance rate during intravenous glucose tolerance testing (ρ = -0.76, P < 0.0001). The GA levels at post-transplant week (PTW) 3 and at PTW 4 in recipients with long-term Ins-Ind (>90 days) were significantly lower than those with short-term Ins-Ind, revealing excellent performance for prediction of long-term Ins-Ind, similar to that of porcine C-peptide (historic data). Conclusions As a surrogate indicator for graft function, serial measurement of GA may provide supplemental information to conventional monitoring techniques for graft function in assessing porcine islet grafts in NHP models.

The value of glycated albumin for the prediction of graft outcome in the non-human primate porcine islet transplantation model.

The development of a precise and easy-to-use tool for monitoring islet graft function is important in clarifying the causes of graft loss, identifying appropriate therapy, and ensuring graft survival in the nonhuman primate (NHP) model of porcine islet transplantation (PITx). Glycated albumin (GA) is an indicator of intermediate-term changes in blood glucose control and is useful in clinical diabetes management. The validity of GA for monitoring graft function in NHP recipients of PITx was evaluated using a retrospective analysis of cohort samples. Data from a total of 23 PITxs performed in 20 recipients (3 were retransplanted) were included in this study. Islet clusters purified from adult wild-type pigs were transplanted via the intraportal route into streptozotocin-induced diabetic rhesus monkeys with immune suppression. Blood samples were obtained once per week from the recipients until they lost insulin-independence. Blood samples were also obtained from 69 non-diabetic monkeys that served as a control group. The levels of GA and albumin in stored plasma aliquots were measured using each enzymatic method, and the GA result was expressed as the percentage of GA level to the total albumin level. The median level of GA in the recipients on the day of PITx (median 18.6%, 95% confidence interval [CI] 16.7%-20.4%) was significantly higher than that of healthy controls (median 9.14%, 95% CI 9.0%-9.3%, P<.0001). However, the level decreased after PITx and remained low or increased depending on the extent of residual graft function. The GA level at a nadir (median 11.6%, 95% CI 10.8%-13.0%) and the time to reach a nadir (median 43days, 95% CI 21.7-69.3days) both correlated with the duration of insulin-independence (rho [ρ]=-.605, P=.0028 and ρ=.662, P=.0008, respectively). The GA level strongly correlated with KG , the glucose disappearance rate during intravenous glucose tolerance testing (ρ=-.76, P<.0001). At post-transplant week (PTW) 3 and at PTW 4, the GA levels in recipients with long-term insulin-independence (>90days) were significantly lower than those with short-term insulin-independence, which revealed the excellent performance for the prediction of long-term insulin-independence that is comparable to that of porcine C-peptide (historic data). As a surrogate indicator for graft function, serial measurement of GA may provide Supporting Information to that obtained from conventional monitoring techniques of graft function for assessing porcine islet grafts in NHP models.

P-35 * THE CHANGES OF BLOOD GLUCOSE CONTROL AND LIPID PROFILES AFTER SHORT-TERM SMOKING CESSATION IN HEALTHY MALES

The changes in blood glucose control, lipid profiles, and insulin resistance-associated hormones both before and after 2-months of smoking cessation in Korean male smokers were examined. Smoking abstinence was evaluated through self-report and urine cotinine levels. 12 individuals who succeeded in quitting smoking were analyzed. Fasting values of glucose and insulin were used to estimate the b-cell activity and insulin resistance was evaluated using the Homeostasis Model Assessment (HOMA) and Quantitative Insulin Sensitivity Check Index (QUICKI). The data showed that the subjects had a significant increase in weight, body mass index and fasting plasma glucose levels after smoking cessation. The HOMA-Insulin Resistance (HOMA-IR) and The HOMA b-cell function (HOMA-b) increased significantly. The QUICKI showed a significant decrease. In addition, the low-density lipoprotein cholesterol levels decreased significantly; however, changes in the high-density lipoprotein cholesterol, the triglyceride and total cholesterol levels were not significant. The results of this study showed during the initial stage of smoking cessation, insulin resistance increased and insulin sensitivity decreased due to elevated body weight and fat composition. Moreover, the likely explanation for this finding is the compensation of beta cells for insulin resistance.

The Changes of Blood Glucose Control and Lipid Profiles after Short-Term Smoking Cessation in Healthy Males

ObjectiveOur aim was to evaluate the changes in blood glucose control and lipid profiles after 2-months of smoking cessation in healthy males.MethodsSmoking abstinence was evaluated through self-report and urine cotinine levels. 12 individuals who succeeded in quitting smoking were analyzed. Fasting values of glucose and insulin were used to estimate the β-cell activity and insulin resistance was evaluated using the Homeostasis Model Assessment (HOMA) and Quantitative Insulin Sensitivity Check Index (QUICKI).ResultsThe data showed that the subjects had a significant increase in weight, body mass index and fasting plasma glucose levels after smoking cessation. The HOMA-Insulin Resistance and the HOMA β-cell function increased significantly (p=0.005, p=0.047 respectively). The QUICKI showed a significant decrease (p=0.005). In addition, the low-density lipoprotein cholesterol levels decreased significantly (p=0.028); however, changes in the high-density lipoprotein cholesterol, the triglyceride and total cholesterol levels were not significant (p=0.284, p=0.445 respectively).ConclusionDuring the initial stage of smoking abstinence, insulin resistance increased and insulin sensitivity decreased due to elevated body weight and fat composition. Therefore, it is important to educate individuals that stop smoking about the necessity of weight control during smoking cessation programs.

Comparison of indices of insulin resistance with metabolic syndrome classifications to predict the development of impaired fasting glucose in overweight and obese subjects: a 3-year prospective study

To compare the ability of biochemical indices of insulin resistance (IR) with metabolic syndrome (MetS) classifications to predict changes in blood glucose control over a 3-year period in overweight and obese subjects. This was a longitudinal, prospective study, with data collected at baseline, 18 and 36 months. A total of 175 overweight (body mass index (BMI)>25 kg m(-2)) and obese (BMI>30 kg m(-2)) subjects were enrolled in the study. The IR indices assessed included fasting insulin concentration, the insulin/glucose-derived indices, homeostasis assessment model of insulin resistance (HOMA-IR) and quantitative insulin sensitivity check index (QUICKI), the insulin/triglyceride-derived McAuley index, plasma adiponectin concentration and the triglyceride (trig) and high-density lipoprotein (HDL)-cholesterol ratio (trig:HDL). The two MetS classifications were assessed according to the definitions of the National Cholesterol Education Program-Third Adult Treatment Panel (NCEP-ATPIII) and the International Diabetes Federation (IDF). The potential of the IR indices and MetS classifications at baseline to predict the development of impaired fasting glucose (IFG) was examined using receiver-operator characteristic (ROC) curve analysis and analysis of variance. Complete data were collected on 158 subjects. In all, 51 (32%) subjects developed IFG during the study. The analysis of variance showed significant differences between the IFG and normoglycaemic group in the baseline values of the McAuley index, trig:HDL, plasma adiponectin concentration and prevalence of the MetS. The ROC curve analysis confirmed this result and showed that the strongest predictors of IFG were baseline trig:HDL and IDF MetS classification, followed in order by the McAuley index, plasma adiponectin concentration and NCEP-ATPIII MetS classification. In contrast, the baseline values of fasting insulin, HOMA-IR and QUICKI did not predict IFG. This study showed that the IR indices, derived, in part, from plasma triglyceride concentration, were sensitive predictors for the development of IFG in normoglycaemic overweight and obese subjects. Indices derived from glucose and insulin did not identify this at-risk group. The study also showed that the presence of MetS and its abnormalities of an increased trig:HDL ratio and low plasma adiponectin concentration were all sensitive predictors of IFG.

Variation of patients’ views on Type 2 diabetes management over time

The aim of the study was to examine the relationship between participants' views about their role in diabetes treatment and their glycaemic control 3-7 years after having entered an educational intervention, and to investigate whether people's attitudes towards diabetes management change over an extended period of time. The present study is a long-term follow-up analysis of data collected from 193 persons with Type 2 diabetes. A qualitative content analysis of three open-ended questions about participants' self-perceived role in diabetes treatment was used. The related outcome measure was haemoglobin A(1c) (HbA(1c)). The way people viewed their role in diabetes management affected glycaemic control. Individuals in the Disease Manager or Compliant categories had significantly lower HbA(1c) compared with those in the Disheartened category. Furthermore, in people whose attitudes towards diabetes treatment was variable, weight and age influenced why participants changed their views and thus switched categories. Paradoxically, when people changed their views, this change did not produce a change in blood glucose control, which would have been expected. From the health-care provider's perspective, it is important to know how the person with diabetes perceives his/her role in disease management and to determine if a change in perception would be followed by intervention to adjust glycaemic control. Consequently, individuals' perception of disease management should be incorporated in patient education programmes and routine diabetes care to enable customized care and prevent stagnation in negative roles.

Islet Cell Function Its Role in the Onset and Progression of Type 2 Diabetes

Studies of the natural history of type 2 diabetes have transformed views on the nature of the condition in the last two decades.The Belfast Study is one of the earliest and most complete studies to observe the change in blood glucose control during six years of best possible management by dietary means. After the rapid initial fall from presenting blood glucose levels over 11mM, mean fasting blood glucose was maintained around 8mM for only two years before an inexorable rise occurred. By six years after diagnosis mean plasma glucose was over 10mM.This work is all the more impressive as no oral agent therapy was used during the course of the study which truly observed natural history modified only by consistent and expert dietary advice. Calculated beta cell function revealed a fall from around 30% of normal function at diagnosis to around 22% after six years.

Intraperitoneal insulin infusion improves the depletion in choline-containing phospholipids of lipoprotein B particles in type I diabetic patients

Insulin-dependent diabetes mellitus (IDDM) is characterized by altered composition of atherogenic lipoproteins, especially a depletion in choline-containing phospholipids (PL) of apolipoprotein (apo) B lipoproteins (LpB). To determine the effects of continuous intraperitoneal (IP) insulin infusion (CIPII) on this qualitative lipoprotein abnormality, we compared lipoprotein profiles of 14 IDDM patients treated by continuous subcutaneous insulin infusion (CSII) and at 2 and 4 months after treatment with CIPII using an implantable pump. IDDM patients were in fair metabolic control and were compared with 14 healthy control subjects matched for sex, age, body mass index, and plasma lipids. The following parameters were studies: hemoglobin A1c (HbA1c), monthly blood glucose, daily insulin dose (units per kilogram per day), total cholesterol (TC), triglycerides (TG), high-density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol, apo A-I, and apo B. Choline-containing PL were assessed in plasma and in apo B- and no-apo B-containing lipoprotein particles (LpB and Lp no B). As compared with the control group, plasma PL and LpB-PL were significantly lower in IDDM patients treated by CSII (2.95 +/- 0.26 v 3.30 +/- 0.45 mmol/L,P<.05, and 1.09 +/- 0.45 v 1.68 +/- 0.33 mmol/L,P<.01, respectively). No significant differences were observed for Lp no B lipid determinations between both groups. After initiation of CIPII, IDDM patients did not experience any significant changes in mean values for body mass index, HbA1c, and monthly blood glucose throughout the study. Daily insulin doses were identical to those observed before IP therapy. Lipid parameters remained unchanged in IDDM patients (TC, TG, HDL and LDL cholesterol, apo A-I, and apo B). A moderate but progressive elevation of plasma PL was noted, and after 4 months of CIPII, PL and LpB-PL levels were no longer significantly different between IDDM patients and controls. The increase in plasma and LpB choline-containing PL observed after 2 and 4 months of CIPII is not linked to changes in blood glucose control, body weight or daily insulin requirements. These changes may be related to the route of insulin administration, which may be accompanied by a reduction of lipoprotein lipase (LPL) activity and consequently a reduction of phospholipase activity. These results suggest that IP insulin delivery may be a more physiological route that increases the choline-containing PL content of LpB particles.

Predominantly Vegetarian Diet in Patients with Incipient and Early Clinical Diabetic Nephropathy: Effects on Albumin Excretion Rate and Nutritional Status

Several studies have suggested that dietary protein quality may be an important determinant in the natural history of renal disease. We have therefore studied the effects of a predominantly vegetarian diet in eight patients with Type 1 diabetes mellitus and an albumin excretion rate (AER) in excess of 30 micrograms min-1. The AER was measured after an 8-week run-in period on the patient's usual diet, and again after 8 weeks of a predominantly vegetarian diet in which the proportion of vegetable protein was supplemented in order to minimize the reduction in total dietary protein intake. The median fractional albumin clearance fell during the study from an initial value of 188 x 10(-+) (range 58-810 x 10(-4)) at the end of the run-in period to 87 x 10(-4) (23-829 x 10(-4)) at the end of the period on low animal protein diet (difference 79 x 10(-4) (95% Cl 9-149 x 10(-4)), p less than 0.05). The AER then returned to values similar to those obtained at the beginning of the study after a further 8 weeks in those patients returning to their usual diet. No significant changes in blood glucose control or in arterial pressure were observed. A predominantly vegetarian diet may therefore have important beneficial effects on diabetic nephropathy without the need for a heavily restricted total protein intake.

The Effects of Diet and Insulin Therapy on Coagulation Factor VII, Blood Viscosity, and Platelet Release Proteins in Diabetic Patients with Secondary Sulphonylurea Failure

The effect of intensified dietary measures and subsequently insulin therapy upon haemorheological measures were studied in Type 2 diabetic patients with secondary sulphonylurea failure. Coagulation factors VIIc and VIIIc, fibrinogen, plasma viscosity, whole blood viscosity, beta-thromboglobulin, platelet factor 4, von Willebrand factor, and euglobulin clot lysis time were measured at baseline, after 3 months intensified dietary therapy and after 4 months insulin therapy. During intensified dietary therapy there was a significant fall in serum cholesterol (p less than 0.05) and a small decrease in weight, but no significant change in blood glucose control. Factor VIIc levels fell significantly (1.22 (SE 0.07) vs 1.42 (0.08) u ml-1, p less than 0.01), and plasma viscosity and whole blood viscosity (23 s-1) also improved (both p less than 0.05). Insulin therapy was instituted with either continuous subcutaneous insulin therapy or twice daily injections of soluble and isophane (NPH) insulin. During this period glycosylated haemoglobin improved (mean (SE) 49.5 (1.4) vs 65.0 (2.1) mmol-HMF mol-Hb-1, p less than 0.001; normal range 29-39 mmol-HMF mol-Hb-1) as did serum triglyceride (p less than 0.01), but weight increased (p less than 0.001). The only haemorheological changes with insulin were increased levels of the platelet release proteins beta-thromboglobulin (37 (3) vs 28 (2) micrograms l-1, p less than 0.01) and platelet factor 4 (median 7.5 (range 3.0-18.0) vs 4.5 (2.0-10.5) micrograms l-1, p less than 0.01).

Abnormalities of the Cardiovascular Response to Cold Pressor Test in Type 1 Diabetes

Left-ventricular (LV) function in type 1 diabetics without clinical heart disease was compared with that found in matched normal subjects. Although diabetics had a normal LV ejection fraction (66% +/- 6%), they showed a trend toward smaller left ventricles. Their cardiovascular response to a cold pressor test was abnormal and cardiac function after the cold pressor test correlated with hemoglobin A1c levels: Average hemoglobin A1c was inversely related to ejection fraction and early filling volume and directly related to the ratio of pre-ejection period to ejection time (PEP/LVET) after a cold pressor test. Hemoglobin A1c at the time of study correlated more closely with PEP/LVET after cold pressor test than did the six-month average hemoglobin A1c level, suggesting that cardiac function fluctuates with recent changes in blood glucose control. Thus, even when diabetics have a normal LV ejection fraction, an abnormal cardiovascular response to stress may still be present, and such abnormalities correlate with blood glucose control.