Current American Diabetes Association Research Articles

Diabetic ketoacidosis resolution: From the traditional way to guideline-based management in the MICU at University Medical Center, Lubbock, Texas

Diabetes is a chronic, metabolic disease characterized by hyperglycemia which eventually can cause serious organ damage. The prevalence of diabetes has steadily increased over the past few decades, and approximately 1.4 million Americans are diagnosed with diabetes every year. Diabetes was the seventh leading cause of death in the United States in 2019. Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening. It occurs more frequently in the patients with type 1 diabetes but can also develop in people with type 2 diabetes. It was determined that the average cost per DKA episode was $6,444, and that the annual cost of medical treatment in a diabetic patient with a prior episode of DKA was 2.67 times higher than a diabetic patient with no history of DKA. The criteria for DKA resolution at University Medical Center (UMC) in Lubbock, Texas, are different from current American Diabetes Association (ADA) guidelines. At UMC, a plasma bicarbonate ≥18 mEq/L, a venous pH > 7.3, and anion gap ≤12 mEq/L must be recorded twice (4 hours apart) before bridging to subcutaneous long-acting insulin administration. This time requirement could contribute to a longer time for DKA resolution and longer intensive care unit and hospital stays.Keywords: Diabetic ketoacidosis, DKA resolution

Abstract P432: Validation and Optimization of the American Diabetes Association Score for Undiagnosed Type 2 Diabetes Risk in Hispanic or Latino Adults

Background: The prevalence of type 2 diabetes (T2D) is increasing in Hispanic or Latino adults. The American Diabetes Association (ADA) score to identify current risk of T2D was developed with limited Hispanic or Latino representation. Therefore, we sought to validate the ADA score in a cohort of Hispanic or Latino adults. Methods: At enrollment in the Sangre Por Salud Biobank, 3,625 Hispanic or Latino adults from Phoenix, Arizona completed a baseline questionnaire. Current risk of undiagnosed T2D was based on non-laboratory risk factors and ADA score ≥5 (Table). Participants also completed T2D screening (ie, fasting glucose, 2-hour oral glucose tolerance test, and/or hemoglobin A1c). Undiagnosed T2D was based on 'no self-reported T2D but meeting T2D diagnostic’ criteria. Multivariable logistic regression analyzed associations of ADA risk factors and undiagnosed T2D, and model performance was based on sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results: At enrollment, 7.3% of participants had undiagnosed T2D (n=265/3,625). In multivariable analysis, most risk factors described for the ADA score were significantly associated with T2D, except for sex, which showed no association. ADA score ≥5 had sensitivity 50%, specificity 79%, PPV 18%, and NPV 95%. However, ADA score ≥4 had sensitivity 72%, specificity 61%, PPV 14%, and NPV 96%. ADA score ≥4 vs ≥5 identified 22% (n=59) additional cases of undiagnosed T2D. Furthermore, using the revised definition for elevated blood pressure (>120/80 mmHg) vs ≥140/90 mmHg (current ADA score) further improved the ADA score ≥4 (sensitivity 81%; specificity 52%). Other scores had lower performance using both hypertension definitions. Conclusion: In Hispanic or Latino adults, a lower ADA score than currently recommended identified additional cases of undiagnosed T2D. The ADA score requires validation and recalibration, including for the updated hypertension guidelines.

What are we waiting for? A review of early basal insulin therapy in diabetic ketoacidosis management

Diabetic ketoacidosis (DKA) remains a significant challenge for healthcare systems due to prolonged lengths of stay and rising costs. The current American Diabetes Association (ADA) guidelines recommend starting basal insulin after resolution of DKA. However, these guidelines have not been updated since 2009, which can potentially limit optimal care. Meanwhile, the Joint British Society guidelines on DKA management, which were more recently updated in March 2023, do advocate for early administration of basal insulin in their treatment algorithm. This article assesses the rationale and literature associated with the recommendation for early basal insulin administration in the management of DKA. Benefits of early basal insulin in this cohort appears to be associated with less rebound hyperglycemia, reduction in time to DKA resolution, reduced intravenous insulin requirements, and reduced length of stay without associated increases in hypoglycemic or hypokalemic events.

ISPAD Clinical Practice Consensus Guidelines 2022: Glycemic targets and glucose monitoring for children, adolescents, and young people with diabetes.

ISPAD Clinical Practice Consensus Guidelines 2022: Glycemic targets and glucose monitoring for children, adolescents, and young people with diabetes.

A Pilot Study of Modified Mini-Clinical Evaluation Exercises (Mini-CEX) in Rotation Students in the Department of Endocrinology.

BackgroundThe mini-clinical evaluation exercise (mini-CEX) is an excellent tool for assessing the clinical abilities of medical students in intense clinical practice. In this study, the Mini-CEX was adapted to professional questionnaires for Diabetes Mellitus (DM), and examined in medical students completing their clerkship rotation in the department of endocrinology.MethodsFrom January 2021 to January 2022, all rotating medical students at Shanghai Pudong Hospital completed two mini-CEX exams before and following their rotation under the supervision and guidance of six tutors. The mini-CEX form was modified in this study primarily for inpatient management based on our clinical experience and updated DM guidelines of the American Diabetes Association (ADA), the European Association for the Study of Diabetes (EASD), and the Chinese Diabetes Society (CDS). Each component of the mini-CEX assessment, including medical interviews, physical examination, clinical judgment, clinical management, and overall clinical competence was evaluated using a nine-item questionnaire.ResultsOur findings revealed that the second-round performance on the assessments significantly improved, as indicated by higher scores on each component. The Pearson association analysis revealed that the feedback time of the first examination was markedly associated with improved overall scores (r= 0.391, p<0.001). However, no correlations were discovered between patient age, gender, disease severity disparity, or the interval between examinations (p>0.05). Additional regression analysis revealed that the feedback time during the initial examination was the most significant contributor to the increased overall scores (β=0.391, p<0.001).ConclusionThis newly designed mini-CEX form based on current ADA and EASD guidelines may assist trainees in more effectively diagnosing and managing DM in inpatients, particularly those with macrovascular, microvascular, or peripheral nerve neuropathy. This study aims to assess the efficacy of administering a modified mini-CEX form to rotating trainees participating in an endocrine clerkship.

Prediabetes and Diabetes Screening Eligibility and Detection in US Adults After Changes to US Preventive Services Task Force and American Diabetes Association Recommendations

This cross-sectional study using NHANES data assesses the proportion of asymptomatic US adults eligible for screening based on new vs current US Preventive Services Task Force and American Diabetes Association screening guidelines, overall and among those with prediabetes or undiagnosed diabetes.

Management of Hypoglycemia in Adults with Type 1 Diabetes in Real-Life Condition

Introduction: Hypoglycemia is the most common acute complication in individuals with type 1 diabetes (T1D). Episodes of mild or moderate hypoglycemia should be treated in adults with a dose of around 15–20 g fast-acting carbohydrates. However, this self-treatment of hypoglycemia in real-life condition is not well documented. Objective: The aim of this study wasto determine the characteristics of hypoglycemia treatment in adults with T1D in a prospective study design. Methods: Individuals with T1D were advised to record information related to hypoglycemia episodes for a period of 14 days. Quantity and quality (including glycemic index [GI] and glycemic load) of carbohydrates consumed in every hypoglycemia episode and others factors related with hypoglycemia such as physical activity, fear of hypoglycemia, or hypoglycemia awareness were analyzed. Results: A total of 93 individuals (36.5 ± 16.2 years old, BMI of 24.9 ± 3.8 kg/m², diabetes duration of 14.9 ± 10.4 years, and HbA1c levels of 7.3 ± 0.8%) were included in the study. A total of 483 episodes of mild or moderate hypoglycemia were reported, which supposed on average 2.7 ± 2.0 episodes a week. The quantity of carbohydrates consumed in all episodes of hypoglycemia was 25.9 ± 9.2 g. GI of food consumed in all episodes of hypoglycemia was classified as low (53.9 ± 8.3). Overtreatment of hypoglycemia, defined as ingestion of more than 20 g of carbohydrates, occurred in 50.3% of hypoglycemic episodes; even 22.3% of these episodes were treated with more than 30 g of carbohydrates. Fruit juice was the most popular option, chosen in almost 70% of the events. In addition, we observed other moderate or low GI foods such as milk, bread, cookies, and bakery products among the most consumed foods. Conclusion: A majority of the studied individuals with T1D does not manage hypoglycemia according to current American Diabetes Association guidelines, in most cases by overtreating, choosing foods with low glycemic effect, and not varying the dose of carbohydrates, depending on the physical activity performed.

Primary cutaneous mucormycosis of the abdomen at the site of repeated insulin injections

A 71-year-old woman with metastatic squamous cell carcinoma of the lung and insulin-dependent type 2 diabetes mellitus presented with a necrotic lesion on her lower abdomen. Further history revealed that...

Finding the Sweet Spot: An Interactive Workshop on Diabetes Management in Older Adults.

Intensive glucose lowering in older adults with diabetes leads to increased risks with minimal benefits. Surveys indicate that clinician confidence for individualizing glycemic goals and regimens remains low. We created an interactive workshop and clinical tool kit to improve clinician knowledge of safe diabetes management in older adults. Finding the Sweet Spot was a 1-hour workshop taught by pharmacists to medical and pharmacy learners that introduced a five-step framework for diabetes management in older adults. The interactive presentation included cases and a clinical tool kit based on current recommendations from the American Diabetes Association and American Geriatrics Society. Pilot workshops were held for 6 months, allowing for real-time revisions based on feedback; final implementation occurred for 6 months thereafter. We evaluated learner self-efficacy (via a 5-point Likert scale) and knowledge (via multiple-choice questions) of diabetes management in older adults before and after the workshop. Thirty learners participated in Finding the Sweet Spot (70% medicine, 30% pharmacy). The percentage of confident learners increased from 55% to 97% (p < .05) after the workshop. All learners demonstrated improvements in knowledge, with the mean score on the knowledge assessment increasing from 61% to 80% (p < .05). Via open-ended feedback, learners expressed satisfaction and found the clinical tool kit especially helpful. Our Finding the Sweet Spot workshop demonstrated statistically significant changes in self-efficacy and knowledge among learners, indicating that this interactive workshop improves medical and pharmacy provider confidence and skills in caring for older adults with diabetes.

155-OR: Are the American Diabetes Association Screening Guidelines Appropriate for the Racial/Ethnically Diverse U.S. Population? Evidence from the Multiethnic Study of Atherosclerosis

Objective: Current ADA screening guidelines recommend screening adults with a BMI ≥25 (or ≥23 for Asian Americans) who have at least one risk factor (e.g., belonging to a race/ethnic minority group, hypertension, dyslipidemia, physical inactivity) for diabetes. We determined if these guidelines are appropriate when applied to a multi-ethnic cohort of adults free of diabetes at baseline. Research Design and Methods: We used data from the Multi-Ethnic Study of Atherosclerosis (exams 1-5 every 1.5 to 3 years between 2002-2013). Incident cases of diabetes were defined as fasting glucose ≥ 126 mg/dL and/or use of any diabetes medication. We used multivariable Weibull regression adjusting for age, sex, education, diet, exercise, hypertension, and dyslipidemia to estimate the differential association between BMI and incident diabetes by race/ethnicity. Results: Among 4,541 MESA participants without prevalent diabetes, 1,860 were white, 539 Chinese American, 1,167 African American, and 975 Hispanic. In a median 9.1 years of follow-up, 557 new cases of diabetes occurred (166 in whites, 66 in Chinese Americans, 169 in African Americans, and 156 in Hispanics). Incidence rates were 11.4 (95% CI 9.8 to 13.2), 15.9 (12.5 to 20.3), 19.9 (17.1 to 23.1) and 22 (18.8 to 25.7) per 1,000 person-years among whites, Chinese Americans, African Americans and Hispanics, respectively. The race/ethnic-specific BMI for participants without any additional diabetes risk factors, compared to whites with a BMI of 25 and one or more diabetes risk factor was 29.2 in whites, 22.8 in Chinese Americans, 26.2 in African Americans and 25.4 in Hispanics. Conclusions: Our findings show that the current American Diabetes Association diabetes screening guidelines are appropriate for the ethnically and racially diverse populations, and suggest that a higher BMI cut point, such as 29, may be appropriate for screening whites without other risk factors. Disclosure L.A. Rodriguez: None. P.T. Bradshaw: None. S. Shiboski: None. A. Fernandez: None. D.M. Herrington: None. J. Ding: None. A.M. Kanaya: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (F31DK115029)

New-Onset Pancreatogenic Diabetes After Near-Total Pancreatectomy for Treatment of an Insulinoma (FS17-04-19)

ObjectivesAn insulinoma is an insulin-secreting neuroendocrine tumor of the pancreas. This rare tumor induces severe hypoglycemia and is often resolved through total or near-total pancreatectomy (TP). With the removal of the pancreas, patients lose their insulin and glucagon function, thus inducing a Type 1 diabetic state with complete dependence on insulin replacement therapy. This diabetes type is known as Type 3c or pancreatogenic diabetes. MethodsThe patient was a 58-year-old female that presented with severe hypoglycemia (fasting blood glucose (FBG) 20–30 mg/dL). She was diagnosed with an insulinoma and underwent a near-TP. After surgery, she was diagnosed with new-onset Type 1 Diabetes Mellitus (T1DM) with FBG 137–207 mg/dL. The nutrition diagnosis was food- and nutrition-related knowledge deficit related to lack of exposure to information as evidenced by new diagnosis of insulin dependent diabetes secondary to near-TP. She began insulin therapy along with education on diabetes management using dietary approaches. She will be monitored for malabsorption from pancreatic insufficiency. An interdisciplinary approach was used for treatment including a registered dietitian, endocrinologist, diabetes educator, and primary care physician. ResultsThe literature on pancreatogenic diabetes treatment is scarce. Current American Diabetes Association standards of care do not set specific glycemic targets for Type 3c. Cases are treated as T1DM due to the reliance on exogenous insulin, yet there are some differences owing to the insufficiency of digestive enzymes and glucagon unique to Type 3c (e.g., patients may be more vulnerable to hypoglycemia). A multidisciplinary approach to bridge the patient’s knowledge gap was used for disease management. ConclusionsAn insulinoma induces severe hypoglycemia, while its treatment induces diabetes. In the absence of evidence-based guidelines, the clinical course and treatment is similar to that of T1DM due to the dependence on exogenous insulin. Thus, a multidisciplinary approach with focus on dietary strategies to manage glucose was used treat the disease. More research on the differences between Type 3c and T1DM and its subsequent treatment is necessary to minimize risk of chronic micro- and macro-vascular complications and hypoglycemia. Funding SourcesNA.

Practice Variance in Thyroid Screening of Youth with Type 1 Diabetes Mellitus

Background: Variance between current American Diabetes Association (ADA) and International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines and in clinical practice exists for the use of thyroid antibody and thyroid function screening in pediatric patients with new-onset type 1 diabetes (T1D). Methods: North American Pediatric Endocrine Society (PES) members were surveyed regarding their thyroid screening practices of euthyroid youth with T1D. An institutional analysis of the ability of antithyroid peroxidase (aTPO) and antithyroglobulin antibodies (aTG) to predict the subsequent use of levothyroxine was performed. Results: Forty-eight percent of 374 survey respondents tested both aTPO and aTG at diagnosis of T1D, but 35% performed no baseline antibody testing. If antibodies were positive, 89% of the respondents would perform annual thyroid function testing, but if antibodies were negative, 62% would follow thyroid function annually and 29% biannually. Institutionally, aTPO had significantly greater sensitivity (p = 0.04) but lower specificity (p = 0.008) than aTG for predicting the use of levothyroxine. Conclusions: Variance exists among North American PES members regarding thyroid disease screening for pediatric patients diagnosed with T1D, and this appears to reflect differences between ADA and ISPAD guidelines. A prospective multicenter observational study which shares electronic medical record data and compares aTPO and TSH as primary screening tests may allow for more uniform guidelines and address the possibility of using TSH alone.

Baseline Characteristics of the Vitamin D and Type 2 Diabetes (D2d) Study: A Contemporary Prediabetes Cohort That Will Inform Diabetes Prevention Efforts.

To describe baseline characteristics of the Vitamin D and Type 2 Diabetes (D2d) study, the first large U.S. diabetes prevention clinical trial to apply current American Diabetes Association (ADA) criteria for prediabetes. This is a multicenter (n = 22 sites), randomized, double-blind, placebo-controlled, primary prevention clinical trial testing effects of oral daily 4,000 IU cholecalciferol (D3) compared with placebo on incident diabetes in U.S. adults at risk for diabetes. Eligible participants were at risk for diabetes, defined as not meeting criteria for diabetes but meeting at least two 2010 ADA glycemic criteria for prediabetes: fasting plasma glucose (FPG) 100-125 mg/dL, 2-h postload glucose (2hPG) after a 75-g oral glucose load 140-199 mg/dL, and/or a hemoglobin A1c (HbA1c) 5.7-6.4% (39-46 mmol/mol). A total of 2,423 participants (45% of whom were women and 33% nonwhite) were randomized to cholecalciferol or placebo. Mean (SD) age was 59 (9.9) years and BMI 32 (4.5) kg/m2. Thirty-five percent met all three prediabetes criteria, 49% met the FPG/HbA1c criteria only, 9.5% met the 2hPG/FPG criteria only, and 6.3% met the 2hPG/HbA1c criteria only. Black participants had the highest mean HbA1c and lowest FPG concentration compared with white, Asian, and other races (P < 0.01); 2hPG concentration did not differ among racial groups. When compared with previous prediabetes cohorts, the D2d cohort had lower mean 2hPG concentration but similar HbA1c and FPG concentrations. D2d will establish whether vitamin D supplementation lowers risk of diabetes and will inform about the natural history of prediabetes per contemporary ADA criteria.

Influence of Diabetes Complications on the Cost-Effectiveness of A1C Treatment Goals in Older U.S. Adults

The American Diabetes Association (ADA) recommends glycemic management goals for older diabetes patients take into account the complexity of complications. Little information is available on how cost-effectiveness (CE) of glycemic control goals relates to a patient’s level of complications. We examined the CE of intensive glycemic control (A1c &amp;lt;7.5%) compared to standard treatment (A1c &amp;lt;8.5%) among adults aged 65 y with type 2 diabetes having various complications. 2011-2016 National Health and Nutrition Examination Survey data were used to generate nationally representative samples with various complications. The CDC-RTI diabetes simulation model was used to project the long-term health and cost consequences of intensive/standard glycemic control. The CE of the intensive glycemic control was measured in costs (2017 USD) per quality adjusted life year (QALY). Based on a $50,000/QALY threshold, intensive glycemic control was only marginally cost effective for patients with no complications or any microvascular complication (excluding renal failure) but was not cost-effective for patients with one or more macrovascular complications. Current ADA standards recommend intensive glycemic control among older adults with fewer than 3 complications. From a CE perspective, our results only support the intervention among those with no complications or only microvascular complication. Disclosure H. Shao: None. D.B. Rolka: None. E.W. Gregg: None. P. Zhang: None.

Improving diabetes control in the community: a nurse managed intervention model in a multidisciplinary clinic

Objective: To assess diabetes management and control measures in a central multidisciplinary primary care clinic, conducted by a nurse. Design: A cross sectional study. Setting: Central, multidisciplinary, primary care clinic. Subjects: Randomly selected 100 people with diabetes. Interventions: People with diabetes with suspected non-optimal glucose control (HbA1c &gt; 7%), were invited to the clinic nurse to discuss optimal personal diabetes control, treatment and follow up. All were provided the necessary referrals to consultants and were called in for follow up visits, and received telephone reminders. All interventions were made according to the current American Diabetes Association Standards of Medical Practice recommendations. Main outcome measures: Retrospective data were collected. Data included demographics and diabetes control measures (e.g. HbA1c, LDL, blood pressure, ophthalmologic examination etc.). Data was collected for three x 6 months periods: 1) six months before the nurse visit; 2) six months following the first nurse visit (the intervention); and 3) for patients who were followed up for at least one year after the intervention, the last six months of follow-up. Results: With a median follow up of 25 months, HbA1c, LDL and systolic blood pressure levels dropped significantly from before starting the clinic through the intervention and remained low in the last half year of follow up. GP, Ophthalmologist and Dietician visits increased significantly during the study. Non-significant trends were observed with total and diabetes-related hospitalisations decreased, foot examination rates increased and mild weight loss. Conclusion: Multidisciplinary intervention managed by a nurse, improve diabetes management and control measures. Observed changes persisted after the intervention period. A cross sectional study.

Higher fiber intake is associated with lower blood pressure levels in patients with type 1 diabetes.

Objective The present investigation sought to evaluate the potential association between dietary fiber intake and blood pressure (BP) in adult patients with type 1 diabetes (T1D). Subjects and methods A cross-sectional study was carried out in 111 outpatients with T1D from Porto Alegre, Brazil. Patients were predominantly male (56%) and white (88%), with a mean age of 40 ± 10 years, diabetes duration of 18 ± 9 years, BMI 24.8 ± 3.85 kg/m2, and HbA1c 9.0 ± 2.0%. After clinical and laboratory evaluation, dietary intake was evaluated by 3-day weighed-diet records, whose reliability was confirmed by 24-h urinary nitrogen output. Patients were stratified into two groups according to adequacy of fiber intake in relation to American Diabetes Association (ADA) recommendations: below recommended daily intake (< 14g fiber/1000 kcal) or at/above recommended intake (≥ 14g/1000 kcal). Results Patients in the higher fiber intake group exhibited significantly lower systolic (SBP) (115.9 ± 12.2 vs 125.1 ± 25.0 mmHg, p = 0.016) and diastolic blood pressure (DBP) (72.9 ± 9.2 vs 78.5 ± 9.3 mmHg, p = 0.009), higher energy intake (2164.0 ± 626.0 vs 1632.8 ± 502.0 kcal, p < 0.001), and lower BMI (24.4 ± 3.5 vs 26.2 ± 4.8, p = 0.044). Linear regression modelling, adjusted for age, energy intake, sodium intake, and BMI, indicated that higher fiber intake was associated with lower SBP and DBP levels. No significant between-group differences were observed with regard to duration of diabetes, glycemic control, insulin dosage, or presence of hypertension, nephropathy, or retinopathy. Conclusion We conclude that fiber consumption meeting or exceeding current ADA recommendations is associated with lower SBP and DBP in patients with T1D.

Development of Assessment and Screening Tool to Assist with Prevention and Identification of Charcot Foot in Type 2 Diabetics

Development of Assessment and Screening Tool to Assist with Prevention and Identification of Charcot Foot in Type 2 Diabetics by Louise Wade MSN, RN MS, West Texas AM an additional goal was to develop practice guidelines for practitioners to assist in the early recognition, treatment, and referral of adult diabetic patients at risk for Charcot foot. Lippitt’s theory of change was used to guide the project. An interdisciplinary team of stakeholders was assembled to guide development of the tool, algorithm, and practice guidelines. Products were developed in accordance with evidence in current peer-reviewed literature and American Diabetes Association recommendations for Charcot foot diagnosis, treatment, and referral. Content was validated using a scale content validation instrument process to obtain input from experts in the care of Charcot foot. An implementation plan was developed to guide introduction of the products into practice, and an evaluation plan created to determine the extent to which intermediate term outcomes are met using these products. The project may contribute to social change by identifying patients at risk for Charcot foot prior to the onset of the complication, therefore preventing further injury, deformity, or amputation in populations that are often unable to afford quality healthcare. Development of Assessment and Screening Tool to Assist with Prevention and Identification of Charcot Foot in Type 2 Diabetics by Louise Wade MSN, RN MS, West Texas AM Dr. Stoerm Anderson for his constant support and encouragement throughout the project and for being a positive role model in my life; Dr. Deborah Lewis for her support and suggestions for a successful project completion and finally, Dr. Sandra Cadena as serving as the URR on this project and providing positive comments and encouragement. This entire journey would not have been possible without the encouragement and support of each of these people and I am eternally grateful.

Predictors of Long-Term Remission and Relapse of Type 2 Diabetes Mellitus Following Gastric Bypass in Severely Obese Patients.

Diabetes remission is not observed in all obese patients with type 2 diabetes submitted to bariatric surgery. Relapses occur in patients in whom remission is achieved. We investigated the factors associated with long-term (≥3years) remission and relapse of type 2 diabetes after Roux-en-Y gastric bypass (RYGB) in these patients. By a retrospective review, we analyzed data from 254 patients with type 2 diabetes who had undergone RYGB from May 2000 to November 2011 and had at least 3years of follow-up. The criteria for remission and relapse of type 2 diabetes followed the current American Diabetes Association recommendations. Remission was achieved in almost 82% of participants (69.7% complete, and 12.2% partial remission). Of these, 12% relapsed within a mean follow-up of 5.1±2.0years after surgery. Predictors of complete remission were younger age, better preoperative glycemic control, and shorter diabetes duration. Preoperative insulin use was associated with a ninefold increase in the relapse hazard (HR=9.1 (95% CI: 3.3-25.4)). Use of two or more oral anti-diabetic agents increased the relapse hazard sixfold (HR=6.1 (95% CI: 1.8-20.6)). Eighteen point one percent of patients did not achieve any remission during follow-up. However, they exhibited significant improvements in glycemic control. These data indicate that RYGB should not be delayed when remission of type 2 diabetes is a therapeutic goal, and also suggest that the best possible metabolic control should be sought in obese patients who may eventually be candidates for RYGB.

Effect of insulin therapy and dietary adjustments on safety and performance during simulated soccer tests in people with type 1 diabetes: study protocol for a randomized controlled trial

BackgroundDespite the reduction in glycemic derangement in patients with type 1 diabetes mellitus (T1D) through dietary and therapeutic adjustments implemented before, during and after continuous exercise, evidence for its effectiveness with intermittent forms of exercise, such as soccer, is still lacking.Methods/designWe designed a study protocol for a randomized, crossover, double-blinded, controlled trial, for the evaluation of the effect that a strategy of dietary and therapeutic modifications may have on safety and performance of persons with T1D in soccer training sessions and cognitive testing. Inclusion criteria comprise: age older than 18 years, more than 2 years since T1D diagnosis, low C-peptide level, a stable insulin regimen, HbA1c less than 9.0% and regular participation in soccer activities. Our primary outcome evaluates safety regarding hypoglycemia events in patients using dietary and therapeutic adjustments, compared with the performance under the implementation of current American Diabetes Association (ADA) usual recommendations for nutritional and pharmacological adjustments for exercise. Additionally, we will evaluate as secondary outcomes: soccer performance, indexed by performance in well-established soccer skill tests, cognitive functions (indexed by Stroop, digital vigilance test (DVT), Corsi block-tapping task (CBP), and rapid visual information processing (RVIP) tests), and glycemic control measured with a continuous glucose monitor (CGM).DiscussionDietary and insulin adjustments standardized under a 4-step method strategy have never been tested in a clinical trial setting with intermittent forms of exercise, such as soccer. We hypothesize that through this strategy we will observe better performance by persons with T1D in soccer and cognitive evaluations, and more stable control of glycemic parameters before, during and after exercise execution, indexed by CGM measurements.Trial registrationISRCTN, ISRCTN17447843. Registered on 5 January 2017.

Glycaemic, blood pressure and lipid goal attainment and chronic kidney disease stage of type 2 diabetic patients treated in primary care practices.

The prevalence of chronic kidney disease and diabetes is rising in Europe. These patients are at high cardiovascular and renal risk and need a challenging multifactorial therapeutic approach. The goal of this cross-sectional study was to examine the treatment and attainments of goals related to cardiovascular risk factors within chronic kidney disease stages in type 2 diabetic patients followed up by primary care physicians in Switzerland. Each participating physician entered into a web database the anonymised data of up to 15 consecutive diabetic patients attending her/his office between December 2013 and June 2014. Diabetes, hypertension and lipid lowering therapies were analysed, as well as glycated haemoglobin (HbA1c), blood pressure and low-density lipoprotein-cholesterol (LDL-c) levels and goal attainments by KDIGO chronic kidney disease stage 1 to 4. A total of 1359 patients (mean age 66.5±12.4 years) were included by 109 primary care physicians. Chronic kidney disease stages 0-2, 3a, 3 b and 4 were present in 77.6%, 13.9%, 6.1%, and 2.4%, respectively. Average HbA1c was independent of chronic kidney disease stage and close to 7%; more than half of the patients reached the HbA1c goal. Eighty-four percent of patients were hypertensive and only 18.2% reached the then current Swiss or American Diabetes Association 2013 blood pressure goals. Despite loosening of blood pressure goals in 2015, only half of the patients reached them and most needed multiple therapies. Increased body mass index and advanced chronic kidney disease stage decreased the chance of reaching blood pressure goals. Lipid lowering therapy was prescribed in 62.1% of cases, with average LDL-c levels similar across chronic kidney disease stages. Only 42% of patients reached the LDL-c goal of <2.5 mmol/l in primary prevention and 32% reached <1.8 mmol/l in secondary prevention. Younger patients were treated significantly less aggressively than older patients (≥68 years, median age) for HbA1c, LDL-c and diastolic blood pressure control. This cross-sectional study demonstrates that blood pressure and lipid goals are less often achieved than blood glucose control in type 2 diabetic patients followed up by primary care physicians in Switzerland. Goal attainments for HbA1c and LDL-c were not influenced by chronic kidney disease stages, in contrast to blood pressure. Reaching all three goals was rare (2.2%). There is a need for improvement in blood pressure control in advanced chronic kidney disease, whereas HbA1c goals may be loosened in the elderly and in advanced chronic kidney disease.