Insulin-dependent Type 2 Diabetes Mellitus Research Articles

Improving Diabetic Care Through Education and Innovation.

Background: Despite the innovative advancements in diabetes care, providers may not recognize patients with type 2 diabetes mellitus (T2DM) who qualify for a continuous glucose monitoring (CGM) device or the benefits of a telemedicine program for improving self-management behaviors. Objective: This quality improvement (QI) project aimed to determine if an advanced practice registered nurse (APRN)-led telemedicine program using CGM could improve glycemic control and self-management in patients with insulin-dependent T2DM. Methods: A 6-week telemedicine program was developed and implemented using the CGM's time-in-range to deliver patient-specific education. Clinical metrics were collected at each visit. All patients completed a pre- and postintervention Diabetes Self-Management Questionnaire-Revised (DSMQ-R) survey. Results: A repeated measures analysis of variance revealed that the telemedicine program had a statistically significant impact on time-in-range outcomes, F(2, 14) = 18.203, p < .001. Paired-samples t tests indicate that APRN-led education improved body mass index, t(8) = 4.232, p = .002; decreased systolic blood pressure, t(8) = 2.90, p = .010, and diastolic blood pressure, t(8) = 3.21, p = .007; and increased self-management skills as evidenced by DSMQ-R, t(8) = -5.498, p < .001. Conclusions: This QI project highlights multiple interventions for improving diabetes management in a primary care facility. Implications for Nursing: An APRN-led telemedicine program integrating CGM time-in-range data can improve glycemic control and self-management skills in patients with T2DM who administer insulin.

Simultaneous Pancreas-kidney Transplantation Candidates With Type 2 Diabetes Mellitus: Elevated C-peptide Levels Warrant Scrutiny, May Portend Worse Outcomes.

Simultaneous Pancreas-kidney Transplantation Candidates With Type 2 Diabetes Mellitus: Elevated C-peptide Levels Warrant Scrutiny, May Portend Worse Outcomes.

The complexities of insulin allergy: a case and approach

BackgroundInsulin hypersensitivity is rare, but challenging for individuals with diabetes. The prevalence of insulin allergy has decreased since the introduction of human recombinant insulin preparations. Hypersensitivity reactions range from injection site erythema and swelling, to anaphylaxis. While some reactions are to excipients (zinc, protamine, metacresol), many are to recombinant insulin itself. We present a case of type 1 hypersensitivity to various preparations of insulin in a patient with insulin-dependent type 2 diabetes mellitus (T2DM).Case presentationA 61-year-old woman with a 30-year history of insulin-dependent T2DM was referred for evaluation of reactions to insulin. She had two episodes over 5-months; both required Emergency Department visits and epinephrine administration. The first episode entailed a burning sensation of the extremities and nausea, immediately after injecting NovoRapid® insulin. The second event entailed a similar reaction but this time there was also angioedema of the upper airway with difficulty breathing and hypotension, immediately after injecting Levemir® and NovoRapid®, and taking metformin. There were no cofactors such as exercise, infectious illness, or NSAIDs use. Skin testing was performed with metformin, Lantus®, Humalog®, NovoRapid®, glulisine, insulin regular, NPH, Levemir® and the excipient protamine, as per published testing concentrations. Metacresol was not tested as its use was restricted by the hospital pharmacy. Insulin preparations with and without metacresol were included in testing however. A clinic staff served as a negative control. The patent had negative testing with protamine, but sensitization to all insulin preparations. Metformin skin testing and challenge along with latex IgE were negative. Subsequently, she underwent intentional weight loss of 70 lb, and was started on oral hypoglycemics with good effect.ConclusionsOur case highlights the importance of diagnosing insulin allergy through a detailed history and focused testing. Therapeutic strategies include avoidance and insulin alternatives, alternate insulin preparations, or desensitization. In severe recurrent hypersensitivity reactions, Omalizumab or pancreatic transplantation have been effective.

Type 2 diabetes and neonatal hypoglycemia: role of route of delivery and insulin infusion

Objective To compare the rate of neonatal hypoglycemia among newborns delivered by individuals with Type 2 diabetes mellitus (T2DM) in two clinical scenarios: who attempted vaginal delivery vs. had a planned cesarean delivery (CD); who had intrapartum insulin infusion vs. who did not. Methods This was a retrospective cohort study of individuals with insulin-treated T2DM who had non-anomalous singleton pregnancy and delivered at a single tertiary center (March 2012 and May 2018). Individuals with chronic renal failure, proliferative retinopathy, or major congenital anomalies were excluded. The primary outcome was neonatal hypoglycemia (blood glucose < 40 mg/dl <24 h of age or < 50 mg/dl >24 h of age). Secondary outcomes included neonatal outcomes. Multivariable Poisson regression models with robust error variance were used to examine the association between groups and the primary outcome. Adjusted relative risk (aRR) and 95% confidence intervals (CI) were calculated. Results Of 233 individuals with T2DM, 215 (92.2%) met the inclusion criteria, of whom 95 (44%) attempted vaginal delivery and 120 (56%) had a planned CD. Individuals who labored had a higher gestational age at delivery (36.6 vs. 35.8 weeks, p = .005), and higher blood glucose levels upon admission (125 vs 103, p < .001) compared to those with a planned CD. After adjustment for potential confounders, there was no difference in risk of neonatal hypoglycemia between the groups (41.2 vs 44.1%, aRR 1.05, 95% CI = 0.75–1.45). Among those who attempted vaginal delivery, 34 (35.8%) required insulin infusion. There was no difference in the risk of neonatal hypoglycemia (aRR = 0.79, 95% CI = 0.45–1.37) between newborns delivered by individuals who required insulin infusion and those who did not. Conclusion Over 40% of newborns delivered by individuals with insulin-dependent T2DM had hypoglycemia; however, there was no significant difference in the risk of hypoglycemia, irrespective of the route of delivery and the use of insulin infusion.

Prolonged Hypoglycemic Effect Due to Intentional Massive Insulin Glargine Overdose

Introduction: Since its discovery in 1921, insulin has served as the mainstay of treatment for patients with both type 1 and insulin-dependent type 2 diabetes mellitus (T2DM). Insulin is available in both long and short acting formulations. Glargine, a long-acting insulin, has an onset of action in one to two hours and length of duration of 24 hours. Although generally well tolerated, when taken in overdose, insulin can lead to severe hypoglycemia, seizures, unconsciousness, or even death. We present a case of an insulin-dependent male with refractory hypoglycemia after an intentional glargine overdose. Case: A 57-year-old man with past medical history of insulin-dependent T2DM, alcohol abuse, cirrhosis, and depression, presented to the hospital after a suicide attempt. The patient reported that after a night of drinking he experienced suicidal thoughts and injected himself with 8 vials of 100 Units (800 units) of insulin glargine. On initial presentation, the patient had a GCS of 15/15 and was in slight distress. The remainder of his exam was normal. Initial laboratory workup was pertinent for a blood glucose of 86mg/dL. Poison control was contacted and the patient was started on an intravenous infusion of 10% Dextrose with blood glucose checks every 15 minutes; subsequently reduced to every 60 minutes. Despite continuous glucose administration, the patient still suffered from severe hypoglycemic episodes (glucose < 70mg/dL) requiring glucose boluses in the first 96 hours of hospitalization. His glucose infusion was transitioned to D5 and then discontinued. Psychiatry determined the patient was no longer a risk to himself and outpatient therapy was warranted. His blood glucose was well controlled and he was not discharged with insulin. Discussion: Insulin glargine is a long-acting human insulin analogue with a prolonged activity profile and no pronounced peak. At doses between 0.4 IU/kg to 0.8 IU/kg, insulin glargine is metabolized in 24 hours. However, in cases of insulin overdose, insulin effects and absorption are highly variable. Multiple studies have illustrated the unusual prolonged hypoglycemic effect of glargine after massive doses. The mechanism behind this is still unclear but several factors may result in this prolonged duration of action. Larger injection volumes create a larger depot that may have a mechanical effect on the microcirculation leading to delayed absorption. Presence of lipodystrophy from repeated insulin injection, hepatic impairment, and renal impairment may also alter insulin kinetics. Another contributing factor in our patient is obesity, which is associated with delayed insulin absorption. Conclusion: Insulin glargine overdose can lead to prolonged hypoglycemic effect due to altered pharmacokinetics. Physicians should be cognizant about this and closely monitor blood glucose levels and anticipate the possibility for prolonged IV dextrose infusion.

317 Type 2 diabetes and neonatal hypoglycemia: role of route of delivery and insulin infusion

The primary objective was to compare the rate of neonatal hypoglycemia among individuals with Type 2 diabetes mellitus (T2DM) who attempted labor vs. had planned cesarean delivery (CD); the secondary objective was the rate of neonatal hypoglycemia among T2DM who did not vs had insulin infusion during labor. This was a retrospective cohort study of individuals with insulin treated T2DM and singleton pregnancy who delivered at a single tertiary center between March 2012 and May 2018. Individuals with chronic renal failure, proliferative retinopathy, or major congenital anomalies were excluded. The primary outcome was neonatal hypoglycemia (blood glucose < 40 mg/dl in the first 24 hours of life or < 50 mg/dl >24 hours of age). Secondary outcomes included several maternal and neonatal outcomes (see table). Multivariable Poisson regression models with robust error variance were used to examine the association between groups and the primary outcome Adjusted relative risk (aRR) and 95% confidence intervals (CI) were calculated. Of 233 T2DM, 215 (92.2%) met inclusion criteria, of whom 95 (44%) attempted labor and 120 (56%) had a planned CD. Compared to those with planned CD, individuals who labored had higher gestational age at delivery (36.6 vs 35.8 weeks, p=0.005), and higher blood glucose upon admission (125 vs 103, p<0.001). After adjusting for potential confounders, there was no difference in the risk of neonatal hypoglycemia between the groups (aRR=1.07, 95% CI=0.78-1.48) (Table 1). Among those who attempted labor, 34 (35.8%) required insulin infusion. There was no difference in the risk of neonatal hypoglycemia (aRR=0.79, 95% CI=0.45-1.37) between women who required insulin infusion and those who did not (Table 2). Upwards of 40% of newborns of insulin dependent T2DM have hypoglycemia, irrespective of whether they labored or had planned cesarean, whether they received insulin infusion or not. An improved understanding of modifiable factors which reduce neonatal hypoglycemia is warranted.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Evaluation of Basal Insulin Dose Reductions in Hospitalized Patients With Diabetes While Unable to Eat.

Background: The American Diabetes Association guidelines recommend a basal plus correction or basal insulin regimen for patients with type 2 diabetes mellitus (T2DM) receiving nothing by mouth (NPO; nil per os) in the non-intensive care unit setting. In the perioperative setting, 60% to 80% of long-acting insulin or half-dose morning insulin NPH is recommended. Objective: The goal of this study was to determine the impact of basal insulin dose reduction for hospitalized patients with insulin-dependent T2DM while NPO. Methods: This retrospective, single-center study evaluated patients admitted to the non-intensive care unit setting. Administration of >50% of home basal insulin was compared with administration of ≤50% of home basal insulin. The primary outcome was the difference in hypoglycemic events (blood glucose [BG] < 70 mg/dL). Secondary outcomes included comparing severe hypoglycemic events (BG < 40 mg/dL), hyperglycemic events (BG > 180 mg/dL), and hospital length of stay (LOS). Results: Two hundred fifty-eight patient encounters were included, of which 85 and 173 patients received ≤50% and >50% of their home basal insulin dose, respectively. There were no significant differences in hypoglycemia (21.2% vs 21.4%; P = .97), severe hypoglycemia (1.2% vs 2.9%; P = .67), and hospital LOS (3 [IQR 2.13-6.74] days vs 4.66 [IQR 2.94-8.17] days; P = .74). Hyperglycemia occurred at a higher rate in patients receiving ≤50% of their home basal insulin dose (97.6% vs 89%; P = .02). Conclusions: No differences were observed in hypoglycemic events between those patients receiving ≤50% and >50% of their home basal insulin.

Carriers of the TCF7L2 rs7903146, rs12255372 Risk Alleles in the South Tamil Nadu T2DM Patients Present with Early Incidence and Insulin Dependence.

Background and Aims:Metabolic abnormalities in T2DM (Type 2 diabetes mellitus) include classic manifestations such as impaired insulin secretion, synthesis and peripheral insulin resistance. The intronic variants rs7903146 and rs12255372 of the TCF7L2 (transcription factor 7-like 2) gene are strongly associated with risk of incidence of T2DM and impaired β-cell functions. Studies addressing the early T2DM onset, and early insulin dependence in T2DM patients of south Tamil Nadu are still lacking, and hence the present study focuses in determining the influence of the TCF7L2 polymorphisms in the incidence and disease course in the T2DM patients of south Tamil Nadu.Methods:Anthropometric measurements and biochemical parameters were carried out in early onset (Group A), early onset insulin dependent T2DM patients (Group B) and non-insulin dependent T2DM patients (Group C). PCR, allele specific PCR (ASP), PCR product sequencing strategies were utilized to determine the genotype and the impact of the TCF7L2 SNPs in the T2DM disease course.Results:Female T2DM patients with the CT/TT rs7903146 genotype (P = 0.005) and the rs12255372 GT/TT genotype (P = 0.036) exhibited a significantly low mean age for T2DM incidence. Correlation/regression analysis in the T2DM patients revealed that rs12255372 (P = 0.042) is associated with early onset in the Group C patients and the rs7903146 (P = 0.018), rs12255372 (P = 0.026) are associated with insulin dependence in the group B patients.Conclusion:Screening for the TCF7L2 polymorphisms will prevent T2DM incidence and enable life style changes, appropriate therapeutic strategies that would help combat the accelerated disease course in the T2DM patients.

Risk of Malnutrition, Trace Metal, and Vitamin Deficiency Post Roux-en-Y Gastric Bypass--a Prospective Study of 20 Patients with BMI < 35 kg/m².

Due to its reliable effects on type 2 diabetes mellitus (T2DM) remission, Roux-en-Y gastric bypass (RYGB) has recently been investigated as a treatment option for nonseverely obese patients with T2DM (body mass index (BMI) <35 kg/m(2)). The purpose of this study was to investigate whether RGYB induces malnutrition of macro- and micronutrients within 24 months in these patients. A prospective cohort of 20 patients with longstanding, insulin-dependent T2DM and a BMI of 25-35 kg/m(2) were treated with RYGB. The patients were supplemented with over-the-counter, multivitamin, and micronutrient supplements. Serum concentrations of albumin, vitamins, and trace elements, hemoglobin, and bone density were measured preoperatively and over a 24-month period (DRKS00004605). RYGB did not result in underweight or protein malnutrition. No new onset of deficiencies of water- or fat-soluble vitamins developed over the study period. However, serum selenium, zinc, and ferritin decreased significantly (selenium, 1.17 ± 0.13 to 0.89 ± 0.11 μmol/l, p = 0.018; zinc, 13.9 ± 0.5 to 10.8 ± 0.5 μmol/l, p = 0.012; ferritin, 171.7 ± 26.9 to 31.8 ± 11.2 μg/l, p = 0.018). Hemoglobin remained stable. Vitamin D (13.7 ± 1.8 to 19.1 ± 1.1 ng/ml, p = 0.017) and osteocalcin (15.3 ± 1.7 to 25.4 ± 2.7 ng/ml, p = 0.025) rose significantly, whereas the parathyroid hormone remained stable. Despite increased bone formation, bone density decreased (T score hip, 0.15 ± 0.25 to -0.71 ± 0.34, p = 0.005) resulting in a significant increase in osteopenia rates (18 to 50 %, p = 0.046). This is the first prospective cohort to investigate malnutrition after RYGB in nonseverely obese patients. These patients are at risk of developing iron, selenium, and zinc deficiencies within 24 months, as well as osteopenia despite an increase in bone formation.

Metabolic Surgery for the Treatment of Type 2 Diabetes in Pancreas After Kidney Transplant Candidates

Metabolic surgery for the treatment of type 2 diabetes mellitus (T2DM) in patients not morbidly obese (BMI <35) has been widely studied. Taking into account that ∼12% of pancreas transplants are performed in patients with T2DM, our goal was to evaluate the impact of metabolic surgery on the management of obese patients with T2DM on waiting lists for a pancreas transplant. We performed a Roux-en-Y gastrointestinal bypass in 5 patients with insulin-dependent T2DM who were candidates for pancreas after kidney transplant and with a BMI <35. Three patients became insulin independent by the end of the first year while the other 2 reduced their insulin requirements by 70%. Furthermore, all patients achieved improved control of lipid levels. We concluded that the surgery was effective in controlling blood glucose and lipid metabolism in these obese T2DM kidney transplant recipients. In this population, a pancreas transplant, along with its associated morbidity, may be avoided.

Xenograft of Microencapsulated Sertoli Cells for the Cell Therapy of Type 2 Diabetes Mellitus in Spontaneously Diabetic Nonhuman Primates: Preliminary Data

Insulin resistance in type 2 diabetes mellitus (T2DM) may be due to a chronic inflammation of the visceral adipose tissue (VAT) leading to local and systemic increases in proinflammatory cytokines. Microencapsulated porcine Sertoli cells (MC-pSC), by provision of immunomodulatory and trophic factors, have been successfully used to reduce such inflammation in rodent animal models of type 1 diabetes with no complications or deleterious side effects. Herein, we have begun to investigate this novel and safe therapeutic approach in the spontaneously obese nonhuman primate with spontaneous, insulin-dependent T2DM. After MC-pSC intraperitoneal injection we have evaluated, throughout a 6-month follow-up period, daily ad libitum fed glucose levels, daily exogenous insulin supplementation, biweekly body weight measurements, periodic fasting blood glucose concentrations, glycated hemoglobin (HbA1c) levels, glucose tolerance tests (GTT), and fluorescence-activated cell sorting cytometry (FACS) assessment of peripheral blood mononuclear cells. Very preliminarily, we have observed a slight reduction in fasting (FPG) and mean nonfasting (NF) plasma glucose levels. We found minimal changes, only in 1 animal, in daily exogenous insulin requirements and HbA1c levels. Flow cytometric analysis was associated with decrease in CD8+ cells only in 1 recipient with a reduction in mean regulatory T Cells (Treg), whereas interestingly, decrease of B lymphocytes was observed in both animals. These results may suggest that this novel MC-SC–based transplantation protocol might possibly impact the metabolic status of T2DM in higher mammals that are close to humans.

Gastric Bypass Leads to Improvement of Diabetic Neuropathy Independent of Glucose Normalization—Results of a Prospective Cohort Study (DiaSurg 1 Study)

Surprisingly, 40% to 95% of patients with type 2 diabetes mellitus (T2DM) show early remission of hyperglycemia after obesity surgery. It is unknown to what extent other diabetes-associated comorbidities such as distal peripheral neuropathy (DPN) might be influenced by obesity surgery. This pilot study aimed at providing further evidence for the impact of Roux-en-Y gastric bypass (RYGB) on both glycemic control and DPN in non-severely obese patients with insulin-dependent T2DM. In the present prospective cohort study, 20 patients with long-standing, insulin-dependent T2DM and a body mass index (BMI) between 25 and 35 kg/m underwent laparoscopic RYGB. Body mass index, glycosylated hemoglobin (HbA1c), and DPN [quantified by the Neuropathy Symptom Score (NSS) and the Neuropathy Deficit Score (NDS)] were investigated. Six months after surgery, the preoperative BMI of 32.8 ± 2.1 kg/m (mean ± standard deviation) dropped to 25.6 ± 2.5 kg/m (P < 0.001). Preoperative HbA1c levels decreased from 8.5 ± 1.2% to 7.1 ± 1.2% (P < 0.001), with 15% of patients having a normalized HbA1c level lower than 6.2%. Of 12 patients with documented DPN, the median NSS was 8 (range, 0-10) preoperatively and 0 (range, 0-9) postoperatively (P = 0.004), with 8 patients scoring an NSS of 0. The median NDS was 6 (range, 2-8) preoperatively and 4 (range, 0-8) postoperatively (P = 0.027), with 1 patient scoring an NDS of 0. All patients had an improvement or normalization in either 1 or both scores. As expected, BMI and HbA1c levels improved significantly after RYGB. More interestingly, neuropathy scores, such as NSS and NDS, improved significantly early after surgery. Symptomatic neuropathy was completely reversible in 67% of the patients. These findings add further evidence to the fact that RYGB might be a valuable treatment option not only for improving glycemic control but also for reducing diabetes-associated comorbidities, such as DPN. This points to a complex metabolic effect of RYGB that exceeds glucose normalization. However, the results still need to be confirmed in controlled trials.

Sustained cardiac remodeling after a short-term very low calorie diet in type 2 diabetes mellitus patients

A very low calorie diet (VLCD) results in cardiac remodeling and improved diastolic function. It is unknown how long these effects sustain after reintroduction of a regular diet. We aimed to assess the long-term effects of initial weight loss by VLCD on cardiac dimensions and function in type 2 diabetes mellitus (T2DM) patients. Fourteen insulin-dependent T2DM patients (mean ± SEM: age 53 ± 2 years; BMI 35 ± 1 kg/m(2)) were treated by a VLCD (450 kcal/day) during 16 weeks. Cardiac function and myocardial triglyceride (TG) content were measured by magnetic resonance imaging and spectroscopy at baseline, after a 16-week VLCD and after 14 months of follow-up on a regular diet. BMI decreased from 35 ± 1 to 28 ± 1 kg/m(2) after VLCD and increased again to 32 ± 1 kg/m(2) at 18 months (both P < 0.05 vs. baseline). Left ventricular (LV) end-diastolic volume index increased after the 16-week VLCD (80 ± 3 to 89 ± 4 ml/m(2), P < 0.05) and remained increased after follow-up (90 ± 3 ml/m(2); P < 0.05 vs. baseline) at comparable filling pressures. The improvement in LV diastolic function after the 16-week VLCD, was sustained at 18 months [early (E)/atrial (A) diastolic filling phase ratio: 0.96 ± 0.07 (baseline); 1.12 ± 0.06 (after VLCD); 1.06 ± 0.07 (18 months, P < 0.05 vs. baseline)]. Myocardial TG content decreased after the 16-week VLCD [0.74 (0.41-1.10) to 0.45 (0.31-0.54) %, P < 0.05], but returned to baseline levels at 18 months [0.76 (0.65-1.32) %]. Weight reduction by a 16-week VLCD in T2DM patients results in sustained cardiac remodeling and improved diastolic function after 14 months of follow-up, despite weight regain on a regular diet.

Immediate and long-term effects of addition of exercise to a 16-week very low calorie diet on low-grade inflammation in obese, insulin-dependent type 2 diabetic patients

ObjectiveTo assess the short- and long-term effects of addition of exercise to a very low calorie diet (VLCD) on low-grade inflammation in obese patients with type 2 diabetes mellitus (T2DM). MethodsTwenty seven obese, insulin-dependent T2DM patients followed a 4-month VLCD with (n=13) or without (n=14) exercise and were followed up to 18months. Anthropometric measurements, metabolic and inflammatory parameters were assessed before, directly after the intervention and at 6 and 18months follow-up. The same measurements were performed only once in 56 healthy lean and 56 healthy obese controls. ResultsAt baseline hsCRP, IL10 and IL8 were significantly elevated in obese T2DM compared to lean healthy controls. After 4months, despite substantial weight loss (−25.4±1.3kg), neither the VLCD nor VLCD+exercise had an effect on plasma cytokines. At 6months, in the weight-stabilizing period, measures of low-grade inflammation had decreased substantially and equally in both intervention groups. Despite subsequent weight regain, beneficial effect was sustained up to 18months in both groups, except for IL1 and hsCRP which had returned to baseline in the VLCD-only group. ConclusionOur findings suggest that severe caloric restriction increases cytokine production by adipose tissue macrophages and that the beneficial effects of weight loss become apparent only in the eucaloric state.

Willingness to Pay for Improvements in Chronic Long-Acting Insulin Therapy in Individuals With Type 1 or Type 2 Diabetes Mellitus

Background Long-acting insulin treatments with varying clinical benefits are currently available for patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). The current evidence base demonstrates the efficacy of treatments, but it is critical also to understand patient preferences regarding treatments and how they are determined. Objective This study aimed to measure the willingness to pay (WTP) of individuals with diabetes in the United Kingdom for different attributes of long-acting insulin therapy. Methods A survey based on discrete choice experiment methodology was developed to elicit the preferences and values of adults with T1DM or insulin-dependent T2DM regarding different aspects of their therapy. Participants were presented with a series of 27 paired choices and asked which they preferred. WTP values were calculated for relevant attribute levels. Results A total of 252 participants completed the questionnaire (52% response rate); 143 had T1DM and 109 had insulin-treated T2DM. The highest WTP values in participants with T1DM were avoiding 2-kg or 4-kg weight gain (£29 and £58, respectively), avoiding major difficulties with the injection device (£49), increasing the number of days per week when blood glucose levels are in the target range from 2 to 6 (£40), reducing the number of daily injections from 3 to 1 (£39), and avoiding nighttime hypoglycemia (£33). In participants with T2DM, similar factors had the highest WTP. Conclusions This is the first study to assess WTP for long-acting insulin therapy and could have implications for future guidelines on diabetes management, however some limitations, notably in sample selection, could affect generalizability of the results. In both T1DM and T2DM, the highest WTP values were for avoidance of weight gain, and reduction in the number of injections and hypoglycemia.

Quality of life in type 2 diabetes mellitus after a very low calorie diet and exercise

ObjectiveTo evaluate whether the addition of exercise to a very low calorie diet (VLCD) has beneficial short- and long-term effects on health-related quality of life (QoL) in obese patients with type 2 diabetes mellitus (T2DM). MethodsWe included 27 obese, insulin-dependent T2DM patients in a 16-week VLCD study, of whom 13 participated simultaneously in an exercise program (VLCD+E). Before, immediately after and 18months after the intervention anthropometric measurements, glucoregulation and QoL (SF-36, HADS, NHP and MFI-20) were assessed. Patients were compared to healthy lean and obese (matched for body mass index) controls matched for gender and age. ResultsAt baseline, T2DM patients had significantly worse QoL scores in 18 and 14 of the 22 subscales of the QoL questionnaires, compared to lean and obese controls, resp. The 16-week VLCD (n=27) decreased bodyweight (−25.4±1.3kg, p<0.0001, p=0.179 between groups), and improved glucoregulation (HbA1c −1.3±0.3%, p<0.0001, p=0.488 between groups) and 9 (VLCD-only) and 11 (VLCD+E) of the 22 subscales of QoL.After 18months, in the VLCD+E group the QoL subscales did not differ from those in obese controls and only 4 of the 22 subscales were significantly worse compared to lean controls. However, in the VLCD-only group 17 and 13 of the 22 QoL subscales were significantly worse compared to the lean and obese controls, resp. ConclusionA 16-week VLCD induces considerable weight loss, metabolic amelioration, and major improvements in QoL in obese T2DM patients. The addition of exercise is of paramount importance for the maintenance of better QoL.

Remission of type 2 diabetes after Roux-en- Y gastric bypass is associated with greater weight loss

Background Physiologic studies in rodents and preliminary human studies have suggested that Roux-en- Y gastric bypass (RYGB) improves type 2 diabetes mellitus (T2DM) by way of metabolic changes, long before the bariatric or weight loss effects occur, leading to the concept of “metabolic surgery.” To test this hypothesis, we studied patients with insulin-dependent T2DM who underwent RYGB to determine whether T2DM remission in this treatment-resistant subgroup occurred independent of weight loss. Methods Of all the patients undergoing RYGB from 2000 to 2006 (n = 1546) with ≥12 months of follow-up, 318 had T2DM (21%), and 75 (24%) of these were insulin dependent. Of the 75 patients, 4 were found to have T1DM (5.3%) and were excluded, leaving a study population of 71 patients. The patients who achieved remission, defined as a cessation of diabetic medications with a hemoglobin A1c level of <7%, were compared with those who did not achieve remission. Statistical significance was set at P < .05, using the Student t test, chi-square test, and logistic regression analysis, as appropriate. Results After RYGB, all 71 patients with insulin-dependent T2DM had achieved a reduction in the dose and/or number of medications at 29.6 ± 17.0 months. Of these 71 patients, 35 (49%) demonstrated a remission of T2DM. The preoperative body mass index, age, number of medications, and hemoglobin A1c level did not differentiate between those who attained remission and those who still required diabetic medication. From the multivariate analysis, the significant factors associated with remission were the preoperative insulin dose and the percentage of excess weight loss. The percentage of excess weight loss was greater in the remission patients as early as 3 months postoperatively ( P = .04) and also at 6, 12, 18, and 24 months. Conclusion RYGB uniformly improved the medication requirements of patients with insulin-dependent T2DM. Although physiologic mechanisms likely contributed, early rapid weight loss was associated with the remission of T2DM.