Management Of T2DM Research Articles

Experiences of barriers to self-monitoring and medication-management among Indian patients with type 2 diabetes, their primary family-members and physicians.

This study explored the subjective accounts of the main barriers to self-monitoring of blood-glucose (SMBG) and medication-management among Indian patients with type 2 diabetes (T2DM), their primary family-members (PFMs) and physicians. Using convenience sampling, patients with T2DM, their PFMs, and physicians, residing in a South Indian capital city, were recruited for semi-structured, audio-recorded interviews. Thematic analysis was used to analyze the data. Fifty patients (female = 14; mean age = 42.5 years) and their PFMs (female = 38; mean age = 39 years), and 25 physicians (female = 4; mean age = 49.8 years) were recruited. Three superordinate themes were identified: (i) complex medication-regimen: confusion, forgetting and reduced motivation, (ii) family recommendations of alternative therapies due to the social pressures of avoiding stigma, intrusiveness and being misrepresented for injecting insulin, and (iii) an expensive illness: choosing to spend money on only medication. Implications of the findings highlight the need to (i) train physicians in communication and empathy skills, (ii) empower patients to communicate their barriers to physicians through triadic communication models and question-prompt lists, (iii) educate communities on the benefits of insulin for managing T2DM to reduce stigma, and (iv) equip communities with information about health insurance to address the financial toll of T2DM management.

Effect of Family Empowerment on Self Care of Patients with Type-2 Diabetes Mellitus: A Systematic Review

Introduction: Diabetes Mellitus Type 2 (T2DM) is a chronic disease that will be suffered for life, so it is necessary to provide education to patients and families so that it is easy to understand the course of the disease, prevention and obstacles in the management of T2DM. Family empowerment can be started by optimizing family functions to help patients with T2DM to adapt and comply with self-care actions through four dimensions, empathic (emotional), encouragement (reward), facilitative (instrumental), and participatory (participation). This systematic review aims to identify and evaluate the effect of family empowerment interventions on self-care for T2DM patients.
 Methods: The database used for article searches consisted of EBSCO, PubMed and ProQuest using relevant keywords based on the topic and title of the study. The selection of articles used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram method, the overall results were 2,635 articles and 8 articles that fit the inclusion criteria and were analyzed descriptively narrative and had met the methodological quality study according to JBI guidelines (Joanna Briggs Critical Appraising Methodology).
 Results: 8 articles with the Family Empowerment Process Model intervention program and the Diabetes Mellitus Education Program which is a family-oriented program that includes education classes, group discussions, home visits, and telephone follow-up. Education is provided to families through direct discussion and through telephone calls with a duration of each call of approximately 15 to 20 minutes scheduled for 9 am to 12 noon. Follow-up was done by telephone in the intervention group for approximately 3 months to 12 months.
 Conclusion: The findings of this systematic review indicate that family empowerment interventions based on health education can have a good effect on improving self-care for patients with type 2 diabetes mellitus

The experience of type 2 diabetes: Application of the Model of Human Occupation

Introduction Integrating type 2 diabetes (T2DM) self-care behaviors into daily life is complex and poorly understood. Occupational therapists, as experts in life context, habits, roles, and routines, can foster new ways of understanding and promoting daily engagement in T2DM self-care. The Model of Human Occupation (MOHO), a conceptual practice model, may have applicability to better understanding the experience of living with T2DM and engaging in necessary self-care behaviors. Methods We conducted focus group interviews with individuals with T2DM ( n = 10). We applied the MOHO to understand the experience of living with T2DM and engaging in related self-care behaviors. Findings Participants discussed each element of MOHO and how it related to living with and managing type 2 diabetes. Participants identified obtaining skills for self-advocacy with family, individualized/adapted exercise, stable health-promoting environments and routines, and problem-solving skills for disruptions to routine as critical needs for managing T2DM. These intervention strategies are well-aligned with MOHO and occupational therapy practice. Conclusion We found that MOHO was a useful tool for exploring the experience and daily management of T2DM.

TRPV1 Activation by Capsaicin Mediates Glucose Oxidation and ATP Production Independent of Insulin Signalling in Mouse Skeletal Muscle Cells.

Background: Insulin resistance (IR), a key characteristic of type 2 diabetes (T2DM), is manifested by decreased insulin-stimulated glucose transport in target tissues. Emerging research has highlighted transient receptor potential cation channel subfamily V member (TRPV1) activation by capsaicin as a potential therapeutic target for these conditions. However, there are limited data on the effects of capsaicin on cell signalling molecules involved in glucose uptake. Methods: C2C12 cells were cultured and differentiated to acquire the myotube phenotype. The activation status of signalling molecules involved in glucose metabolism, including 5’ adenosine monophosphate-activated protein kinase (AMPK), calcium/calmodulin-dependent protein kinase 2 (CAMKK2), extracellular signal-regulated protein kinases 1 and 2 (ERK1/2), protein kinase B (AKT), and src homology phosphatase 2 (SHP2), was examined. Finally, activation of CAMKK2 and AMPK, and glucose oxidation and ATP levels were measured in capsaicin-treated cells in the presence or absence of TRPV1 antagonist (SB-452533). Results: Capsaicin activated cell signalling molecules including CAMKK2 and AMPK leading to increased glucose oxidation and ATP generation independent of insulin in the differentiated C2C12 cells. Pharmacological inhibition of TRPV1 diminished the activation of CAMKK2 and AMPK as well as glucose oxidation and ATP production. Moreover, we observed an inhibitory effect of capsaicin in the phosphorylation of ERK1/2 in the mouse myotubes. Conclusion: Our data show that capsaicin-mediated stimulation of TRPV1 in differentiated C2C12 cells leads to activation of CAMKK2 and AMPK, and increased glucose oxidation which is concomitant with an elevation in intracellular ATP level. Further studies of the effect of TRPV1 channel activation by capsaicin on glucose metabolism could provide novel therapeutic utility for the management of IR and T2DM.

Inhibitory effects of chondroitin sulfate on alpha-amylase activity: A potential hypoglycemic agent

Inhibiting the activity of the intestinal enzyme α-amylase that catalyzes the degradation of starch into glucose can control blood glucose and provide an essential way for the treatment of Type-II diabetes mellitus (T2DM). Here, we compared the structural information of chondroitin sulfate (CS) from different origins and the effects on activity of α-amylase and blood glucose have been investigated. The inhibitory effects of shark and porcine CSs against α-amylase activity is obvious with IC50 values of 11.97 and 14.42 mg/ml, respectively, but the bovine CS almost no effect. From the data of fluorescence spectroscopic analyses, CSs from shark and pig quench Try fluorescence intensity of the enzyme, whereas bovine CS induces an increase. In vivo, oral administration of shark and porcine CSs efficiently suppresses postprandial blood glucose levels in normal and diabetic mice. Our study found that CSs from different sources showed different biological functions even if both molecular weight and disaccharide subunit composition are almost the same, and demonstrated that the CSs from shark and pig as α-amylase inhibitors could be regarded as a novel functional food ingredient in T2DM management.

Translational Medicine and Exercise Prescription (TMEP): Advancing the Era of Exercise Medicine

Translational Medicine and Exercise Prescription (TMEP): Advancing the Era of Exercise Medicine

Macroalgal protein hydrolysates from Palmaria palmata influence the \u2018incretin effect\u2019 in vitro via DPP-4 inhibition and upregulation of insulin, GLP-1 and GIP secretion

PurposeThis study investigated metabolic benefits of protein hydrolysates from the macroalgae Palmaria palmata, previously shown to inhibit dipeptidylpeptidase-4 (DPP-4) activity in vitro.MethodsPreviously, Alcalase/Flavourzyme-produced P. palmata protein hydrolysate (PPPH) improved glycaemia and insulin production in streptozotocin-induced diabetic mice. Here the PPPH, was compared to alternative Alcalase, bromelain and Promod-derived hydrolysates and an unhydrolysed control. All PPPH’s underwent simulated gastrointestinal digestion (SGID) to establish oral bioavailability. PPPH’s and their SGID counterparts were tested in pancreatic, clonal BRIN-BD11 cells to assess their insulinotropic effect and associated intracellular mechanisms. PPPH actions on the incretin effect were assessed via measurement of DPP-4 activity, coupled with GLP-1 and GIP release from GLUTag and STC-1 cells, respectively. Acute in vivo effects of Alcalase/Flavourzyme PPPH administration on glucose tolerance and satiety were assessed in overnight-fasted mice.ResultsPPPH’s (0.02–2.5 mg/ml) elicited varying insulinotropic effects (p < 0.05–0.001). SGID of the unhydrolysed protein control, bromelain and Promod PPPH’s retained, or improved, bioactivity regarding insulin secretion, DPP-4 inhibition and GIP release. Insulinotropic effects were retained for all SGID-hydrolysates at higher PPPH concentrations. DPP-4 inhibitory effects were confirmed for all PPPH’s and SGID counterparts (p < 0.05–0.001). PPPH’s were shown to directly influence the incretin effect via upregulated GLP-1 and GIP (p < 0.01–0.001) secretion in vitro, largely retained after SGID. Alcalase/Flavourzyme PPPH produced the greatest elevation in cAMP (p < 0.001, 1.7-fold), which was fully retained post-SGID. This hydrolysate elicited elevations in intracellular calcium (p < 0.01) and membrane potential (p < 0.001). In acute in vivo settings, Alcalase/Flavourzyme PPPH improved glucose tolerance (p < 0.01–0.001) and satiety (p < 0.05–0.001).ConclusionBioavailable PPPH peptides may be useful for the management of T2DM and obesity.

412-P: Increased Peripheral Neutrophil Count Is Closely Associated with the Incidence and Progression of Chronic Kidney Disease in Older Type 2 Diabetic Patients

Preventing and managing chronic kidney disease (CKD) is the primary task of the overall management of T2DM. An increasing number of studies has indicated that low-grade chronic inflammation plays a crucial role in the pathophysiology of CKD. A total of 3345 subjects were recruited in this study of whom 1257 derived from one centre and served as case-controls and 2088 with T2DM derived from two other centres and were followed up annually for 4 years and entered into a retrospective cohort study. In the case-control study, neutrophil count performed best as an independent risk factor for CKD even after 1:1 case-control matching for age, gender, and history of high blood pressure (HBP). Spline regression revealed a significant linear association between CKD incidence and continuous neutrophil count in excess of 3.6 × 109/L. In the cohort study, subjects were grouped based on tertile of neutrophil count and neutrophil-to-lymphocyte ratio (NLR), respectively. COX regression analysis showed that only neutrophil count demonstrated an increased HR for estimated glomerular filtration rate (eGFR) reduction greater than 30% (the highest group vs. the lowest group, 1.604 (1.029 - 2.501), P &amp;lt; 0.05) after fully adjusting for potential confounders. The cumulative incidence of CKD in T2DM patients gradually increased with increasing neutrophil count. This study suggested that neutrophil count is associated with the incidence and progression of CKD in T2DM patients. Disclosure R. Zhang: None. Funding Medical Key Faculty Foundation of Shanghai (ZK2019B15)

810-P: The Diminishing Cost-Effectiveness of the Newer Glucose-Lowering Drugs in the United States, 2010-2018

Background: The difference between the costs of the newer and older glucose-lowering drugs has been steadily increasing since 2010. In 2018, newer drugs cost 8-12 times more than older drugs (except for insulin). This study aimed to understand how this change in drug cost influenced the cost-effectiveness (CE) of newer drugs compared with older drugs. Methods: We conducted a systematic literature review to identify US-based CE studies comparing newer (i.e., dipeptidyl peptidase-4 inhibitors (DPP4), glucagon-like peptide 1 receptor agonists (GLP1-RA), and sodium-glucose transport protein 2 inhibitors) with older glucose-lowering drugs. The identified 12 studies all reported the CE of newer drugs based on drug costs estimated before 2010. We have updated the corresponding CE of each study by replacing the old cost estimates with 2018 estimates from the 2018 IBM® MarketScan® Commercial Claims Databases. The time window and willingness to pay threshold were consistent with each original study. Results: Only 8% of the original studies suggested that the older drugs were cost-effective. However, 58% of studies were in favor of the older drugs after the cost update. Among the 4 studies comparing newer drugs with thiazolidinediones, all studies suggested thiazolidinedione to be cost-effective in the updated analysis, while the original results all favored newer drugs. For the 4 studies comparing newer drugs with sulfonylureas, 2 studies suggested the sulfonylureas to be cost-effective after the cost update. All 4 studies suggested newer drugs to be cost-effective when compared with insulin in the original study. Only 1 flipped its conclusion when 2018 costs were used. Our sensitivity analysis shows that our results are robust up to a 30% rebate. Conclusion: Significant changes in the cost of glucose-lowering drugs have impacted the economic value of different glucose-lowering agents substantially. More CE analyses are warranted to support the drug choice in T2DM management. Disclosure P. Li: None. R. S. Patel: None. S. M. Vouri: None. L. Shi: Research Support; Self; AstraZeneca, Sanofi. V. Fonseca: Consultant; Self; Abbott Diabetes, Asahi Kasei Corporation, Bayer Inc., Boehringer Ingelheim Pharmaceuticals, Inc., Intarcia Therapeutics, Inc., Novo Nordisk, Pfizer Inc., Sanofi-Aventis, Stock/Shareholder; Self; Amgen Inc., Bravo4health, Mellitus Health. H. Shao: Research Support; Self; Sanofi.

22-LB: Use of a Novel Virtual Patient Simulation Application to Assess Providers’ Knowledge in Management of T2 Diabetes

The goals of Type 2 diabetes (T2DM) management include achievement of glycemic, blood pressure (BP), and lipid control. All three variables must be addressed adequately in order to prevent diabetic complications. Aim: Using a proprietary smartphone-based application (APP) developed by Edocate Ltd, that simulates virtual visits, we assessed how well healthcare providers (HCPs) manage T2DM. Materials &amp; Methods: A total of 461 HCPs (247 MD, MD/PhD, or DO and 214 NPs) downloaded and used the APP to treat their virtual patients over multiple visits. All patients presented with poorly controlled T2DM, hypertension (HTN) and hyperlipidemia. HCPs chose the first, second and third lines of medications, made diagnostic adjustments, initiated appropriate referrals to specialists, and ordered laboratory tests of their choice. Based on their selections, the APP simulated the course of diabetes and its complications, requiring diverse management decisions on the subsequent virtual visits. Results: In the Edocate virtual clinic, only 53% of HCPs achieved good glycemic control (A1c &amp;lt; 7%), 41% achieved BP control (&amp;lt;130/80 mmHg), and 66% prescribed high-intensity statins. NPs performed slightly but not significantly better than the physician cohort. Only 48% of HCPs checked microalbuminuria, 54% ordered creatinine and 55% ordered LDL. Interestingly, 79% of HCPs either kept or started Metformin as the first line medication. The most commonly ordered second line of medications for glycemic control was either GLP-1 receptor agonists (39%) or SGLT2 inhibitors (36%), while 23% of HCPs kept their patients on or added sulfonylurea or basal insulin (11%). Conclusions: Despite a worldwide effort in diabetes education, the knowledge of T2DM management remains suboptimal (as assessed by the simulation APP) and underscores the need for better professional education. Innovative patient simulation-based learning applications can dramatically improve the level of competency in HCPs. Disclosure B. Draznin: None. I. Iancu: None.

Abstract P058: Risk Of Heart Failure In Type 2 Diabetes Has Decreased Over Time - A Danish Nationwide Cohort Study

Introduction: Although type 2 diabetes (T2DM) is one of the strongest risk factors for heart failure (HF), there is limited data on contemporary lifetime risk estimates in this segment. Incident HF appears to be decreasing in the general population, but little is known how the risk has changed over time in patients with T2DM. The increasing prevalence and rapidly evolving management of T2DM has furthered interest in the epidemiological relationship between HF and T2DM. We therefore sought to investigate the lifetime risk of HF in people with T2DM and how the long term risk of HF has changed over time in patients with T2DM. Hypothesis: We assessed the hypothesis that there would be a statistically significant reduction in the ten- year risk of HF among patients with T2DM over time in all age groups except the youngest (&lt;50 years old), mimicking trends in the general population and that men would have a higher cumulative risk than women. Methods: We employed the Danish nationwide databases which included information on all Danish citizens’ hospitalizations, outpatient visits, and medication use since 1978 (diagnoses) and 1995 (medications). Using this data, we calculated the cumulative incidence of HF among patients with T2DM who were free from HF at age 30, 40, 50, 60, and 70 years, respectively. We censored people at time of emigration or at Dec 31, 2017 and we used Aalen-Johnsen estimators to adjust for the competing risk of death. Results: A total of 473,685 patients (47% women) had a diagnosis of T2DM between Jan 1, 1995 and Dec 31, 2017. Of those who were free from HF before T2DM onset, 21,030 were diagnosed before the age of 30; 33,786 before age 40; 55,537 before 50 years of age; 85,108 before age 60; and 98,631 before age 70. During follow-up, 48,026 (10%) were diagnosed with HF and 133,561 were censored for death. The cumulative life-time risk of developing HF among people with diabetes at age 50 was 24% (95% CI 21-27%) in females and 27% (25-29%) in men, p for difference &lt;0.0001. Among patients aged 50 years, the 10-year risk of HF decreased from 12.2% (1995-2005) to 9.6% (2005- 2015), p&lt;0.0001. Similar 10-year risks decreased for those free from HF at age 60 year (from 19.0% in 1995-2005 to 13.3% in 2005-2015, p&lt;0.0001) and 70 years old (from 22.2% to 17.1% between 1995-2005 and 2005-2015, p&lt;0.0001). Conclusion: The lifetime risk of HF among patients with T2DM exceeds 1 in 4 for both men and women. There was, however, a decrease in ten-year cumulative incidence of HF over time among patients with T2DM in all age groups.

Personalized Type 2 Diabetes Management Using a Mobile Application Integrated with Electronic Medical Records: An Ongoing Randomized Controlled Trial.

Controlling type 2 diabetes (T2DM) requires a comprehensive approach including patient education, self-monitoring of blood glucose, individualized behavioral strategies, and frequent contact with healthcare professionals (HCPs). We aimed to compare the efficacy of a personalized lifestyle intervention based on a mobile phone application with regular care in participants with T2DM. This is an ongoing randomized controlled open-label parallel-group trial with a target accrual of 282 participants, of which 181 have been enrolled to date. Participants are randomly assigned to one of three groups: (1) regular care; (2) mobile diabetes management; or (3) mobile diabetes management with HCP feedback. The mobile application is enabled to integrate with both electronic medical records (EMR) and a web-based diabetes management system for HCPs. It can send customized messages based on participants’ responses to lifestyle questionnaires administered at the baseline. The intervention period is 26 weeks followed by observation for 26 weeks. We evaluate the intervention’s features in order to assess its clinical utility and efficacy and compare outcomes with regular care considering relevant clinical factors, such as age, baseline HbA1c, etc. We expect our study to provide new evidence in support of customized mobile application tools for the management of T2DM.

Vitamin D Deficiency Induces Macrophage Pro-Inflammatory Phenotype via ER Stress-Mediated Activation of Renin-Angiotensin System

Chronic inflammation and local activation of the renin-angiotensin-aldosterone system (RAAS) play a pivotal role in the pathogenesis and progression of diabetic complications. In patients with type 2 diabetes (T2DM), the prevalence of vitamin D deficiency is almost twice that of non-diabetics, and vitamin d deficiency nearly doubles the risk of developing hypertension and cardiovascular complications compared to diabetics with normal vitamin D levels. Interestingly, mice lacking the vitamin D receptor (VDR) in macrophages (KODMAC) develop renin-dependent hypertension, insulin resistance, and inflammation via up-regulation of macrophage ER stress. Macrophages also express all major components of the RAAS system. However, little is known about the regulation of macrophage-generated renin and its role in modulating the sequelae of VDR signaling in macrophage function and cytokine production. This study found that KODMAC macrophages and vitamin D-deficient macrophages have increased expression and secretion of renin, angiotensin II, ACE, and AT1 receptor and that adhesion, migration, and cytokine release were also increased. Inhibition of ER stress in KODMAC macrophages and vitamin D-deficient macrophages with 4-Phenylbutyric acid (PBA) reduced RAS gene expression and macrophage pro-inflammatory phenotype. Renin 1c gene deletion decreased macrophage adhesion, migration, and cytokine release compared to macrophages with disrupted VDR signaling. Notably, disruption of VDR signaling induced peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α) expression in macrophages, and upregulation of renin expression in response to vitamin D deficiency was blunted in PCG1α-deficient macrophages. In conclusion, our findings delineate a mechanism by which impaired VDR signaling induces ER stress to drive PGC1α-dependent expression of renin and RAAS hyperactivation, thereby altering macrophage function and cytokine production. These data implicate RAAS as an essential mediator of VDR-mediated macrophage function and support ongoing investigations of VDR and RAAS modulation as therapeutic approaches in the management of T2DM and its complications.

Medullary Carcinoma of Thyroid Due to GLP-1 Receptor Agonist

Introduction: The first GLP-1 receptor agonist (GLP-1 RA) was approved for the treatment of type 2 Diabetes mellitus in 2005. This class has gained popularity due to its anti-glycemic effect, weight loss and reduction in Cardiovascular disease outcomes1. The effects of this drug class on human thyroid cells are not well known. We hereby report a case of a woman who developed medullary carcinoma of thyroid (MTC) after using Dulaglutide.CaseA 63-year-old female with T2DM for 3 years, taking dulaglutide for 2 years, who presented with a lump in the neck. She had no personal or family history of MEN 2 syndrome, radiation exposure or cancer. Examination showed a 2cm firm nodule in the left lower neck. Thyroid ultrasound revealed a large nodule in the left upper lobe of thyroid. Lab work showed TSH of 1.55mIU/L (0.27-4.2 mIU/L) and serum calcitonin level of 1903 pg/ml (0.0-5.1 pg/mL). FNA biopsy of the nodule showed MTC. She tested negative for RET MEN 2 gene mutation. She underwent total thyroidectomy and neck dissection. Pathological examination confirmed MTC. Post-op calcitonin improved to 2.1 pg/ml.Discussion: GLP-1 RAs provide glycemic control by many mechanisms, including increase in insulin secretion, reduction in postprandial glucagon secretion, delaying gastric emptying, increasing satiety and weight loss. Although they have proved effective in T2DM management, the potential effects on thyroid C-cells should not be ignored. Several in-vitro studies have shown GLP-1 receptors on the rat thyroid tissue C-cells. Stimulation of these receptors resulted in increased production of calcitonin in a dose dependent manner and increased risk of C-cell tumor formation at 104 weeks. Studies initially done by Knudsen et al2 showed that this effect was not seen in humans due to lower expression of GLP-1 receptors in human thyroid tissue C cells. However, a study conducted by Gier et al showed the expression of GLP-1 receptor in some patients with C-cell hyperplasia as well as papillary and medullary carcinoma3. FDA adverse event reporting system database suggested an increased risk of thyroid cancer associated with GLP-1 RAs. It is unclear whether dulaglutide contributed to the development of MTC in this patient. She had not had a baseline calcitonin level prior to the initiation of dulaglutide. The consequence of long-term use of GLP-1 RAs in the thyroid gland in humans still remains unknown and further studies to determine if they increase the risk of MTC are warranted.

Combination Therapy With Premixed & Basal Insulin Analogues in Asian Indians With Type 2 Diabetes

Many individuals with type 2 diabetes (T2DM) eventually need insulin for better glycaemic control. Different insulin regimens like basal, premixed, basal plus, split mixed and basal bolus are used in T2DM management. There is not much literature on a combination of premixed insulin in the morning along with basal insulin at night. Such a regimen is preferred by people with T2DM, who do not want to take an afternoon insulin dose due to inconvenience. To study the effect of a premixed insulin given in the morning and long acting basal insulin analogue given at night in T2DM subjects, we looked into this combination. We performed a retrospective study to look into the effects of premixed and basal insulin analogue combination in patients with T2DM (in addition to oral antidiabetic agents). From the diabetes electronic medical records of a tertiary care hospital for diabetes at Chennai in South India, 648 patients on premixed and basal insulin analogue combination, who came for a follow-up visit were included in the final analysis. Baseline characteristics included body weight, BMI, blood pressure, fasting lipid profile, fasting and post prandial plasma glucose and HbA1c were analysed at baseline, and a change in the parameters was studied at the first follow up visit between 5 to 7 months. Mean age of the study population was 60.7± 13.1 years with mean diabetes duration of 20.5 ± 8.0 years. Out of 648 patients included, three fifths were male. Statistically significant improvement was observed in body weight, BMI, HbA1c, systolic blood pressure, lipid profile, fasting blood sugars (P < 0.001) and post prandial blood sugars (P= 0.005) in comparison to baseline values. Significant reduction in HbA1c (1.7 %, p < 0.0001) was observed in those with in the highest tertile of HbA1c (11.3 ± 1.0 %) in comparison to the baseline values. At follow up, nearly a third of study subjects achieved a HbA1c target of < 8% (30.1 % vs 18.4 0%, p =0.0005) in comparison to the baseline values. 28.7 % patients on combination therapy achieved a fasting blood sugar value of < 130 mg/dl at follow up compared to 18.2 % patients at baseline (p <.0001). Similarly, 22 % of the patients on combination therapy also achieved post prandial blood sugars of <180 mg/dl at follow up, compared to 12.2 % (P<.0001) at baseline. This study shows that in T2DM subjects, a simple regimen of premixed and basal insulin analogue combination helps in improving the glycaemic control.

Endocrinology in the Time of Coronavirus: A Virtual Endocrinology Elective for Medical Students

Introduction: During the COVID-19 pandemic, the Association of American Medical Colleges recommended that medical students halt in-person learning. Our institution created a competency based virtual endocrinology elective to provide continued clinical experience with a focus on type 2 diabetes (T2DM) and health equity in diabetes care.Methods: A 4-week virtual endocrinology elective alternated between different mini-rotations to maximize exposure to inpatient and outpatient endocrine care, as well as self-directed and faculty/fellow directed educational experiences. Post-elective surveys assessed student satisfaction with elective components and change in comfort levels with T2DM management and social determinants of health (SDH) on diabetes care.Results: Overall, 87% (n=13) of students were “extremely satisfied” with the elective. Increased comfort was seen with management of type 2 DM and the impact of SDH on DM care (DM 88% neutral/uncomfortable to 94% comfortable, SDH 50% neutral/uncomfortable to 94% comfortable). Students were satisfied with the quality of patient care and requested opportunities for more direct involvement.Conclusions: This virtual endocrine elective shows that curricula can be creatively designed to educate students in endocrinology, assess students across core competencies, and demonstrate impacts of telehealth and social determinants of health on endocrine and patient care.

Gender Differences and Their Influences on T2DM Self-Management Among Spanish-Speaking Latinx Immigrants.

Evidence suggests that gender may influence many aspects of type 2 diabetes (T2DM) self-management (SM) and we posit that limited English language-proficient Latinx immigrants face additional challenges. Instruments and semi-structured interviews were used to examine gender differences on health literacy, diabetes knowledge, health-promoting behaviors, diabetes, eating and exercise self-efficacy (SE), and T2DM SM practices among a cohort of limited English language-proficient Latinx immigrants. Statistical and qualitative analysis procedures were performed comparing males and females. Thirty persons participated. Males tended to be older, have higher educational achievement, and more financial security than females. Physiologic measures tended worse among female participants. Health literacy and exercise SE scores were similar, but females scored lower on Eating and Diabetes SE. Forty-seven percent (n= 9) of the women reported a history of gestational diabetes mellitus and a majority of men (n = 7) cited difficulty with excessive alcohol. Males appeared to receive more SM support compared to females. Females more frequently noted how family obligations and a lack of support impeded their SM. Work environments negatively influenced SM practices. Men and women have unique SM challenges and as such require individualized strategies and support to improve T2DM management.

An overview of dietary supplements on obesity and type 2 diabetes: efficacy and mechanisms.

Obesity is a common nutritional disorder, associated with a variety of chronic diseases, among them, type 2 diabetes (T2DM) has emerged as a serious worldwide health problem. Insulin resistance and β cell dysfunction are the main pathological characteristics of T2DM, and obesity and hyperlipidemia are the critical causal factors. It is commonly accepted that dietary factors are of paramount importance in the management of obesity and T2DM. Particularly, many botanic products and their extracts are endowed with a wide spectrum of biological activities, making them extensively studied as anti-obesity and anti-diabetes dietary supplements or new drug candidates. In this review, we aimed to summarize the effects, related mechanisms, and safety issues of dietary continents on obesity and T2DM, to provide theoretical support for better research and development of dietary therapy strategy for the treatment of obesity and T2DM. Based on a bunch of clinical investigations, specific carbohydrates and fatty acids, such as dietary fibers, polysaccharides, unsaturated fatty acids, have hypoglycemic and hypolipidemic effects. Vitamin D plays important role in metabolism and immunity modulation. Apart from them, natural bioactive ingredients from plants, such as flavonoids, polyphenols, alkaloids, terpenoids, polysaccharides, and quinones are efficient in helping weight loss and improving insulin sensitivity and glycemic control. They can protect β cell function by anti-inflammation, anti-oxidation, and anti-apoptosis properties, as well as regulating lipid metabolism. Therefore, promoting the consumption of diverse natural bioactive ingredients-rich products could be an effective nutritional strategy to benefit patients with obesity and type 2 diabetes.

Suboptimal glycemic control and prevalence of diabetes-related complications in Kenyan population with diabetes: cohort analysis of the seventh wave of the International Diabetes Management Practices Study (IDMPS)

• The 7th wave of the IDMPS is an international, multicenter, non-interventional, cross-sectional, observational study aimed at assessment of current practices in the management of both T1DM and T2DM in 24 countries in Africa, Eurasia, Middle East, and South Asia. It was conducted as a continuation of the previous waves of the IDMPS and data was collected during the period of January to September 2016 • At the time of the study, target HbA1c of <7.0% was reportedly achieved in only 36.6% of subjects with T2DM • The two most cited reasons for not attaining HbA1c targets in insulinized subjects were – lack of appropriate titration of insulin dose and lack of experience among patients in the management of their insulin dose • Diabetes-related complications were reported by 34.6% subjects overall with a predominance of microvascular complications over macrovascular complications. • This study highlights that the achievement of glycemic target in Kenyan subjects with T2DM is suboptimal and further investigations are required to formulate effective health policies to improve rates of glycemic target attainment in Kenya. To identify real-life medical practices in the management of diabetes mellitus (DM) in the Kenyan population. Kenyan subjects with DM were recruited as part of the 7 th wave of the International Diabetes Management and Practices Study in between September and October 2016. Data on demographics; medical history; glycemic control; concomitant anti-diabetic therapy; and hypoglycemic episodes were analyzed using descriptive statistics. Analysis of subjects with type 2 DM (T2DM), representing 96.7% (n/N: 187/194) of evaluable subjects, is presented. Target HbA1c achievement rate and average HbA1c at last measurement were 36.6% (n/N: 68/187) and 8.2% (66 mmol/mol), respectively. Microvascular complications were prevalent in 35.3% (n=65) of subjects, most frequently as neuropathy (n=41, 21.5%) and microalbuminuria (n=27, 14.1%). Most common comorbidities were dyslipidemia (n=125, 73.5%) and hypertension (n=123, 65.8%). Oral antidiabetic drugs, either alone (n=120, 64.2%) or in combination with insulin (n=48, 25.7%), were the preferred treatment. Inability in reaching glycemic targets in insulinized subjects were mostly attributed to lack of appropriate dose titration and lack of experience in management of dose. The achievement of glycemic target in Kenyan subjects with T2DM is suboptimal. Further investigations are required to formulate effective health policies to improve rates of glycemic target attainment in Kenya.

Painless foot drop: an unusual acute presentation of new onset type 1 diabetes mellitus.

SummaryA 26-year-old Caucasian female with no past medical history or family history of auto-immune disease presented to the emergency department with new onset painless left foot drop. A panel of blood tests revealed blood glucose of 49.9 mmol/L and raised blood ketone levels. The patient was referred to the diabetes team who made a clinical diagnosis of type 1 diabetes (T1DM) and insulin treatment was initiated. Elevated levels of diabetes auto-antibodies were subsequently detected. Nerve conduction studies demonstrated a left common peroneal nerve lesion with conduction block at the fibular head. After 2 weeks of insulin treatment, a significant improvement of her foot drop was observed and after 8 weeks she was walking normally. The most probable cause of her foot drop was acute diabetic mononeuropathy. To our knowledge, there are no similar cases in adult patients reported in the literature. Our case highlights the importance of physicians being aware of atypical presentation of new onset T1DM.Learning points There is an increasing incidence of T1DM with more than half of patients presenting after the age of 20. Diabetic peripheral neuropathy can present both acutely and as a mononeuropathy. Although rare, clinicians should be aware of mononeuropathy as a presenting symptom of T1DM to avoid delay in the treatment initiation. This case highlights an unusual presentation of T1DM and illustrates the importance of the early diagnosis and management of T1DM.