Suboptimal Blood Glucose Control Research Articles

A transparent machine learning algorithm uncovers HbA1c patterns associated with therapeutic inertia in patients with type 2 diabetes and failure of metformin monotherapy

AimsThis study aimed to identify and categorize the determinants influencing the intensification of therapy in Type 2 Diabetes (T2D) patients with suboptimal blood glucose control despite metformin monotherapy. MethodsEmploying the Logic Learning Machine (LLM), an advanced artificial intelligence system, we scrutinized electronic health records of 1.5 million patients treated in 271 diabetes clinics affiliated with the Italian Association of Medical Diabetologists from 2005 to 2019. Inclusion criteria comprised patients on metformin monotherapy with two consecutive mean HbA1c levels exceeding 7.0%. The cohort was divided into “inertia-NO” (20,067 patients with prompt intensification) and “inertia-YES” (13,029 patients without timely intensification). ResultsThe LLM model demonstrated robust discriminatory ability among the two groups (ROC-AUC = 0.81, accuracy = 0.71, precision = 0.80, recall = 0.71, F1 score = 0.75). The main novelty of our results is indeed the identification of two main distinct subtypes of therapeutic inertia. The first exhibited a gradual but steady HbA1c increase, while the second featured a moderate, non-uniform rise with substantial fluctuations. ConclusionsOur analysis sheds light on the significant impact of HbA1c levels over time on therapeutic inertia in patients with T2D, emphasizing the importance of early intervention in the presence of specific HbA1c patterns.

Preliminary efficacy of an acceptance-based diabetes education (ACT-DE) programme for people with type 2 diabetes on diabetes distress and self-care behaviours: A pilot randomised controlled trial

BackgroundDiabetes distress is often characterised by aversive feelings about diabetes and avoidance of diabetes self-care, leading to suboptimal blood glucose control, diabetes complications and depression. Evidence from a recent review has indicated the potential efficacy of acceptance-based diabetic self-management programmes for improving blood glucose levels and mental health outcomes by fostering psychological flexibility. MethodsWe conducted a two-arm and assessor-blinded pilot randomised controlled trial (RCT) with 48 participants aged 18–64 with type 2 diabetes and moderate distress levels, in which we compared a 6-week acceptance and commitment therapy and diabetes education (ACT-DE) programme intervention with diabetes education. Diabetes distress (the primary outcome), self-care behaviour, self-efficacy in diabetes management, and psychological inflexibility were measured at baseline and post-intervention. Focus group interviews were conducted to explore the intervention group's perceptions of the benefits and limitations of the intervention. ResultsResults of ANCOVA test showed that the intervention group exhibited significantly greater decrease in diabetes distress (effect size [Cohen's d] = 0.65), and increase in exercise frequency (d = 1.16), and foot-care frequency (d = 0.59) than the diabetes education group. The qualitative feedback of the intervention group revealed that the learnt ACT skills can be effectively applied in self-care and highlighted the utility of some of the intervention's therapeutic components, primarily mindfulness practices, metaphors, and interactive diabetes education. The intervention was well-accepted, with an 87.5% completion rate, but caution is needed due to a low recruitment rate (28.1%) during COVID-19 pandemic peak. ConclusionThis pilot study confirmed that ACT-DE programme is an acceptable intervention for people with type 2 diabetes. It demonstrated preliminary efficacy with medium-to-large effect sizes in alleviating the participants’ diabetes distress and improving their self-care. Recruitment strategies can be improved to enhance the feasibility. Moreover, a full-scale RCT with longer-term follow-up is warranted to examine the intervention effects on diabetes distress, blood glucose control and other health outcomes.

Current Smoking: An Independent Predictor of Elevated A1C in Persons With Type 2 Diabetes.

Purpose The purpose of this study is to examine the association of current smoking as one of several potential predictors of elevated A1C in adults with type 2 diabetes (T2D). Methods Using a cross-sectional design, baseline data (N = 282) were analyzed from a randomized clinical trial examining treatment of obstructive sleep apnea in persons with T2D. Sociodemographic, clinical, and behavioral data were collected using questionnaires and physical examinations. Physical activity (mean daily steps walked) was measured with the BodyMedia Armband. Participants were asked if they never smoked, had previously smoked, or currently smoke. The sample distributions of demographic and clinical characteristics were examined using descriptive statistics. Continuous variables were described using means and standard deviations; categorical variables were described as numbers and percentages. Multiple linear regression analysis with backward selection was conducted to develop a parsimonious predictive model for the dependent variable A1C. Results Participants were generally middle-aged and, on average, obese with suboptimal blood glucose control; almost 1 of every 5 participants currently smoked. After controlling for age, race, education, financial difficulty, diabetes education, physical activity, and diabetes knowledge, 4 variables were found in the final model to be independently associated with higher A1C: (1) current smoking status, (2) younger age, (3) longer diabetes duration, and (4) higher diabetes-related distress. Conclusions The study found that not only is smoking prevalent among persons with T2D with self-reported sleep problems but smoking is also an independent predictor of elevated A1C. The results highlight the vital role diabetes educators have in promoting risk reduction through education and support for smoking cessation.

Preserving Insulin Secretion in Diabetes by Inhibiting VDAC1 Overexpression and Surface Translocation in β Cells

SummaryType 2 diabetes (T2D) develops after years of prediabetes during which high glucose (glucotoxicity) impairs insulin secretion. We report that the ATP-conducting mitochondrial outer membrane voltage-dependent anion channel-1 (VDAC1) is upregulated in islets from T2D and non-diabetic organ donors under glucotoxic conditions. This is caused by a glucotoxicity-induced transcriptional program, triggered during years of prediabetes with suboptimal blood glucose control. Metformin counteracts VDAC1 induction. VDAC1 overexpression causes its mistargeting to the plasma membrane of the insulin-secreting β cells with loss of the crucial metabolic coupling factor ATP. VDAC1 antibodies and inhibitors prevent ATP loss. Through direct inhibition of VDAC1 conductance, metformin, like specific VDAC1 inhibitors and antibodies, restores the impaired generation of ATP and glucose-stimulated insulin secretion in T2D islets. Treatment of db/db mice with VDAC1 inhibitor prevents hyperglycemia, and maintains normal glucose tolerance and physiological regulation of insulin secretion. Thus, β cell function is preserved by targeting the novel diabetes executer protein VDAC1.

Hyperinsulinemia and sulfonylurea use are independently associated with left ventricular diastolic dysfunction in patients with type 2 diabetes mellitus with suboptimal blood glucose control

ObjectiveAlthough diabetes mellitus is associated with an increased risk of heart failure with preserved ejection fraction, the underlying mechanisms leading to left ventricular diastolic dysfunction (LVDD) remain poorly understood. The...

Latent Autoimmune Diabetes of Adult Masquerading as Type 2 Diabetes Mellitus

Latent autoimmune diabetes of adults (LADA) is a slowly progressing subtype of type 1 diabetes mellitus (DM) that shares features of both type 1 and type 2 diabetes mellitus (T2DM), leading to its misdiagnosis and mismanagement. We present a case of a 30-year-old man who was diagnosed and managed as T2DM but later confirmed as a case of LADA. He was sent to the endocrinology clinic by his primary care physician for management of “uncontrolled T2DM”. He had been placed on glipizide and metformin, but was noted to have suboptimal blood glucose control and unintentional weight loss of about 20 - 30 lbs over a 3-month period. A diagnosis of LADA was confirmed by the presence of autoantibody to glutamic acid decarboxylase 65 (anti-GAD-65 antibody). His oral medications were discontinued and he was started on basal and mealtime insulin. It is important to identify LADA in adult patients thought to have T2DM, as these patients respond poorly to oral hypoglycemic drug therapy, require insulin and are at increased risk for developing ketoacidosis. Clinical presentation of LADA is often similar to T2DM, with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) being uncommon complications. J Med Cases. 2015;6(7):327-329 doi: https://doi.org/10.14740/jmc2183w

Latent Autoimmune Diabetes of Adult Masquerading as Type 2 Diabetes Mellitus

Latent autoimmune diabetes of adults (LADA) is a slowly progressing subtype of type 1 diabetes mellitus (DM) that shares features of both type 1 and type 2 diabetes mellitus (T2DM), leading to its misdiagnosis and mismanagement. We present a case of a 30-year-old man who was diagnosed and managed as T2DM but later confirmed as a case of LADA. He was sent to the endocrinology clinic by his primary care physician for management of “uncontrolled T2DM”. He had been placed on glipizide and metformin, but was noted to have suboptimal blood glucose control and unintentional weight loss of about 20 - 30 lbs over a 3-month period. A diagnosis of LADA was confirmed by the presence of autoantibody to glutamic acid decarboxylase 65 (anti-GAD-65 antibody). His oral medications were discontinued and he was started on basal and mealtime insulin. It is important to identify LADA in adult patients thought to have T2DM, as these patients respond poorly to oral hypoglycemic drug therapy, require insulin and are at increased risk for developing ketoacidosis. Clinical presentation of LADA is often similar to T2DM, with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) being uncommon complications. J Med Cases. 2015;6(7):327-329 doi: https://doi.org/10.14740/jmc2183w

Acknowledging and allocating responsibility for clinical inertia in the management of Type 2 diabetes in primary care: a qualitative study.

Failure to intensify treatment in patients with Type 2 diabetes with suboptimal blood glucose control has been termed clinical inertia and has been shown to contribute to poorer patient outcomes. We aimed to identify and explore perceptions about clinical inertia from the perspective of primary healthcare providers. A qualitative study was conducted in Leicestershire and Northamptonshire, UK. Purposive sampling was based on healthcare providers working in primary care settings with 'higher' and 'lower' target achievement based on routine data. Twenty semi-structured interviews were conducted, face-to-face or by telephone. Thematic analysis was informed by the constant comparative approach. An important broad theme that emerged during the analysis was related to attribution and explanation of responsibility for clinical inertia. This included general willingness to accept a degree of responsibility for clinical inertia. In some cases, however, participants had inaccurate perceptions about levels of target achievement in their primary care centres, as indicated by routine data. Participants sought to lessen their own sense of accountability by highlighting patient-level barriers such as comorbidities and human fallibility, and also system-level barriers, particularly time constraints. Perceptions about ways of addressing the problem of clinical inertia were not seen as straightforward, further emphasizing a complex and cumulative pattern of barriers. In order to understand and address the problem of clinical inertia, provider, patient- and system-level barriers should be considered together rather than as separate issues. Acknowledgement of responsibility should be regarded positively as a motivator for change.

Self-care practices of Chinese individuals with diabetes

The aim of this study was to investigate the self-care practices of Chinese individuals with diabetes. Data were collected from 163 Chinese individuals with diabetes using a one-to-one interview approach. The Chinese version of the Summary of Diabetes Self-Care Activities (SDSCA) was used to assess diabetes-related knowledge and self-care practices. The majority of participants were aware of the importance of self-care in managing diabetes. However, only 70 participants (43%) scored >50% in the diabetes-related questionnaires. Mean fasting blood glucose (FBG) levels were higher (P<0.04) for participants who had extra meals per day (46%). The majority of participants took oral hypoglycemic agents (OHAs; 60.1%) and some were also treated with OHA-insulin combination therapy (17.8%). Participants with medication adherence (52%) tended to have lower FBG levels. Only 13% of participants practiced self-monitoring of blood glucose (SMBG). The predictors of a knowledge deficit or poor self-care were a low level of education (P<0.01) or old age (older than 53 years old; P=0.002). Deficits in diabetes-related knowledge and self-care practices existed among the majority of patients with suboptimal blood glucose control. The understanding of the importance of self-care practices requires improvement in individuals with diabetes. The development of effective education strategies to improve the awareness of self-care practices by Chinese individuals with diabetes is necessary.

Blood glucose control and quality of health care in non‐insulin‐treated patients with Type 2 diabetes in Spain: a retrospective and cross‐sectional observational study

AimsTo assess blood glucose control and quality of health care provided to non-insulin-treated patients with Type 2 diabetes mellitus in routine clinical practice in Spain.MethodsIn this observational, retrospective, cross-sectional study, patients were grouped as either having good or suboptimal blood glucose control according to International Diabetes Federation or American Diabetes Association HbA1c goals. Clinical and socio-demographic data and compliance with the main standard level of care recommendations of the International Diabetes Federation were recorded during a routine visit. Correlates of glucose control were analysed by logistic regression.ResultsMany patients were grouped as having suboptimal control under International Diabetes Federation (61.9%) or American Diabetes Association (45.0%) criteria. The mean number of accomplished International Diabetes Federation recommendations (7.3 out of 11) was higher for endocrinologists (than for internists or primary care physicians), and significantly more patients under their care were in the good glucose control group (than with primary care physicians). More recommendations were associated with blood glucose control using International Diabetes Federation than American Diabetes Association criteria, demanding higher quality of health care for achieving stricter goals. Some recommendations were poorly observed, particularly those concerning patients’ education on diabetes, the prompt prescription of effective treatments and monitoring of complications. Diabetes complications were associated with being in the suboptimal control group. Patients’ education on diabetes and HbA1c monitoring were associated with being in the good control group.ConclusionsThese results demonstrate the need for improvement in the management of patients with non-insulin-treated Type 2 diabetes in actual clinical practice in Spain. Such improvement would entail a stricter adherence to International Diabetes Federation recommendations.

Endurance Athletes and Type 1 Diabetes

The purpose of this study was to gain insight into the current diabetes management practices of endurance athletes with type 1 diabetes and to compare these practices with the guidelines for athletes established by the American Diabetes Association (ADA). Participants included in this descriptive study were endurance athletes aged 18 years and older with type 1 diabetes. The survey questions were based on the current clinical recommendations for endurance athletes with type 1 diabetes, as established by the ADA. A link to the questionnaire was posted on the Web site of the Diabetes Exercise and Sports Association (DESA). A total of 38 questions were included in the survey, and 91 usable surveys were received. Analysis of variance was used for several comparisons using SPSS version 17. Half of the clinical guidelines were followed by the participants. Among these, about 50% followed many of the guidelines "most of the time" or "almost always" and 40% followed the guidelines "sometimes" or "most of the time." Results of ANOVA showed several trends (nonsignificant) in the occurrence of low blood glucose when the guidelines were not followed. Endurance athletes with type 1 diabetes do not consistently follow the clinical guidelines for blood glucose management as recommended by the ADA. The results of this study reflect a need among athletes for diabetes management education programs that promote a better understanding of the potential negative side effects of suboptimal blood glucose control.

The influence of dietary intake and meal pattern on blood glucose control in children and adolescents using intensive insulin treatment

We studied dietary factors and their association with blood glucose control in type 1 diabetic children and adolescents using intensive insulin treatment. A total of 550 children and adolescents with type 1 diabetes mellitus (age 2-19 years) recorded their diet for 4 days in pre-coded food diaries. Of the study group, 34% used insulin pumps, 43% used four or more injections and 16% three injections per day. HbA(1c) was related to targets of optimal blood glucose control defined by the International Society for Pediatric and Adolescent Diabetes (ISPAD). Adolescents with optimal glucose control (HbA(1c) < or = 7.5%) had a lower intake of added sugar (7.7 vs 9.1% of energy intake, p = 0.004), a higher intake of fibre (19.3 vs 17.0 g/day, p = 0.01) and a higher intake of fruits and vegetables (257 vs 227 g/day, p = 0.04) than those with suboptimal metabolic control (HbA(1c) > 7.5%). Multiple regression analysis in adolescents showed that fibre and meal pattern were significantly associated with blood glucose control (effect fibre intake = -0.02, p = 0.04, effect having breakfast regularly = -0.89, p = 0.009). In children meal pattern was associated with blood glucose control (effect having dinner regularly = -0.66, p = 0.02, effect having supper regularly = -0.78, p = 0.03). In diabetic adolescents both intake of fibre and having a regular meal pattern are associated with blood glucose control. Lower intake of added sugar and sugar-sweetened soft drinks and higher intake of fruits and vegetables are observed among those with optimal compared with those with suboptimal blood glucose control. Dietary guidance should be intensified during adolescence to improve dietary intake and blood glucose control.

Do Glucose and Lipids Exert Independent Effects on Atherosclerotic Lesion Initiation or Progression to Advanced Plaques?

It is becoming increasingly clear that suboptimal blood glucose control results in adverse effects on large blood vessels, thereby accelerating atherosclerosis and cardiovascular disease, manifested as myocardial infarction, stroke, and peripheral vascular disease. Cardiovascular disease is accelerated by both type 1 and type 2 diabetes. In type 1 diabetes, hyperglycemia generally occurs in the absence of elevated blood lipid levels, whereas type 2 diabetes is frequently associated with dyslipidemia. In this review article, we discuss hyperglycemia versus hyperlipidemia as culprits in diabetes-accelerated atherosclerosis and cardiovascular disease, with emphasis on studies in mouse models and isolated vascular cells. Recent studies on LDL receptor-deficient mice that are hyperglycemic, but exhibit no marked dyslipidemia compared with nondiabetic controls, show that diabetes in the absence of diabetes-induced hyperlipidemia is associated with an accelerated formation of atherosclerotic lesions, similar to what is seen in fat-fed nondiabetic mice. These effects of diabetes are masked in severely dyslipidemic mice, suggesting that the effects of glucose and lipids on lesion initiation might be mediated by similar mechanisms. Recent evidence from isolated endothelial cells demonstrates that glucose and lipids can induce endothelial dysfunction through similar intracellular mechanisms. Analogous effects of glucose and lipids are also seen in macrophages. Furthermore, glucose exerts many of its cellular effects through lipid mediators. We propose that diabetes without associated dyslipidemia accelerates atherosclerosis by mechanisms that can also be activated by hyperlipidemia.

The Impact of Glycemic Control on Neonatal Outcome in Singleton Pregnancies Complicated by Gestational Diabetes

To identify the impact of suboptimal blood glucose control on neonatal outcomes in women with gestational diabetes mellitus (GDM). Included were patients with singleton gestation enrolled in an outpatient GDM management program for at least 7 days who delivered at term. Blood glucose control was defined as an average fasting blood glucose of <95 mg/dl, 1-h postprandial of <140 mg/dl, or 2-h postprandial of <120 mg/dl. Data were compared between patients with optimal blood glucose control (n = 2,030) and those with suboptimal blood glucose control (n = 1,188). The primary study outcome was a composite variable consisting of macrosomia, large-for-gestational-age, hypoglycemia, jaundice, or stillbirth. Over one-third of infants in the poorly controlled group were positive for at least one factor comprising the composite variable compared with 24% from the controlled group (P < 0.001). Suboptimal glycemic control in women with GDM is associated with adverse neonatal outcome. Careful monitoring of blood glucose levels and initiation of appropriate treatment are essential in the care of women with GDM.

The impact of glycemic control on neonatal outcome in singleton pregnancies complicated by gestational diabetes

To compare neonatal outcome in women diagnosed with gestational diabetes (GDM) whose average blood glucose (BG) values were within recommended guidelines to those with higher than recommended BG averages.

Atherosclerosis in childhood and adolescent type 1 diabetes: early disease, early treatment?

Autopsy studies have shown that atherosclerosis begins in adolescence in otherwise healthy individuals, and imaging techniques have shown that atherosclerosis develops earlier and is more prevalent in children with diabetes than in age-matched healthy controls. Cardiovascular disease has now overtaken diabetic nephropathy as the leading cause of premature mortality in young adults with diabetes, and the emphasis on disease prevention has accordingly shifted to a younger age group. The majority of children and adolescents with diabetes have suboptimal blood glucose control, and this contributes to accelerated arterial disease in this age group. Other conventional risk factors for coronary heart disease also need to be considered and treated aggressively. Effective early prevention of cardiovascular disease will involve lifestyle modification and full implementation of existing treatment guidelines, and large-scale prospective studies will be needed to establish the risks and benefits of early pharmacological intervention in children and adolescents.