Suboptimal Glycemic Control Research Articles

Mindful Eating and Current Glycemic Control in Patients With Type 2 Diabetes.

Objective Lifestyle adjustments are essential in the management of type 2 diabetes mellitus (T2DM). Mindful eating involves being more attentive to and aware of meals. This study aimed to investigate the relationship between mindful eating and glycemic control, as well as body mass index (BMI), in people with T2DM. Materials and methods This cross-sectional study included 448 participants who had been diagnosed with T2DM for at least six months. The participants were categorized into three groups based on their HbA1c levels. The Turkish adaptation of the Mindful Eating Questionnaire (MEQ-30) was employed to assess levels of mindful eating behavior. Obesity was defined as a BMI ≥ 30. Anthropometric measurements, laboratory tests, and questionnaire responses were also collected. Results Participants with well-controlled diabetes (HbA1c ≤7%) demonstrated significantly higher scores on the MEQ-30 and its various subgroups in comparison to those with poorly controlled diabetes (HbA1c >9%). The suboptimal glycemic control groups exhibited noticeable variations in mindful eating behaviors. Moreover, participants with lower BMIs displayed stronger inclinations toward mindful eating. Weak negative correlations were observed between BMI and specific MEQ-30 subgroups. Notably, subgroups such as emotional eating, eating control, eating discipline, and interference demonstrated weak negative correlations with the HbA1c levels. Conclusion Higher levels of mindful eating were associated with lower levels of HbA1c and BMI, indicating that incorporating mindful eating practices may present promising advantages for individuals diagnosed with type 2 diabetes, specifically in terms of glycemic control and weight management.

Discrete glucose profiles identified using continuous glucose monitoring data and their association with adverse pregnancy outcomes

Continuous glucose monitoring has facilitated the evaluation of dynamic changes in glucose throughout the day and their effect on fetal growth abnormalities in pregnancy. However, studies of multiple continuous glucose monitoring metrics combined and their association with other adverse pregnancy outcomes are limited. This study aimed to (1) use machine learning techniques to identify discrete glucose profiles based on weekly continuous glucose monitoring metrics in pregnant individuals with pregestational diabetes mellitus and (2) investigate their association with adverse pregnancy outcomes. This study analyzed data from a retrospective cohort study of pregnant patients with type 1 or 2 diabetes mellitus who used Dexcom G6 continuous glucose monitoring and delivered a nonanomalous, singleton pregnancy at a tertiary center between 2019 and 2023. Continuous glucose monitoring data were collapsed into 39 weekly glycemic measures related to centrality, spread, excursions, and circadian cycle patterns. Principal component analysis and k-means clustering were used to identify 4 discrete groups, and patients were assigned to the group that best represented their continuous glucose monitoring patterns during pregnancy. Finally, the association between glucose profile groups and outcomes (preterm birth, cesarean delivery, preeclampsia, large-for-gestational-age neonate, neonatal hypoglycemia, and neonatal intensive care unit admission) was estimated using multivariate logistic regression adjusted for diabetes mellitus type, maternal age, insurance, continuous glucose monitoring use before pregnancy, and parity. Of 177 included patients, 90 (50.8%) had type 1 diabetes mellitus, and 85 (48.3%) had type 2 diabetes mellitus. This study identified 4 glucose profiles: (1) well controlled; (2) suboptimally controlled with high variability, fasting hypoglycemia, and daytime hyperglycemia; (3) suboptimally controlled with minimal circadian variation; and (4) poorly controlled with peak hyperglycemia overnight. Compared with the well-controlled profile, the suboptimally controlled profile with high variability had higher odds of a large-for-gestational-age neonate (adjusted odds ratio, 3.34; 95% confidence interval, 1.15-9.89). The suboptimally controlled with minimal circadian variation profile had higher odds of preterm birth (adjusted odds ratio, 2.59; 95% confidence interval, 1.10-6.24), cesarean delivery (adjusted odds ratio, 2.76; 95% confidence interval, 1.09-7.46), and neonatal intensive care unit admission (adjusted odds ratio, 4.08; 95% confidence interval, 1.58-11.40). The poorly controlled profile with peak hyperglycemia overnight had higher odds of preeclampsia (adjusted odds ratio, 2.54; 95% confidence interval, 1.02-6.52), large-for-gestational-age neonate (adjusted odds ratio, 3.72; 95% confidence interval, 1.37-10.4), neonatal hypoglycemia (adjusted odds ratio, 3.53; 95% confidence interval, 1.37-9.71), and neonatal intensive care unit admission (adjusted odds ratio, 3.15; 95% confidence interval, 1.20-9.09). Discrete glucose profiles of pregnant individuals with pregestational diabetes mellitus were identified through joint consideration of multiple continuous glucose monitoring metrics. Prolonged exposure to maternal hyperglycemia may be associated with a higher risk of adverse pregnancy outcomes than suboptimal glycemic control characterized by high glucose variability and intermittent hyperglycemia.

Expert Opinion on Current Trends in the Use of Insulin in the Management of People with Type 2 Diabetes from the South-Eastern European Region and Israel.

Despite the availability of various antihyperglycaemic therapies and comprehensive guidelines, glycaemic control in diabetes management has not improved significantly during the last decade in the real-world clinical setting. Treatment inertia arising from a complex interplay among patient-, clinician- and healthcare-system-related factors is the prime reason for this suboptimal glycaemic control. Also, the key factor leading to inadequate glycaemic levels remains limited communication between healthcare professionals (HCPs) and people with type 2 diabetes (PwT2D). Early insulin administration has several advantages including reduced glucotoxicity, high efficacy and preserved β-cell mass/function, leading to lowering the risk of diabetes complications. The current publication is based on consensus of experts from the South-Eastern European region and Israel who reviewed the existing evidence and guidelines for the treatment of PwT2D. Herein, the experts emphasised the timely use of insulin, preferably second-generation basal insulin (BI) analogues and intensification using basal-plus therapy, as the most-potent glucose-lowering treatment choice in the real-world clinical setting. Despite an increase in the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs), the experts urged timely insulin initiation for inadequate glycaemic control in PwT2D. Furthermore, the combination of BI and GLP-1 RA addressing both fasting plasma glucose and post-prandial excursions as a free- or fixed-ratio combination was identified to reduce treatment complexity and burden. To minimise discontinuation and improve adherence, the experts reiterated quality, regular interactions and discussions between HCPs and PwT2D/carers for their involvement in the diabetes management decision-making process. Clinicians and HCPs should consider the opinions of the experts in accordance with the most recent recommendations for diabetes management.

The Rate of Insulin use and Suboptimal Glycemic Control among Egyptian Patients with T2DM: Cohort Analysis of Eighth Wave of the International Diabetes Management Practices Study (IDMPS).

The International Diabetes Management Practices Study (IDMPS) is an international annual survey aiming to study and characterize the current standards of care for managing DM in developing countries. In Egypt, DM represents a substantial burden on the healthcare system, with an estimated 10.9 million patients, ranking it 10th amongst countries with the highest prevalence of DM. Previous studies showed that to maintain safety and achieve treatment goals among diabetic patients, optimal insulin therapy should be selected individually based on the patient's needs. We reported the proportion of Egyptian T2DM patients on insulin therapy who participated in the eighth wave of the IDMPS. The 2018 IDMPS wave consisted of cross-sectional and longitudinal phases and aimed to evaluate the proportion of T2DM who were on insulin therapy in 13 countries from four regions. In Egypt, 17 physicians agreed to participate in the present study and were required to include at least one patient. A total of 180 T2DM patients were included in the cross-section phase. At the end of the ninth month of follow-up, data from 170 T2DM patients were available. A total of 39 T2DM patients (21.7%) were on insulin therapy, with a mean duration of 32.4 ± 36.6 months. More than half of the patients (n = 22; 56.4%) were on basal insulin, mainly long-acting (n = 20; 90.9%). The mean basal insulin daily dose was 0.3 ± 0.1 IU/Kg. Notably, 28.2% of the patients received insulin via vials, and 46.2% stated that they were adjusting the insulin dose by themselves. On the other hand, 60.2% of the study population was on oral antidiabetic drugs at the cross-sectional phase. Nearly 17.4% and 27% of the patients in the cross-sectional phase achieved the glycemic target per recommendations of international guidelines and the treating physicians, respectively. At the end of the longitudinal phase, the percentage of T2DM patients who achieved glycemic targets increased to 38.4% and 77.4% as per recommendations of international guidelines and the treating physicians, respectively. Overall, 38.3% of T2DM patients received diabetes education, and 28.9% were involved in an educational program provided by the physician or their clinical staff. Besides, 85.5% of T2DM patients followed their diabetes medication dosage and frequency strictly as prescribed. The proportion of insulin use in patients with T2DM aligned with the previous studies from different countries; however, it is still inadequate to achieve the targeted glycemic control. Nearly one-third of Egyptian patients received diabetes education, highlighting the need for adopting a national educational program. Nonetheless, the level of adherence among T2DM from Egypt appears to be high.

Dysregulated inflammatory response to urogynecologic meshes in women with diabetes and its implications

BackgroundDiabetes is an independent risk factor for mesh complications in women undergoing mesh-augmented surgical repairs of stress urinary incontinence and/or pelvic organ prolapse. The underlying mechanism remains unclear. ObjectivesTo define the diabetes-associated alterations in the host inflammatory response to mesh and correlate them with perioperative glucose managements. Study DesignDeidentified demographics and medical records of patients who underwent mesh removal and participated in a Mesh Biorepository study were reviewed (n=200). In patients with diagnosed diabetes (n=25), blood glucose management prior to initial mesh implantation, and before and after mesh removal was assessed by blood glucose and HbA1c levels. Age- and BMI-matched tissue samples excised from patients with or without diabetes were examined. Transcriptomic profiles of immune cell markers, immune mediators, key inflammatory regulators, cell senescence, and epigenetic enzymes were determined by multiplex transcriptomic assays (NanoString). Ratio of apoptotic cells to CD68+ macrophages were examined with immunofluorescence. Protein profile of 12 molecules involved in apoptotic cell clearance were assayed with a multiplex protein assay (Luminex). ResultsDemographic and clinical characteristics, including duration between mesh implantation and removal, reason for removal, and type of mesh, etc., were comparable between patients with and without diabetes, except for 11.6% higher BMI in the former (p<0.001). In patients with diabetes, suboptimal management of blood glucose following mesh implantation was observed, with 59% of the patients having loosely or poorly controlled glucose before and after the mesh removal. Ongoing chronic inflammatory response was observed in the excised mesh-tissue complexes in both groups, while markers for M2 macrophages (mannose receptor C-type 1 [Mrc1]) and helper T cells (CD4 molecule [Cd4]) were increasingly expressed in the diabetic vs. nondiabetic groups (p=0.023, 0.047, respectively). Furthermore, the gene expression of proinflammatory C-C motif chemokine ligand 24 (Ccl24) and C-C motif chemokine ligand 24 (Ccl13) were upregulated by 1.5- and 1.8-fold (p=0.035, 0.027, respectively), while that of interleukin 1 alpha (Il1a) was paradoxically downregulated by 2.2-fold (p=0.037) in the diabetic vs. nondiabetic group. Interestingly, strong positive correlations were found between the expression of Ccl13, SET domain bifurcated histone lysine methyltransferase 2 (Setdb2), and M2 macrophage markers, as well as between the expression of Il1a, activator protein-1 transcription factor subunit (Fosl1), and dendritic cell markers, suggesting the involvement of macrophages and dendritic cells in the diabetes-dysregulated proinflammatory response. Supportively, apoptotic cell clearance, which is an important function of macrophages, appeared to be impaired in the diabetic group with a significantly increased protein level of calreticulin (CALR), an ‘eat-me’ signal on apoptotic cell surface (p=0.03), along with an increase of AXL receptor tyrosine kinase (AXL) (p=0.03), which mediates apoptotic cell clearance. ConclusionsDiabetes was associated with altered long-term inflammatory response in complicated mesh implantation, particularly involving innate immune cell dysfunction. Suboptimal blood glycemic control following mesh implantation may contribute to this immune dysregulation, necessitating further mechanistic studies.

Optimising renal risk parameters in type 2 diabetes mellitus: Perspectives from a retinal viewpoint

Diabetic retinopathy and nephropathy share pathophysiological mechanisms and there is a defined correlation between the severity of both these microvascular complications from suboptimal glycaemic control. The reno-protective properties offered by sodium–glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists should be applicable to diabetic retinopathy as well. However, in patients with pre-existing diabetic retinopathy, sudden improvement in glycaemic control is well documented to cause early worsening of the changes in the retina that is usually transient. This paradoxical phenomenon tends to occur with longer duration of diabetes, higher HbA1c at the outset, rapid improvement of glucose levels and the magnitude of HbA1c reduction with addition of more agents to tighten metabolic control. Interestingly, this progression of pre-existing diabetic retinopathy is not quite observed with newer sodium–glucose co-transporter-2 inhibitors. This article discusses potential further areas of future research where mechanisms of renal protection can be translated to the retina.

Intensive glycaemic targets in overweight and obese individuals with gestational diabetes mellitus: clinical trial protocol for the iGDM study

IntroductionThe prevalence of both obesity and gestational diabetes mellitus (GDM) has increased, and each is associated with adverse perinatal outcomes including fetal overgrowth, neonatal morbidity, hypertensive disorders of pregnancy and...

Efficacy and safety of polyethylene glycol loxenatide in treating mild-to-moderate diabetic kidney disease in type 2 diabetes patients: a randomized, open-label, clinical trial.

This study aimed to evaluate the efficacy and safety of polyethylene glycol loxenatide (PEG-Loxe) compared to those of dapagliflozin in patients with mild-to-moderate diabetic kidney disease (DKD), a prevalent microvascular complication of type 2 diabetes mellitus (T2DM). The study is set against the backdrop of increasing global diabetes incidence and the need for effective DKD management. This study constituted a single-center, randomized, open-label, clinical trial. The trial included patients with mild-to-moderate DKD and suboptimal glycemic control. Eligible participants were randomly allocated to one of the two groups for treatment with either PEG-Loxe or dapagliflozin. The primary endpoint was the change in UACR from baseline at 24 weeks. Overall, 106 patients were randomized and 80 patients completed the study. Following 24 weeks of treatment, the PEG-Loxe group exhibited a mean percent change in baseline UACR of -29.3% (95% confidence interval [CI]: -34.8, -23.7), compared to that of -31.8% in the dapagliflozin group (95% CI: -34.8, -23.7). Both PEG-Loxe and dapagliflozin showed similar efficacy in reducing UACR, with no significant difference between the groups (p = 0.336). The HbA1c levels decreased by -1.30% (95% CI: -1.43, -1.18) in the PEG-Loxe group and by -1.29% (95% CI: -1.42, -1.17) in the dapagliflozin group (p = 0.905). The TG levels decreased by -0.56 mmol/L (95% CI: -0.71, -0.42) in the PEG-Loxe group and -0.33 mmol/L (95% CI: -0.48, -0.19) in the dapagliflozin group (p = 0.023). Differences in TC, HDL-C, LDL-C, SBP, and DBP levels between the groups were not statistically significant (all p > 0.05). Safety profiles were consistent with previous findings, with gastrointestinal adverse events being more common in the PEG-Loxe group. PEG-Loxe is as effective as dapagliflozin in improving urine protein levels in patients with mild-to-moderate DKD and offers superior benefits in improving lipid profiles. These findings support the use of PEG-Loxe in DKD management, contributing to evidence-based treatment options. www.chictr.org.cn, identifier ChiCTR2300070919.

“I Think I Could Have Used It Better”: Experiences of Youth with High HbA1c Commencing Advanced Hybrid Closed‐Loop Therapy in a Clinical Trial Setting—A Qualitative Research

Background. Advanced hybrid closed‐loop (AHCL) therapy improves glycemia. However, it is not known if there is an improvement in overall outcomes with AHCL for youth with type 1 diabetes (T1D) at high risk of diabetes‐related complications. The study aimed to capture the experiences of youth with suboptimal glycemic control when commencing AHCL therapy in a clinical trial setting. Methods. This was a singlecenter substudy of a multicenter 6‐month randomized clinical trial. Youth between 12 and 25 years of age on insulin pump therapy with HbA1c &gt; 8.5% (&gt; 69 mmol/mol) who commenced AHCL therapy with Medtronic MiniMed™ system were invited to participate in a semistructured interview after 6 months of AHCL. Open‐ended questions were used to explore the participants’ lived experience of AHCL in improving their glucose levels and its impact on diabetes management and well‐being. The interviews were audiorecorded, transcribed, and analyzed using thematic analysis. Results. Ten youth with T1D with a mean (SD) age of 17.4 (2.9) years, diabetes duration 10.7 (4.8) years, HbA1c 10.2 (0.8)%, or 87 (9.5) mmol/mol at enrollment participated in the interview. Three main themes were identified: (1) improved glycemia despite not using closed loop to its full potential; (2) persistent diabetes burden; and (3) a need for increased psychosocial and clinical support. Although improved glycemia was noted with AHCL therapy, participants reported ongoing motivation issues and used the system suboptimally. They continued to experience distress with overall diabetes management and acknowledged the need for ongoing support from family and health professionals. Conclusion. All participants reported overall satisfaction with improved glucose levels, however, the persistent diabetes burden impacted their ability to use AHCL optimally. The need for ongoing monitoring with support and interventions to enhance psychological care remains vital for youth with suboptimal diabetes management.

Diabetic peripheral neuropathy: age-stratified glycemic control.

We explore the effect of suboptimal glycemic control on the incidence of diabetic peripheral neuropathy (DPN) in both non-elderly and elderly patients with type 2 diabetes mellitus (T2DM). A 6-year follow-up study (2013-2019) enrolled T2DM patients aged >20 without DPN. Participants were classified into two groups: those below 65 years (non-elderly) and those 65 years or older (elderly). Biochemical measurements, including glycated hemoglobin (HbA1C), were recorded regularly. DPN was diagnosed using the Michigan Neuropathy Screening Instrument examination. The outcome was DPN occurrence in 2019. In 552 enrollments (69% non-elderly), DPN occurred in 8.4% non-elderly and 24.0% elderly patients. A higher initial HbA1C level was significantly linked with a higher risk of future DPN in the non-elderly group (adjusted odds ratio [AOR] 1.46, 95% CI 1.13-1.89, p=0.004). In comparison, HbA1c at the end of the study period was not associated with DPN in the non-elderly group (AOR 1.17, 95% CI 0.72-1.90, p=0.526). In the elderly group, no statistical relationship was found between HbA1C levels and DPN, either in 2013 or in 2019. Suboptimal glycemic control at baseline, rather than at the end of the study period, predicts an increased risk of future DPN in individuals with T2DM under age 65. This correlation is not seen in elderly patients. Therefore, we recommend implementing enhanced glycemic control early in middle-aged T2DM patients and propose individualized therapeutic strategies for diabetes in different age groups.

Patient-caregiver twinned mobile phone application to promote medication adherence

Background Poor medication adherence (MA) is prevalent globally. MA assessment, often based on scales or pill count, lacks actionability. A mobile application (app), MediEasy, targeting patients on multiple daily medications, has been developed to engage their caregivers to enhance their MA. Objectives This pilot single-arm study aimed to determine the feasibility, acceptability, utility and glycaemic control of the MediEasy-app by patients with type-2 diabetes mellitus and their caregivers. Methods 20 Multi-ethnic Asian patients aged 51 to 70 years with suboptimal glycaemic control (HbA1c&gt;7.5%) and their caregivers were recruited at a Primary care outpatient clinic in Singapore. The Medieasy app that contains the following major functionalities such as the alerts to take medications, embedded medication details, personalized dosing options (such as frequency and scheduling dosage settings) is twinned to their designated caregivers. The Caregivers can remind the patients who missed the scheduled medication intake when the paired device was alerted. Results 85% (17/20) of the participants used the app for the entire 4 weeks, reflecting feasibility; 3 dropped out due to technical glitches or failure to adhere to protocol. The app was activated with an average of 2.8 times per day showing adequate utility. The 17 participants and their caregivers agreed that the app supported medication adherence. Their mean HbA1c decreased by 0.2% after 12 weeks of app usage. Conclusions The results showed feasibility, utility and acceptability of the MediEasy-app, with improved glycaemic control after its usage.

Be mindful of the blood glucose measurement: The relevance of blood glucose in the eye emergency department

Aims/Purpose: Diabetic eye disease is a leading cause of blindness worldwide and diabetes‐related eye conditions are frequent presentations in Eye Emergency Departments (EEDs). Early detection and intervention of inadequate blood glucose control in the EED could be sight‐saving.The aims of this study are to determine the: prevalence of pre‐existing diabetes mellitus (DM) in the EED. prevalence of suboptimal (HbA1c 53–70 mmol/mol) or poor (HbA1c &gt;70 mmol/mol) glycaemic control in the EED. proportion of diabetes patients with this diagnosis documented in the EED. proportion of EED patients at risk of undiagnosed diabetes. number of EED patients that had a capillary blood glucose measurement (BgM). Methods: A retrospective review of 683 patients attending the EED over 10 consecutive weekdays at Manchester Royal Eye Hospital, Manchester, United Kingdom. The following parameters were assessed: EED documentation: patient age, gender, presentation, diagnosis, management plan and whether a BgM was done. General Practitioner records: diabetes diagnosis cross‐referenced with EED documentation. If diabetes patients: diabetes type, duration, and glycaemic control. Potentially undiagnosed diabetes. Results: The prevalence of diabetes patients was 9.5%–64.6% of these patients had diabetes documented in EED and 1 had a capillary BgM. 70.7% of diabetes patients had pre‐existing suboptimal [33.8%] or poor [36.9%] glycaemic control. 8.5% of patients were considered high‐risk for undiagnosed diabetes of which 1 had a BgM.Conclusions: There is a high prevalence of diabetes patients in the EED, and most have inadequate glycaemic control. This makes the EED an important setting to detect patients at high risk of diabetes‐related ocular disease and complications. BgM testing for all suspected patients is a quick test to allow earlier detection and intervention of inadequately controlled diabetes and reduce the risk of diabetes‐related vision loss.

Patients’ Perceptions and Knowledge of Diabetes and Medications: Implications for Medication Adherence and Glycemic Control in Type 2 Diabetes Patients, Northern Ethiopia

Globally, adherence to Type 2 diabetes mellitus (T2DM) medications remains suboptimal. There are limited insights, however, on this issue in the northern region of Ethiopia. This cross‐sectional study at Alamata General Hospital investigated the interplay between patients’ medication beliefs, diabetes knowledge, adherence, and glycemic control. Data collection was done using structured questionnaires and chart reviews, while descriptive and inferential statistics were for the analysis. Among 305 T2DM patients, poor medication adherence was prevalent (44.6%), alongside suboptimal glycemic control (75.7%). Patients diagnosed for over a decade had an adjusted odds ratio (AOR) of 3.87 for nonadherence, while high concern about medication side effects was associated with a 20.63‐fold higher nonadherence risk (AOR = 20.63). Low disease awareness increased nonadherence risk by 4.54 times (AOR = 4.54), while a strong belief in medication necessity was protective (AOR = 0.21). Poor glycemic control was associated with educational background, diabetes awareness, monthly income, and treatment modality. Urgently needed are tailored diabetes education programs in Northern Ethiopia to counteract high rates of poor medication adherence (AOR = 3.87) and glycemic control among T2DM patients. Targeted interventions, emphasizing knowledge enhancement and reinforcing positive beliefs, are essential for improving outcomes in this population.

Vitamin D levels in postmenopausal women and their relationship with diabetes mellitus

Background: Vitamin D (VD) plays a crucial role in regulating calcium and phosphorus metabolism and bone growth and has emerging roles beyond the skeleton. Deficiency is linked to various health issues, especially in postmenopausal women. The burden of T2DM in India, particularly among women, emphasizes the need for exploring the VD-diabetes connection. Aim and Objective: To investigate VD levels in postmenopausal women with T2DM compared to premenopausal women, assessing the association between VD deficiency and glycemic control. Materials and Methods: A case–control study was conducted in Chennai, India, involving pre-menopausal and post-menopausal women with T2DM. Ethical clearance was obtained, and participants were recruited with informed consent. Fifty pre-menopausal and post-menopausal women, each with T2DM, were included. Exclusions involved individuals taking calcium and vitamin D supplements, anticonvulsants, and those afflicted with osteoporosis, renal disease, asthma, and hypertension. Blood samples were collected for glucose and VD level assessments, employing standard methodologies. Results: Pre-menopausal women exhibited significantly higher VD levels compared to their post-menopausal counterparts. Blood sugar levels did not significantly differ based on menopausal status. Conclusion: This study contributes valuable insights into the complex interplay between VD, menopausal status, and glycemic control in women with T2DM. The high prevalence of VD deficiency and its association with suboptimal glycemic control emphasize the need for further research. Understanding these relationships is crucial for developing targeted interventions for postmenopausal women with diabetes.

Heterogeneity in glycaemic control in children and adolescents with type 1 diabetes: A latent class trajectory analysis of Danish nationwide data.

Suboptimal glycaemic control in children and adolescents with type 1 diabetes is prevalent and associated with increased risk of diabetes-related complications and mortality later in life. First, we aimed to identify distinct glycated haemoglobin (HbA1c) trajectories in children and adolescents (2-19 years) with type 1 diabetes. Second, we examined their associations with clinical and socio-demographic factors. Data were obtained from the Danish Registry of Childhood and Adolescent Diabetes (DanDiabKids) comprising all Danish children and adolescents diagnosed with type 1 diabetes from 1996 to 2019. Subgroups of distinct mean trajectories of HbA1c were identified using data-driven latent class trajectory modelling. A total of 5889 children (47% female) had HbA1c measured a median of 6 times (interquartile range 3-8) and contributing to 36,504 measurements. We identified four mean HbA1c trajectories, referred to as 'Stable but elevated HbA1c' (83%), 'Increasing HbA1c' (5%), 'Late HbA1c peak' (7%), and 'Early HbA1c peak' (5%). Compared to the 'Stable but elevated HbA1c' group, the three other groups presented rapidly deteriorating glycaemic control during late childhood or adolescence, had higher HbA1c at study entry, and included fewer pump users, higher frequency of inadequate blood glucose monitoring, more severe hypoglycaemic events, lower proportions with Danish origin, and worse educational status of parents. The groups also represented significant differences by healthcare region. Children and adolescents with type 1 diabetes experience heterogenous trajectories with different timings and magnitudes of the deterioration of HbA1c levels, although the majority follow on average a stable, yet elevated HbA1c trajectory. The causes and long-term health implications of these heterogenous trajectories need to be addressed.

Management of type 2 diabetes after metabolic bariatric surgery

Metabolic and bariatric surgery has been proven to be effective in the glycemic and metabolic control of type 2 diabetes (T2D) and obesity. While most patients experience remission of T2D after surgery, some individuals remain with suboptimal glycemic control. In addition, a significant subset of patients experience relapse of diabetes in the long term after attaining diabetes remission. As a heterogenous disease, the underlying etiology of T2D and response to treatment can be variable in different individuals. The mechanism of diabetes relapse is not completely understood as is the optimal medical management of T2D after metabolic and bariatric surgery. Nonetheless, person-centred collaborative and supportive care beyond the monitoring of parameters forms the cornerstone in formulating care for people with diabetes. This paper reviews the clinical management of T2D after bariatric surgery, including persistent T2D or diabetes relapse after initial remission.

Glucagon-like peptide-1 analogues in monogenic syndromic obesity: Real-world data from a large cohort of Alström syndrome patients.

To examine the real-world efficacy of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in monogenic obesity in patients with Alström syndrome (ALMS). We screened 72 UK adult patients with ALMS and offered treatment to 34 patients meeting one of the following criteria: body mass index of 25 kg/m2 or higher, insulin resistance, suboptimal glycaemic control on antihyperglycaemic medications or non-alcoholic fatty liver disease. In total, 30 patients, with a mean age of 31 ± 11 years and a male to-female ratio of 2:1, completed 6 months of treatment with GLP-1 RAs either in the form of semaglutide or exenatide. On average, treatment with GLP-1 RAs reduced body weight by 5.4 ± 1.7 (95% confidence interval [CI] 3.6-7) kg and HbA1c by 12 ± 3.3 (95% CI 8.7-15.3) mmol/mol, equating to 6% weight loss (P < .01) and 1.1% absolute reduction in HbA1c (P < .01). Significant improvements were also observed in serum total cholesterol, triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and alanine aminotransferase. The improvement of metabolic variables in our cohort of monogenic syndromic obesity was comparable with data for polygenic obesity, irrespective of weight loss. Data from our centre highlight the non-inferiority of GLP-1 RAs in monogenic syndromic obesity to the available GLP-1 RA-use data in polygenic obesity, therefore, these agents can be considered as a treatment option in patients with ALMS, as well as other forms of monogenic obesity.

Role and Significance of Dietary Protein in the Management of Type 2 Diabetes and Its Complications in India: An Expert Opinion.

Obesity, prediabetes, and type 2 diabetes mellitus (T2DM) pose a triple burden in India. Almost two-thirds of people with diabetes (PWD) in India are found to have suboptimal glycemic, blood pressure, and lipid control. Medical nutrition therapy (MNT) in diabetes has emphasized on the amount and type of carbohydrates for years. However, protein, an important macronutrient in diabetes management, needs to be focused upon, especially in India, where the consumption is found to be lower than the recommendations provided by most guidelines. An expert committee attempted to review the role of dietary protein in the management of T2DM, arrive at a consensus on the significance of increasing dietary protein for various benefits, and offer practical guidance on ways to improve protein intake among Indians. A total of 10 endocrinologists and diabetologists, one nephrologist, and three registered dietitians representing four zones of India formed the expert committee. An in-depth review of literature in the Indian context was carried out, and the draft document was shared with the expert committee, and their views were incorporated into the same. The expert committee then assembled virtually to deliberate on various aspects of the role of protein in T2DM management. The experts from various specialties gave their valuable inputs and suggestions from their extensive personal clinical experience and research work, which helped to reach a consensus on the role and significance of protein in the management of T2DM and its complications in India. There is abundant evidence that MNT is essential for the prevention and management of T2DM and its complications. Experts agreed that increasing protein intake offers myriad health benefits, namely reducing glycemic variability, improving glycemic control, increasing insulin sensitivity, improvement in lipid profile and immunity, and helping in weight management and preservation of muscle mass in PWD. The expert committee suggested aiming for an increase in protein intake by at least 5-10% of the current intake in lieu of carbohydrates in PWD. Experts also highlighted the need for more data quantifying the unmet protein needs in the Indian PWD, especially among vegetarians. Randomized controlled trials to study the effect of protein in diabetes complications such as cardiovascular disease (CVD) and diabetic kidney disease (DKD) and comorbid conditions such as sarcopenia among the Indian population are also warranted. Increasing protein quantity and quality in the diets of Indian PWD could significantly contribute to positive health outcomes. Increased protein intake, preferably through dietary sources to meet the requirements and, when required using diabetes-specific protein supplements (DSPS), is recommended in the prevention and control of T2DM.

Diabetes Risk Factors and Bone Microarchitecture as Assessed by High-Resolution Peripheral Quantitative Computed Tomography in Adults With Long-standing Type 1 Diabetes.

To determine whether type 1 diabetes and its complications are associated with bone geometry and microarchitecture. This cross-sectional study was embedded in a long-term observational study. High-resolution peripheral quantitative computed tomography (HR-pQCT) scans of the distal radius and distal and diaphyseal tibia were performed in a subset of 183 participants with type 1 diabetes from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study and 94 control participants without diabetes. HbA1c, skin advanced glycation end products (AGEs), and diabetes-related complications were assessed in EDIC participants with >30 years of follow-up. Compared with control participants (aged 60 ± 8 years, 65% female), EDIC participants (aged 60 ± 7 years, diabetes duration 38 ± 5 years, 51% female) had lower total bone mineral density (BMD) at the distal radius (-7.9% [95% CI -15.2%, -0.6%]; P = 0.030) and distal tibia (-11.3% [95% CI -18.5%, -4.2%]; P = 0.001); larger total area at all sites (distal radius 4.7% [95% CI 0.5%, 8.8%; P = 0.030]; distal tibia 5.9% [95% CI 2.1%, 9.8%; P = 0.003]; diaphyseal tibia 3.4% [95% CI 0.8%, 6.1%; P = 0.011]); and poorer radius trabecular and cortical microarchitecture. Estimated failure load was similar between the two groups. Among EDIC participants, higher HbA1c, AGE levels, and macroalbuminuria were associated with lower total BMD. Macroalbuminuria was associated with larger total area and lower cortical thickness at the distal radius. Higher HbA1c and AGE levels and lower glomerular filtration rate, peripheral neuropathy, and retinopathy were associated with deficits in trabecular microarchitecture. Type 1 diabetes is associated with lower BMD, larger bone area, and poorer trabecular microarchitecture. Among participants with type 1 diabetes, suboptimal glycemic control, AGE accumulation, and microvascular complications are associated with deficits in bone microarchitecture and lower BMD.

Social determinants of health and glycemic control in persons with type 2 diabetes mellitus attending a tertiary hospital in Nepal: A cross-sectional study.

Diabetes mellitus (DM) is an emerging global public health challenge worldwide, including Nepal. Social determinants of health (SDOH) play a major role in glycemic control among persons with type 2 DM (T2DM). However, little is known about the association between SDOH and glycemic control among individuals with T2DM in Nepal. This study aimed to identify the level of glycemic control and SDOH associated with glycemic control among Nepalese with T2DM. This cross-sectional study was conducted at a tertiary hospital in Kathmandu, Nepal, among 135 Nepalese diagnosed with T2DM who attended follow-up appointments. Convenience sampling and inclusion criteria were utilized for participant selection. Data were collected from April to June 2021 using validated scales. Descriptive statistics, Chi-square test, and binary logistic regression were employed to analyze the data. The mean age of the participants in this study was 53.84 (SD = 11.78) years, and the average monthly household income was 567.64 (SD = 362.30) USD. The majority of the participants (77.8%) were literate and had no health insurance coverage (73.3%). Approximately 64.4% of the participants showed suboptimal glycemic control indicated by glycated hemoglobin (HbA1c) ≥7%. The significant determinants of good glycemic control included monthly household income of >850 USD (odds ratio [OR] = 12.20, 95% confident interval [CI] = 1.76-84.61, p = 0.011) and 341-600 USD (OR = 7.64, 95% CI 1.35-42.98, p = 0.021), being literate (OR = 6.37, 95% CI = 1.65-24.49, p = 0.007), having health insurance (OR = 5.82, 95% CI = 1.49-22.65, p = 0.011), sufficient health literacy (OR = 3.46, 95% CI = 1.10-10.83, p = 0.03), and high (OR = 16.17, 95% CI = 2.36-110.67, p = 0.005) and moderate (OR = 7.02, 95% CI = 1.26-39.07, p = 0.026) food availability, respectively. The study revealed suboptimal glycemic control in Nepalese with T2DM. This study presents essential social determinants of glycemic control in this population. Therefore, healthcare providers, particularly nurses, should pay more attention to assessing social determinants and provide targeted interventions to patients with T2DM who have low income, are illiterate, have no health insurance coverage, have insufficient health literacy, and have low resources for food availability.