Type 2 diabetes: etiology and reversibility

Observing Islet Function and Islet-Immune Cell Interactions in Live Pancreatic Tissue Slices

Live pancreatic tissue slices allow for the study of islet physiology and function in the context of an intact islet microenvironment. Slices are prepared from live human and mouse pancreatic tissue embedded in agarose and cut using a vibratome. This method allows for the tissue to maintain viability and function in addition to preserving underlying pathologies such as type 1 (T1D) and type 2 diabetes (T2D). The slice method enables new directions in the study of the pancreas through the maintenance of the complex structures and various intercellular interactions that comprise the endocrine and exocrine tissues of the pancreas. This protocol demonstrates how to perform staining and time-lapse microscopy of live endogenous immune cells within pancreatic slices along with assessments of islet physiology. Further, this approach can be refined to discern immune cell populations specific for islet cell antigens using major histocompatibility complex-multimer reagents.

Artificial intelligence in health data analysis: The Darwinian evolution theory suggests an extremely simple and zero-cost large-scale screening tool for prediabetes and type 2 diabetes

AIMS

The effective identification of individuals with early dysglycemia status is key to reduce the incidence of type 2 diabetes. We develop and validate a novel zero-cost tool that significantly simplifies the screening of undiagnosed dysglycemia.

METHODS

We use NHANES cross-sectional data over 10 years (2007-2016) to derive an equation that links non-laboratory exposure variables to the possible presence of undetected dysglycemia. For the first time, we adopt a novel artificial intelligence approach based on the Darwinian evolutionary theory to analyze health data. We collected data for 47 variables.

RESULTS

Age and waist circumference are the only variables required to use the model. To identify undetected dysglycemia, we obtain an area under the curve (AUC) of 75.3%. Sensitivity and specificity are 0.65 and 0.73 by using the optimal threshold value determined from external validation data.

CONCLUSIONS

The use of uniquely two variables allows to obtain a zero-cost screening tool of analogous precision than that of more complex tools widely adopted in the literature. The newly developed tool has clinical use as it significantly simplifies the screening of dysglycemia. Furthermore, we suggest that the definition of an age-related waist circumference cut-off might help to improve existing diabetes risk factors.

The effects of different doses of exercise on pancreatic β-cell function in patients with newly diagnosed type 2 diabetes: study protocol for and rationale behind the "DOSE-EX" multi-arm parallel-group randomised clinical trial

BACKGROUND

Lifestyle intervention, i.e. diet and physical activity, forms the basis for care of type 2 diabetes (T2D). The current physical activity recommendation for T2D is aerobic training for 150 min/week of moderate to vigorous intensity, supplemented with resistance training 2-3 days/week, with no more than two consecutive days without physical activity. The rationale for the recommendations is based on studies showing a reduction in glycated haemoglobin (HbA1c). This reduction is supposed to be caused by increased insulin sensitivity in muscle and adipose tissue, whereas knowledge about effects on abnormalities in the liver and pancreas are scarce, with the majority of evidence stemming from in vitro and animal studies. The aim of this study is to investigate the role of the volume of exercise training as an adjunct to dietary therapy in order to improve the pancreatic β-cell function in T2D patients less than 7 years from diagnosis. The objective of this protocol for the DOSE-EX trial is to describe the scientific rationale in detail and to provide explicit information about study procedures and planned analyses.

METHODS/DESIGN

In a parallel-group, 4-arm assessor-blinded randomised clinical trial, 80 patients with T2D will be randomly allocated (1:1:1:1, stratified by sex) to 16 weeks in either of the following groups: (1) no intervention (CON), (2) dietary intervention (DCON), (3) dietary intervention and supervised moderate volume exercise (MED), or (4) dietary intervention and supervised high volume exercise (HED). Enrolment was initiated December 15th, 2018, and will continue until N = 80 or December 1st, 2021. Primary outcome is pancreatic beta-cell function assessed as change in late-phase disposition index (DI) from baseline to follow-up assessed by hyperglycaemic clamp. Secondary outcomes include measures of cardiometabolic risk factors and the effect on subsequent complications related to T2D. The study was approved by The Scientific Ethical Committee at the Capital Region of Denmark (H-18038298).

TRIAL REGISTRATION

The Effects of Different Doses of Exercise on Pancreatic β-cell Function in Patients With Newly Diagnosed Type 2 Diabetes (DOSE-EX), NCT03769883, registered 10 December 2018 https://clinicaltrials.gov/ct2/show/NCT03769883 ). Any modification to the protocol, study design, and changes in written participant information will be approved by The Scientific Ethical Committee at the Capital Region of Denmark before effectuation.

DISCUSSION

The data from this study will add knowledge to which volume of exercise training in combination with a dietary intervention is needed to improve β-cell function in T2D. Secondarily, our results will elucidate mechanisms of physical activity mitigating the development of micro- and macrovascular complications correlated with T2D.

Factors associated with resolution of type-2 diabetes mellitus after sleeve gastrectomy in obese adults

Many bariatric procedures are more effective for improving type-2 diabetes mellitus (T2DM) than conventional pharmacotherapy. The current research evaluated factors linked to complete and partial remission or improvement of T2DM after laparoscopic sleeve gastrectomy (LSG). The current prospective study included all diabetic patients who were submitted LSG between January 2015 and June 2018 and completed a 2-year follow-up period. Patients were assessed at baseline and 2 years after LSG. This work comprised of 226 diabetic cases. Two years after LSG, 86 patients (38.1%) achieved complete remission of DM, and 24 (10.6%) reached partial remission. Only 14 patients (6.2%) showed no change in their diabetic status. On univariate analysis, age ≤ 45 years, duration of diabetes ≤ 5 years, use of a single oral antidiabetic, HbA1c ≤ 6.5%, HOMA-IR ≤ 4.6, C-peptide > 2.72 ng/mL, and BMI ≤ 40 kg/m2 predicted complete remission. The independent predictors of complete remission were age ≤ 45 years, duration of diabetes ≤ 5 years, use of a single oral antidiabetic, HOMA-IR ≤ 4.6, and C-peptide > 2.72 ng/mL. A combined marker of young age, short duration of DM, and low HOMA-IR predicted complete remission with sensitivity 93% and specificity 82%. Independent predictors of complete remission of T2DM after LSG were younger age, shorter duration, single oral antidiabetic, lower HOMA-IR, and higher C-peptide.

Increased frequency of β cells with abnormal NKX6.1 expression in type 2 diabetes but not in subjects with higher risk for type 2 diabetes

BACKGROUND

NKX6.1 is a transcription factor for insulin, as well as a marker for β cell maturity. Abnormal NKX6.1 expression in β cells, such as translocation from the nucleus to cytoplasm or lost expression, has been shown as a marker for β cell dedifferentiation.

METHODS

We obtained pancreatic sections from organ donors and immunofluorescence staining with NKX6.1 and insulin was performed to characterize NKX6.1 expression in subjects with or without type 2 diabetes mellitus (T2DM).

RESULTS

Our results showed that cells with insulin expression but no nucleic NKX6.1 expression (NKX6.1Nuc-Ins+), and cells with cytoplasmic NKX6.1 expression but no insulin expression (NKX6.1cytIns-) were significantly increased in T2DM subjects and positively correlated with glycated hemoglobin (HbA1c), indicating the elevated β cell dedifferentiation with NKX6.1 inactivation in T2DM. To investigate whether β cell dedifferentiation has initiated in subjects with higher risks for T2DM, we next analyzed the association between β-cell dedifferentiation level in ND subjects with different ages, body mass index, and HbA1c. The results showed the absolute number and percentage of dedifferentiated β cells with NKX6.1 inactivation did not significantly change in subjects with advanced aging, obesity, or modest hyperglycemia, indicating that the β cell dedifferentiation might mainly occur after T2DM was diagnosed.

CONCLUSION

Our results suggested that NKX6.1 expression in β cells was changed in type 2 diabetic subjects, evidenced by significantly increased NKX6.1Nuc-Ins+ and NKX6.1cytIns- cells. This abnormality did not occur more frequently in subjects with a higher risk for T2DM, suggesting that β cell dedifferentiation might be secondary to the pathological changes in T2DM.

Molecular docking and molecular dynamics studies of bioactive compounds contained in noni fruit (Morinda citrifolia L.) against human pancreatic α-amylase

Human pancreatic α-amylase inhibition is currently a promising therapeutic target against type 2 diabetes (DMT2) because it can reduce aggressive digestion of carbohydrates into absorbable monosaccharides. In Indonesia, medicinal plants, e.g. Morinda citrifolia fruit, have been empirically utilized as a blood-sugar reducer, however, the inhibitory activity of compounds in this plant against human pancreatic α-amylase is still limited or none. Therefore, this study aimed to test the interaction of 7 compounds (americanin, asperulosidic acid, damnacanthal, quercetin, rutin, scopoletin, and ursolic acid) contained in noni fruit against human pancreatic α-amylase by molecular docking and molecular dynamics and compared their binding modes with that of acarbose. Results of the molecular docking simulation indicated that the ursolic acid compound possesses the best binding energy (-8.58 kcal/mol) and comparable to that of acarbose (-8.59 kcal/mol). The molecular dynamics study at 100 ns simulation, the values of RMSD, RMSF, the radius of gyration (Rg), the solvent-accessible surface area (SASA), principal component analysis (PCA), and MM-PBSA binding free energy were stable and identical to those of acarbose. It could be concluded that ursolic acid might be potential in inhibiting human pancreatic α-amylase, thus, potential to be developed as an anti-DMT2 drug candidate. Communicated by Ramaswamy H. Sarma.

Development of a salutogenic intervention for healthy eating among Dutch type 2 diabetes mellitus patients

Healthy eating can be challenging for type 2 diabetes mellitus (T2DM) patients. The theory of salutogenesis, which focuses on the resources required to organize behavioural changes in everyday life, was used to develop an intervention for healthy eating. The aim was to describe the development, structure and content of this salutogenic intervention. The development consisted of two phases that were based on the operationalization of important key principles of salutogenesis. In Phase 1 (Exploration and synthesis), a systematic review and three qualitative studies were performed to explore important characteristics to enable healthy eating in everyday life. The results were used to develop the draft intervention. In Phase 2 (Validation and adjustment), interviews and workshops were conducted with T2DM patients, healthcare providers and scientists. Based on this, the draft intervention was modified into its final form. The developmental process resulted in a 12-week, group-based intervention that aimed to enable important resources for healthy eating via self-examination, reflection, setting goals and sharing experiences. Attention was also paid to disease information, disease acceptance, food literacy, stress management, self-identity and social support. The group sessions began following an individual intake session, with a booster session held 3 months after the intervention. The researcher’s translation of the stakeholders’ priorities into an intervention was corrected for and approved by the stakeholders concerned. This comprehensive salutogenic intervention was developed based on practical and scientific evidence. Providing transparency in developmental processes and content is important because it determines the scientific integrity and credibility of an intervention.

Healthy eating can be difficult for people with the disease type 2 diabetes. This article describes how a programme aimed at helping type 2 diabetes patients to eat healthily was developed. The draft version of the programme was based on a theoretical framework that aims to understand what creates health in everyday life, and on conversations with type 2 diabetes patients and healthcare providers. The draft programme was adjusted based on the feedback of type 2 diabetes patients, healthcare providers and scientists. This resulted in a 12-week, group-based programme that enables people to think about who they are and what they want by setting health goals and sharing experiences. Attention was also paid to disease knowledge, disease acceptance, nutritional skills, dealing with stress, self-identity and social support. The group sessions began following an individual intake session, with a booster session held 3 months after the intervention. By involving everybody, we were able to develop a programme that takes into account the preferences, needs and priorities of all stakeholders. It is important to describe the development and the content of programmes encouraging healthy eating to determine their quality and effectivity.

Impacts of high fat diet on ocular outcomes in rodent models of visual disease

High fat diets (HFD) have been utilized in rodent models of visual disease for over 50 years to model the effects of lipids, metabolic dysfunction, and diet-induced obesity on vision and ocular health. HFD treatment can recapitulate the pathologies of some of the leading causes of blindness, such as age-related macular degeneration (AMD) and diabetic retinopathy (DR) in rodent models of visual disease. However, there are many important factors to consider when using and interpreting these models. To synthesize our current understanding of the importance of lipid signaling, metabolism, and inflammation in HFD-driven visual disease processes, we systematically review the use of HFD in mouse and rat models of visual disease. The resulting literature is grouped into three clusters: models that solely focus on HFD treatment, models of diabetes that utilize both HFD and streptozotocin (STZ), and models of AMD that utilize both HFD and genetic models and/or other exposures. Our findings show that HFD profoundly affects vision, retinal function, many different ocular tissues, and multiple cell types through a variety of mechanisms. We delineate how HFD affects the cornea, lens, uvea, vitreous humor, retina, retinal pigmented epithelium (RPE), and Bruch's membrane (BM). Furthermore, we highlight how HFD impairs several retinal cell types, including glia (microglia), retinal ganglion cells, bipolar cells, photoreceptors, and vascular support cells (endothelial cells and pericytes). However, there are a number of gaps, limitations, and biases in the current literature. We highlight these gaps and discuss experimental design to help guide future studies. Very little is known about how HFD impacts the lens, ciliary bodies, and specific neuronal populations, such as rods, cones, bipolar cells, amacrine cells, and retinal ganglion cells. Additionally, sex bias is an important limitation in the current literature, with few HFD studies utilizing female rodents. Future studies should use ingredient-matched control diets (IMCD), include both sexes in experiments to evaluate sex-specific outcomes, conduct longitudinal metabolic and visual measurements, and capture acute outcomes. In conclusion, HFD is a systemic exposure with profound systemic effects, and rodent models are invaluable in understanding the impacts on visual and ocular disease.

β-Cell Dysfunction, Hepatic Lipid Metabolism, and Cardiovascular Health in Type 2 Diabetes: New Directions of Research and Novel Therapeutic Strategies

Cardiovascular disease (CVD) remains a major problem for people with type 2 diabetes mellitus (T2DM), and dyslipidemia is one of the main drivers for both metabolic diseases. In this review, the major pathophysiological and molecular mechanisms of β-cell dysfunction and recovery in T2DM are discussed in the context of abnormal hepatic lipid metabolism and cardiovascular health. (i) In normal health, continuous exposure of the pancreas to nutrient stimulus increases the demand on β-cells. In the long term, this will not only stress β-cells and decrease their insulin secretory capacity, but also will blunt the cellular response to insulin. (ii) At the pre-diabetes stage, β-cells compensate for insulin resistance through hypersecretion of insulin. This increases the metabolic burden on the stressed β-cells and changes hepatic lipoprotein metabolism and adipose tissue function. (iii) If this lipotoxic hyperinsulinemic environment is not removed, β-cells start to lose function, and CVD risk rises due to lower lipoprotein clearance. (iv) Once developed, T2DM can be reversed by weight loss, a process described recently as remission. However, the precise mechanism(s) by which calorie restriction causes normalization of lipoprotein metabolism and restores β-cell function are not fully established. Understanding the pathophysiological and molecular basis of β-cell failure and recovery during remission is critical to reduce β-cell burden and loss of function. The aim of this review is to highlight the link between lipoprotein export and lipid-driven β-cell dysfunction in T2DM and how this is related to cardiovascular health. A second aim is to understand the mechanisms of β-cell recovery after weight loss, and to explore new areas of research for developing more targeted future therapies to prevent T2DM and the associated CVD events.

[The role of counterinsular hormones in the regulation of glucose homeostasis and the pathogenesis of type 2 diabetes mellitus in COPD]

The frequent combination of type 2 diabetes mellitus (T2DM) and chronic obstructive pulmonary disease (COPD) is an important socially significant and far from being studied problem. However, only a few works are devoted to it. To solve this problem, we analyzed the possible pathogenetic mechanisms from the standpoint of the impact on glucose homeostasis of the main hormones - insular and contrainsular.The analysis was carried out using various literature databases, including Index Medicus, Scopus, Pub Med, Embase, Cochrane and others for the period, with rare exceptions, for 2000-2020, of which the works devoted directly to the aspect considered in this work were published in the last 5 years.The analysis revealed a mutual aggravating effect of COPD and T2DM, in which COPD plays an initiating role. It also revealed a significant role of counterinsular hormones, which largely determines the nature of the pathogenesis of T2DM in COPD.In addition, the article draws attention to the possible role of genetic factors that can be common for COPD and T2DM and have a significant role in the comorbidity of COPD and T2DM. The data obtained can be used for both diagnostic and therapeutic purposes in the correction of disorders of carbohydrate metabolism in COPD, which is the lot of further research.

The joint effect of energy reduction with calcium supplementation on the risk factors of type 2 diabetes in the overweight population: a two-year randomized controlled trial

Both excessive energy intake and low calcium intake are inversely associated with the aging-related diseases, particularly for type 2 diabetes mellitus(T2DM). This study examined whether energy reduction coupled with calcium supplementation aided in the prevention of T2DM among the overweight population. A randomized controlled trial(RCT) of 1021 overweight participants was performed, in which participants were randomly assigned to 4 groups: 1) energy-reduction group(ERG), 2) calcium supplementation group(CSG), 3) energy-reduction with calcium supplementation group(ER-CSG), 4) control group(CG). Nutritional habits, anthropometric and diabetes-related indicators were measured at baseline and each follow-up time. To analyze the separate effects of dietary energy reduction and calcium supplementation, ERG and ER-CSG were integrated into ERGs. Similarly, CSG and ER-CSG were integrated into CSGs. Compared to the non-energy-reduction groups(NERGs), ERGs had lower values of ΔBMI(-0.9kg/m²), ΔFSG (-0.34mmol/L), ΔHbA1c(0.16%), and ΔHOMA-IR(-0.13), and higher value of ΔGutt index(-5.82). Compared to the non-calcium supplementation groups(NCSGs), the ΔGutt index(-5.46) in CSGs showed a significant decrease. Moreover, these risk factors for T2DM were most effectively ameliorated in ER-CSG group with the decreased values of ΔFSG(-0.42mmol/L), ΔGutt index(-0.73), and the slowest increasing rate value of Δ2h-glucose(0.37mmol/L). This RCT demonstrated that energy-reduction with calcium supplementation was a useful dietary intervention strategy for preventing the development of T2DM in the overweight population.

Residential Green and Blue Spaces and Type 2 Diabetes Mellitus: A Population-Based Health Study in China

Evidence on the health benefits of green space in residential environments is still limited, and few studies have investigated the potential association between blue space and type 2 diabetes mellitus (T2DM) prevalence. This study included 39,019 participants who had completed the baseline survey from the Henan Rural Cohort Study, 2015-2017. The Normalized Difference Vegetation Index (NDVI) and Enhanced Vegetation Index (EVI) were employed to characterize the residential green space, and the distance from the participant's residential address to the nearest water body was considered to represent the residential blue space. Mixed effect models were applied to evaluate the associations of the residential environment with T2DM and fasting blood glucose (FBG) levels. An interquartile range (IQR) increase in NDVI and EVI was significantly associated with a 13.4% (odds ratio (OR): 0.866, 95% Confidence interval (CI): 0.830,0.903) and 14.2% (OR: 0.858, 95% CI: 0.817,0.901) decreased risk of T2DM, respectively. The residential green space was associated with lower fasting blood glucose levels in men (%change, -2.060 in men vs. -0.972 in women) and the elderly (%change, -1.696 in elderly vs. -1.268 in young people). Additionally, people who lived more than 5 km from the water body had a 15.7% lower risk of T2DM (OR: 0.843, 95% CI: 0.770,0.923) and 1.829% lower fasting blood glucose levels (95% CI: -2.335%,-1.320%) than those who lived closer to the blue space. Our findings suggest that residential green space was beneficially associated with T2DM and fasting blood glucose levels. However, further research is needed to explore more comprehensively the relationship between residential blue space and public health.

Protein Kinases Signaling in Pancreatic Beta-cells Death and Type 2 Diabetes

Type 2 diabetes (T2D) is a worldwide serious public health problem. Insulin resistance and β-cell failure are the two major components of T2D pathology. In addition to defective endoplasmic reticulum (ER) stress signaling due to glucolipotoxicity, β-cell dysfunction or β-cell death initiates the deleterious vicious cycle observed in T2D. Although the primary cause is still unknown, overnutrition that contributes to the induction of the state of low-grade inflammation, and the activation of various protein kinases-related metabolic pathways are main factors leading to T2D. In this chapter following subjects, which have critical checkpoints regarding β-cell fate and protein kinases pathways are discussed; hyperglycemia-induced β-cell failure, chronic accumulation of unfolded protein in β-cells, the effect of intracellular reactive oxygen species (ROS) signaling to insulin secretion, excessive saturated free fatty acid-induced β-cell apoptosis, mitophagy dysfunction, proinflammatory responses and insulin resistance, and the reprogramming of β-cell for differentiation or dedifferentiation in T2D. There is much debate about selecting proposed therapeutic strategies to maintain or enhance optimal β-cell viability for adequate insulin secretion in T2D. However, in order to achieve an effective solution in the treatment of T2D, more intensive clinical trials are required on newer therapeutic options based on protein kinases signaling pathways.

Durability of glycaemic control in type 2 diabetes: A systematic review and meta-analysis for its association with body weight changes

AIMS

To analyse quantitatively the association between the durability of glycaemic control and body weight changes during treatment.

MATERIALS AND METHODS

This study adhered to an appropriate methodology according to Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Studies with follow-ups >12 months, and final and intermediate assessments of haemoglobin A1c (HbA1c) and body weight were included. Four outcomes assessing therapeutic durability were extracted and synthesized using Stata statistical software, including changes in HbA1c, goal-achievement rate, failure rate and coefficient of failure (CoF).

RESULTS

After 8.9 months of treatment, HbA1c levels declined from 8.03% [95% confidence interval (CI), 7.91-8.15; I² = 99.2%] to 7.15% (95% CI, 7.02-7.27; I² = 99.4%) and then gradually increased up to 7.72% (95% CI, 7.50-7.94; I² = 99.0%) 5 years later. The goal-achievement rate decreased from 54.8% (after 1 year of treatment) to 19.4% 5 years later. The CoF was 0.123 ± 0.022%/year (P < .001). After stratification, the CoFs were 0.224 ± 0.025%/year (P < .001) for weight gain, 0.137 ± 0.034%/year (P < .001) for neutral weight and -0.024 ± 0.032%/year (P = .450) for weight loss. After stratification by treatment approaches, the CoFs were 0.45%/year for insulin, 0.43%/year for sulphonylurea, 0.34%/year for thiazolidinediones, 0.29%/year for metformin, 0.16% for glucagon-like polypeptide-1 receptor agonists, 0.12% for surgery, -0.03% for sodium-glucose cotransporter-2 inhibitors and -0.21% for dipeptidyl peptidase-IV inhibitors.

CONCLUSION

Modest weight loss with a goal of 2-3% of body weight should be recommended to improve therapeutic durability and prevent beta-cell deterioration.

The Effect of Physical Activity on Glycemic Variability in Patients With Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

The effect of physical activity on glycemic variability remains controversial. This meta-analysis aimed to assess the overall effect of physical activity treatment on glycemic variability in patients with diabetes.

METHODS

PubMed/MEDLINE, Embase, and Cochrane databases were searched for clinical trials that conducted in patients with type 1 diabetes mellitus and type 2 diabetes mellitus with reports of the mean amplitude of glycemic excursion (MAGE), time in range (TIR), time above range (TAR), or time below range (TBR). Eligible trials were analyzed by fixed-effect model, random effect model, and meta-regression analysis accordingly.

RESULTS

In total, thirteen trials were included. Compared with the control group, physical activity intervention was significantly associated with increased TIR (WMDs, 4.17%; 95% CI, 1.11 to 7.23%, P<0.01), decreased MAGE (WMDs, -0.68 mmol/L; 95% CI, -1.01 to -0.36 mmol/L, P<0.01) and decreased TAR (WMDs, -3.54%; 95% CI, -5.21 to -1.88%, P<0.01) in patients with diabetes, but showed insignificant effects on TBR. Patients with higher baseline BMI levels was associated with a greater decrease in MAGE (β=-0.392, 95% CI: -0.710, -0.074), and patients with lower baseline HbA1c levels was associated with a greater increase in TBR during physical activities (β=-0.903, 95% CI: -1.550, -0.255).

CONCLUSION

Physical activity was associated with significantly decreased glycemic variability in patients with diabetes. Patients with higher BMI might benefit more from physical activity therapy in terms of a lower MAGE. Hypoglycemia associated with physical activity treatment still warranted caution, especially in patients with intensive glycemic control.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO [CRD42021259807].

The Importance of Non-Coding RNAs in Neurodegenerative Processes of Diabetes-Related Molecular Pathways

Diabetes mellitus (DM) is a complex condition and serious health problem, with growing occurrence of DM-associated complications occurring globally. Persistent hyperglycemia is confirmed as promoting neurovascular dysfunction leading to irreversible endothelial cell dysfunction, increased neuronal cell apoptosis, oxidative stress and inflammation. These collaboratively and individually result in micro- and macroangiopathy as well as neuropathy demonstrated by progressive neuronal loss. Recently, major efforts have been pursued to select not only useful diagnostic and prognostic biomarkers, but also novel therapeutic approaches. Both microRNAs (miRNAs) and long non-coding RNAs (lncRNAs) belong to a class of non-coding RNAs identified in most of the body fluids i.e., peripheral blood, cerebrospinal fluid, brain tissue and neurons. Numerous miRNAs, lncRNAs and their target genes are able to modulate signaling pathways known to play a role in the pathophysiology of progressive neuronal dysfunction. Therefore, they pose as promising biomarkers and treatment for the vast majority of neurodegenerative disorders. This review provides an overall assessment of both miRNAs' and lncRNAs' utility in decelerating progressive nervous system impairment, including neurodegeneration in diabetic pathways.

Beta-Cell Mass in Obesity and Type 2 Diabetes, and Its Relation to Pancreas Fat: A Mini-Review

Type 2 diabetes (T2DM) is characterized by insulin resistance and beta-cell dysfunction. Although insulin resistance is assumed to be a main pathophysiological feature of the development of T2DM, recent studies have revealed that a deficit of functional beta-cell mass is an essential factor for the pathophysiology of T2DM. Pancreatic fat contents increase with obesity and are suggested to cause beta-cell dysfunction. Since the beta-cell dysfunction induced by obesity or progressive decline with disease duration results in a worsening glycemic control, and treatment failure, preserving beta-cell mass is an important treatment strategy for T2DM. In this mini-review, we summarize the current knowledge on beta-cell mass, beta-cell function, and pancreas fat in obesity and T2DM, and we discuss treatment strategies for T2DM in relation to beta-cell preservation.

Pathogenesis and remission of type 2 diabetes: what has the twin cycle hypothesis taught us?

Type 2 diabetes has been regarded a complex multifactorial disease that lead to serious health complications including high cardiovascular risks. The twin cycle hypothesis postulated that both hepatic insulin resistance and dysfunction rather than death of beta (β) cell determine diabetes onset. Several studies were carried out to test this hypothesis, and all demonstrated that chronic excess calorie intake and ectopic fat accumulation within the liver and pancreas are fundamental to the development of this disease. However, these recent research advances cannot determine the exact cause of this disease. In this review, the major factors that contribute to the pathogenesis and remission of type 2 diabetes will be outlined. Importantly, the effect of disordered lipid metabolism, characterized by altered hepatic triglyceride export will be discussed. Additionally, the observed changes in pancreas morphology in type 2 diabetes will be highlighted and discussed in relation to β cell function.

A new understanding of GHSR1a--independent of ghrelin activation

Growth hormone secretagogue receptor 1a (GHSR1a), a member of the G protein-coupled receptor (GPCR) family, is a functional receptor of ghrelin. The expression levels and activities of GHSR1a are affected by various factors. In past years, it has been found that the ghrelin-GHSR1a system can perform biological functions such as anti-inflammation, anti-apoptosis, and anti-oxidative stress. In addition to mediating the effect of ghrelin, GHSR1a also has abnormally high constitutive activity; that is, it can still transmit intracellular signals without activation of the ghrelin ligand. This constitutive activity affects brain functions, growth and development of the body; therefore, it has profound impacts on neurodegenerative diseases and some other age-related diseases. In addition, GHSR1a can also form homodimers or heterodimers with other GPCRs, affecting the release of neurotransmitters, appetite regulation, cell proliferation and insulin release. Therefore, further understanding of the constitutive activities and dimerization of GHSR1a will enable us to better clarify the characteristics of GHSR1a and provide more therapeutic targets for drug development. Here, we focus on the roles of GHSR1a in various biological functions and provide a comprehensive summary of the current research on GHSR1a to provide broader therapeutic prospects for age-related disease treatment.

Inducing remission of Type 2 diabetes in the Caribbean: findings from a mixed methods feasibility study of a low-calorie liquid diet-based intervention in Barbados

AIM

In a high proportion of people with recently diagnosed Type 2 diabetes, a short (2-3-month) low-calorie diet is able to restore normal glucose and insulin metabolism. The aim of this study was to determine the feasibility of this approach in Barbados.

METHODS

Twenty-five individuals with Type 2 diabetes diagnosed within past 6 years, not on insulin, BMI ≥ 27 kg/m² were recruited. Hypoglycaemic medication was stopped on commencement of the 8-week liquid (760 calorie) diet. Insulin response was assessed in meal tests at baseline, 8 weeks and 8 months. Semi-structured interviews, analysed thematically, explored participants' experiences. 'Responders' were those with fasting plasma glucose (FPG) < 7 mmol/l at 8 weeks.

RESULTS

Ten men and 15 women (mean age 48, range 26-68 years) participated. Mean (sd) BMI was 34.2 kg/m² (6.0); FPG 9.2 mmol/l (2.2). Mean weight loss at 8 weeks and 8 months was 10.1 kg [95% confidence interval (CI) 8.1, 12.0] and 8.2 kg (95% CI 5.8, 10.6); FPG was lower by 2.2 mmol/l (95% CI 1.2, 3.2) and 1.7 mmol/l (95% CI 0.8, 2.7) respectively. Nine of 11 (82%) of those who lost ≥ 10 kg were 'responders' compared with 6 of 14 (43%) who lost < 10 kg (P = 0.048). The 30-min insulin increment was higher in responders at baseline and follow-up (P ≤ 0.01). A food culture based on starchy foods and pressures to eat large amounts at social events were among the challenges identified by participants.

CONCLUSIONS

The feasibility of this approach to weight loss and diabetes remission in a predominantly black population in Barbados was demonstrated.

Lifestyle medicine for type 2 diabetes: practice-based evidence for long-term efficacy of a multicomponent lifestyle intervention (Reverse Diabetes2 Now)

Introduction

A wealth of evidence supports short-term efficacy of lifestyle interventions in type 2 diabetes (T2D). However, little is known about long-term effects of lifestyle interventions in real-life settings.

Methods

This observational, single-arm study evaluated long-term impact of ‘Voeding Leeft: Reverse-Diabetes2-Now’, a 6-month multicomponent lifestyle programme, on glycaemic control and glucose-lowering medication (GLmed) use, other T2D parameters and quality of life in 438 T2D participants at 6, 12, 18 and 24 months using paired sample t-tests, χ² and generalised linear models.

Results

At 24 months, 234 participants provided information on GLmed and HbA1c (‘responders’). 67% of the responders used less GLmed, and 28% ceased all GLmed. Notably, 71% of insulin users at baseline (n=47 of 66 insulin users) were off insulin at 24 months. Mean HbA1c levels were similar at 24 months compared with baseline (55.6±12.8 vs. 56.3±10.5 mmol/mol, p=0.43), but more responders had HbA1c levels ≤53 mmol/mol at 24 months (53% vs 45% at baseline). Furthermore, triglyceride levels (−0.34±1.02 mmol/L, p=0.004), body weight (−7.0±6.8 kg, p<0.001), waist circumference (−7.9±8.2 cm, p<0.001), body mass index (−2.4±2.3 kg/m², p<0.001) and total cholesterol/high-density lipoprotein (HDL) ratio (−0.22±1.24, p=0.044) were lower, while HDL (+0.17 ± 0.53 mmol/L, p<0.001) and low-density lipoprotein-cholesterol levels (+0.18 ± 1.06 mmol/L, p=0.040) were slightly higher. No differences were observed in fasting glucose or total cholesterol levels. Quality of life and self-reported health significantly improved.

Conclusion

This study indicates robust, durable real-life benefits of this lifestyle group programme after up to 24 months of follow-up, particularly in terms of medication use, body weight and quality of life in T2D patients.

Schizophrenia patients with a metabolically abnormal obese phenotype have milder negative symptoms

BACKGROUND

Schizophrenia patients with a metabolically abnormal obese (MAO) phenotype have been shown poor cardiovascular outcomes, but the characteristics of their current psychiatric symptoms have not been characterized. This study mainly explored the psychiatric symptoms of schizophrenia patients with the MAO phenotype.

METHODS

A total of 329 patients with schizophrenia and 175 sex- and age-matched people without schizophrenia from Anhui Province in China were enrolled. The Positive and Negative Syndrome Scale (PANSS) was used to evaluate the mental symptoms of the schizophrenia patients. The MAO phenotype was defined as meeting 1-4 metabolic syndrome criteria (excluding waist circumference) and having a body mass index (BMI) ≥ 28 kg/m². And, metabolically healthy normal-weight (MHNW) phenotype was defined as meeting 0 criteria for metabolic syndrome and 18.5 ≤ BMI < 24 kg/m².

RESULTS

Overall, 15.8% of the schizophrenia patients and 9.1% of the control group were consistent with the MAO phenotype, and the prevalence of MAO in the schizophrenia group was higher than that in the control group. Among the patients with schizophrenia, the MAO group had lower negative factor, cognitive factor and total PANSS scores than the MHNW group. However, when confounding factors were controlled, only the negative factor remained lower significantly.

CONCLUSION

We found that schizophrenia patients with the MAO phenotype had reduced negative symptoms, which may indicate an internal mechanism linking metabolic disorders and negative symptoms.

TRIAL REGISTRATION

This study was registered in the China Clinical Trial Registration Center (No. chiCTR 1,800,017,044 ).

Benefit of lifestyle-based T2DM prevention is influenced by prediabetes phenotype

The prevention of type 2 diabetes mellitus (T2DM) is a target priority for the WHO and the United Nations and is a key priority in the 2018 Berlin Declaration, which is a global call for early actions related to T2DM. Health-care policies advocate that individuals at high risk of developing T2DM undertake lifestyle modification, irrespective of whether the prediabetes phenotype is defined by hyperglycaemia in the postprandial state (impaired glucose tolerance) and/or fasting state (impaired fasting glucose) or by intermediate HbA_1c levels. However, current evidence indicates that diabetes prevention programmes based on lifestyle change have not been successful in preventing T2DM in individuals with isolated impaired fasting glucose. We propose that further research is needed to identify effective lifestyle interventions for individuals with isolated impaired fasting glucose. Furthermore, we call for the identification of innovative approaches that better identify people with impaired glucose tolerance, who benefit from the currently available lifestyle-based diabetes prevention programmes.

Increased NRSF/REST in anterior cingulate cortex contributes to diabetes-related neuropathic pain

Diabetic neuropathic pain is one of the most common complications of diabetes. Mechanisms underlying the central modulation are still unclear. Here, we investigated the role of the neuron-restricted silencing factor (NRSF/REST) in diabetic-related neuropathic pain. Mechanical allodynia and thermal hyperalgesia were assessed to evaluate painful behaviors. Our results found that in the anterior cingulate cortex (ACC) of db/db mice, NRSF/REST levels increased significantly. Reduction of NRSF/REST improved the painful sensation. Meanwhile, in vitro study found that high glucose and high palmitic acid treatment induced elevation of NRSF/REST and its cofactors (mSin3A, CoREST and HDAC1), whereas downregulation of GluR2 and NMDAR2B. Knockdown of NRSF/REST could attenuate the LDH release and partially reversed the expression changes of HDAC1 and NMDAR2B. Our results suggested that the elevation of NRSF/REST in the ACC area of db/db mice is one of the key mediators of diabetic neuropathic pain.

Fasting in diabetes treatment (FIT) trial: study protocol for a randomised, controlled, assessor-blinded intervention trial on the effects of intermittent use of a fasting-mimicking diet in patients with type 2 diabetes

BACKGROUND

Caloric restriction is an effective way to treat Type 2 diabetes (T2D). However, chronic and severe restriction of food intake is difficult to sustain and is known to promote slower metabolism. Intermittent and frequent fasting can exert similar metabolic effects, but may be even more challenging for most patients. A fasting-mimicking diet (FMD) is low in calories, sugars and proteins, but includes relatively high levels of plant based complex carbohydrates and healthy fats. The metabolic effects of such a diet mimic the benefits of water-only fasting. The effects of a FMD applied periodically in T2D patients are still unknown. The Fasting In diabetes Treatment (FIT) trial was designed to determine the effect of intermittent use (5 consecutive days a month during a year) of a FMD in T2D patients on metabolic parameters and T2D medication use compared to usual care.

METHODS

One hundred T2D patients from general practices in the Netherlands with a BMI ≥ 27 kg/m², treated with lifestyle advice only or lifestyle advice plus metformin, will be randomised to receive the FMD plus usual care or usual care only. Primary outcomes are HbA1c and T2D medication dosage. Secondary outcomes are anthropometrics, blood pressure, plasma lipid profiles, quality of life, treatment satisfaction, metabolomics, microbiome composition, MRI data including cardiac function, fat distribution and ectopic fat storage, cost-effectiveness, and feasibility in clinical practice.

DISCUSSION

This study will establish whether monthly 5-day cycles of a FMD during a year improve metabolic parameters and/or reduce the need for medication in T2D. Furthermore, additional health benefits and the feasibility in clinical practice will be measured and a cost-effectiveness evaluation will be performed.

TRIAL REGISTRATION

The trial was registered on ClinicalTrials.gov. Identifier: NCT03811587. Registered 21th of January, 2019; retrospectively registered.

The Effects of a Low Calorie Ketogenic Diet on Glycaemic Control Variables in Hyperinsulinemic Overweight/Obese Females

Diet is a factor which can influence both glycaemic variables and body mass. The aim of this study was to compare the influence of a 12-week, well-planned, low-calorie ketogenic diet (LCKD) on hyperglycaemic, hyperinsulinemic and lipid profile in adult, overweight or obese females. Ninety-one females who participated in the study were divided into two groups: a LCKD group who followed a hypocaloric ketogenic diet (8% of carbohydrate, 72% of fat and 20% of proteins) (n = 46), and a control group (CG) (n = 45) who continued their typical diet (50% of carbohydrates, 32% of fat and 18% of proteins). Methods: Baseline and post-intervention glucose (Gl), insulin (I), glycated haemoglobin (HbA1c), Homeostatic model assessment HOMA-IR, triglycerides (TG) and high-density cholesterol (HDL-C) were evaluated. Also, body mass (BM), waist circumference (WC), hip circumference (HC) and thigh circumference (TC) were measured. Results: Compared with the CG, there were significant changes observed in the LCKD group regarding all biochemical variables. Also, BM, TC, WC and AC changed significantly in the LCKD group compared with the CG. Conclusions: The 12-week LCKD intervention changed the glucose control variables, body mass, as well as waist, hip and thigh circumferences. A low-calorie ketogenic diet may be recommended for adult females with glucose control variables disturbance and excess body mass.

Association of the Dietary-Based Diabetes-Risk Score (DDS) with the risk of gestational diabetes mellitus in the Seguimiento Universidad de Navarra (SUN) project

It is crucial to identify people at risk for type 2 diabetes mellitus (T2DM) and gestational diabetes mellitus (GDM) to implement preventive interventions in order to address these pandemics. A simple score exclusively based on dietary components, the Dietary-Based Diabetes-Risk Score (DDS) showed a strong inverse association with incident T2DM. The objective was to assess the association between DDS and the risk of GDM in a cohort of Spanish university graduates. The 'Seguimiento Universidad de Navarra' project is a prospective and dynamic cohort which included data of 3455 women who notified pregnancies between 1999 and 2012. The diagnosis of GDM is self-reported and further confirmed by physicians. A validated 136-item semi-quantitative FFQ was used to assess pre-gestational dietary habits. The development of the DDS was aimed to quantify the association between the adherence to this a priori dietary score and T2DM incidence. The score exclusively included dietary components (nine food groups with reported inverse associations with T2DM incidence and three food groups which reported direct associations with T2DM). Three categories of adherence to the DDS were assessed: low (11-24), intermediate (25-39) and high (40-60). The upper category showed an independent inverse association with the risk of incident GDM compared with the lowest category (multivariate-adjusted OR 0·48; 95 % CI 0·24, 0·99; P for linear trend: 0·01). Several sensitivity analyses supported the robustness of these results. These results reinforce the importance of pre-gestational dietary habits for reducing GDM and provide a brief tool to practically assess the relevant dietary habits in clinical practice.

Differential relationships between waist circumference and cardiorespiratory fitness among people with and without type 2 diabetes

Adults with type 2 diabetes mellitus tend to exhibit an increased level of central adiposity, augmenting their risk of further non-communicable diseases (NCDs). Importantly, consistent evidence demonstrates a significant, negative association between cardiorespiratory fitness (CRF) and waist circumference (WC). However, no previous studies have investigated differences in these CRF-related reductions in WC between adults with and without diabetes. This study used data from the Aerobic Center for Longitudinal Studies, conducted between 1970 and 2006 among predominately Non-Hispanic White, middle-to-upper class adults in Texas. Quantile regression models were used to estimate CRF-related differences in WC between persons with and without diabetes. Age, height, smoking status and birth cohort served as covariates. The analytic sample included 45901 adults. Significantly larger reductions in WC were observed among adults with diabetes as compared to without diabetes across all WC percentiles. Among males, high CRF levels were associated with significant reductions, as compared to their low-fit counterparts, in WC as large as 21.9 cm for adults without diabetes and as large as 27 cm for adults with diabetes. Among females, high CRF levels were associated with significant reductions, as compared to their low-fit counterparts, in WC as large as 22.3 and 30.0 cm for adults without and with diabetes, respectively. This study demonstrated that higher CRF is associated with significant reductions in WC, with greater magnitudes found among adults with diabetes, especially among the most centrally obese, highlighting the necessity of exercise prescription in this clinical population potentially leading to lower risks of future NCDs.

Salutogenic model of health to identify turning points and coping styles for eating practices in type 2 diabetes mellitus

BACKGROUND

It is important for people with Type 2 Diabetes Mellitus (T2DM) to eat healthily. However, implementing dietary advice in everyday life is difficult, because eating is not a distinguishable action, but a chain of activities, embedded in social practices and influenced by previous life experiences. This research aims to understand why and how eating practices are developed over the life-course by investigating influential life experiences - turning points - and coping strategies for eating practices of people with T2DM.

METHODS

The Salutogenic Model of Health guided the study's objective, study design and analysis. Seventeen interviews were performed and analysed based on the principles of interpretative phenomenological analysis. Narrative inquiry and the creation of timelines and food boxes were used as tools to facilitate reflection on turning points and eating practices.

RESULTS

Turning points for unhealthier eating were experiences that strongly disturbed the participants' emotional stability. These experiences included psychosocial trauma, physical health disorders, job loss, and smoking cessation. Turning points for healthier eating were experiences that significantly changed participants views on life and made participants reflective about the effects of current eating practices on future health and life goals. These turning points included confrontation with ill-health, becoming a parent, psychosocial therapy, and getting married. Notably, turning points for healthier eating seemed only to happen when life was relatively stress-free. All participants experienced turning points for healthier eating, yet, not all participants succeeded in improving their diets. Two coping styles were distinguished: active and passive coping. Active coping individuals were able to act in line with their personal intentions, whereas passive coping individuals could not. Differences between active and passive coping styles seemed to be explained by differences in available resources important for adapting and maintaining a healthy diet.

CONCLUSION

Disadvantaged childhood and later life adversities together with the inability to manage the mental stress explained the development unhealthier eating practices. All participants experienced turning points for healthier eating that caused eating to become a priority in their life. Yet, the fact that not all were able to eat as they intended, advocates for nutritional guidance for people with T2DM, with a greater emphasis on reflexivity, psycho-social well-being and social support.

Beyond Body Weight-Loss: Dietary Strategies Targeting Intrahepatic Fat in NAFLD

Non-alcoholic fatty liver disease (NAFLD) has emerged as the most prevalent liver disease in industrialized countries. It is regarded as the hepatic manifestation of the metabolic syndrome (MetS) resulting from insulin resistance. Moreover, insulin resistance impairs glycogen synthesis, postprandially diverting a substantial amount of carbohydrates to the liver and storing them there as fat. NAFLD has far-reaching metabolic consequences involving glucose and lipoprotein metabolism disorders and risk of cardiovascular disease, the leading cause of death worldwide. No pharmaceutical options are currently approved for the treatment of NAFLD. Exercise training and dietary interventions remain the cornerstone of NAFLD treatment. Current international guidelines state that the primary goal of nutritional therapy is to reduce energy intake to achieve a 7%-10% reduction in body weight. Meal replacement therapy (formula diets) results in more pronounced weight loss compared to conventional calorie-restricted diets. However, studies have shown that body mass index (BMI) or weight reduction is not obligatory for decreasing hepatic fat content or to restore normal liver function. Recent studies have achieved significant reductions in liver fat with eucaloric diets and without weight loss through macronutrient modifications. Based on this evidence, an integrative nutritional therapeutic concept was formulated that combines the most effective nutrition approaches termed "liver-fasting." It involves the temporary use of a low calorie diet (total meal replacement with a specific high-protein, high-soluble fiber, lower-carbohydrate formula), followed by stepwise food reintroduction that implements a Mediterranean style low-carb diet as basic nutrition.

Age of onset of diabetes and all-cause mortality

Diabetes mellitus continues to present a large social, financial and health system burden across the world. The relationship between age of onset of the different types of diabetes and all-cause mortality is uncertain. In this review paper, the relationship between age of onset of the different types of diabetes and all-cause mortality will be reviewed and an update of the current evidence will be presented. There is strong evidence of the relationship between age of onset of type 2 diabetes mellitus (T2DM) and all-cause mortality, good evidence of the relationship between age of onset of T1DM and all-cause mortality and no evidence of the relationship between age of onset of gestational diabetes or prediabetes and all-cause mortality. Further research is needed to look at whether aggressive management of earlier onset of T2DM can help to reduce premature mortality.

Hypoglycaemic effect of catalpol in a mouse model of high-fat diet-induced prediabetes

Type 2 diabetes mellitus is a major health problem and a societal burden. Individuals with prediabetes are at increased risk of type 2 diabetes mellitus. Catalpol, an iridoid glycoside, has been reported to exert a hypoglycaemic effect in db/db mice, but its effect on the progression of prediabetes is unclear. In this study, we established a mouse model of prediabetes and examined the hypoglycaemic effect, and the mechanism of any such effect, of catalpol. Catalpol (200 mg/(kg·day)) had no effect on glucose tolerance or the serum lipid level in a mouse model of impaired glucose tolerance-stage prediabetes. However, catalpol (200 mg/(kg·day)) increased insulin sensitivity and decreased the fasting glucose level in a mouse model of impaired fasting glucose/impaired glucose tolerance-stage prediabetes. Moreover, catalpol increased the mitochondrial membrane potential (1.52-fold) and adenosine triphosphate content (1.87-fold) in skeletal muscle and improved skeletal muscle function. These effects were mediated by activation of the insulin receptor-1/glucose transporter type 4 (IRS-1/GLUT4) signalling pathway in skeletal muscle. Our findings will facilitate the development of a novel approach to suppressing the progression of diabetes at an early stage. Novelty Catalpol prevents the progression of prediabetes in a mouse model of prediabetes. Catalpol improves insulin sensitivity in skeletal muscle. The effects of catalpol are mediated by activation of the IRS-1/GLUT4 signalling pathway.

Obesity indicators that best predict type 2 diabetes in an Indian population: insights from the Kerala Diabetes Prevention Program

Obesity indicators are known to predict the presence of type 2 diabetes mellitus (T2DM); however, evidence for which indicator best identifies undiagnosed T2DM in the Indian population is still very limited. In the present study we examined the utility of different obesity indicators to identify the presence of undiagnosed T2DM and determined their appropriate cut point for each obesity measure. Individuals were recruited from the large-scale population-based Kerala Diabetes Prevention Program. Oral glucose tolerance tests was performed to diagnose T2DM. Receiver operating characteristic (ROC) curve analyses were used to compare the association of different obesity indicators with T2DM and to determine the optimal cut points for identifying T2DM. A total of 357 new cases of T2DM and 1352 individuals without diabetes were identified. The mean age of the study participants was 46⋅4 (sd 7⋅4) years and 62 % were men. Waist circumference (WC), waist:hip ratio (WHR), waist:height ratio (WHtR), BMI, body fat percentage and fat per square of height were found to be significantly higher (P < 0⋅001) among those with diabetes compared with individuals without diabetes. In addition, ROC for WHR (0⋅67; 95 % 0⋅59, 0⋅75), WHtR (0⋅66; 95 % 0⋅57, 0⋅75) and WC (0⋅64; 95 % 0⋅55, 0⋅73) were shown to better identify patients with T2DM. The proposed cut points with an optimal sensitivity and specificity for WHR, WHtR and WC were 0⋅96, 0⋅56 and 86 cm for men and 0⋅88, 0⋅54 and 83 cm for women, respectively. The present study has shown that WHR, WHtR and WC are better than other anthropometric measures for detecting T2DM in the Indian population. Their utility in clinical practice may better stratify at-risk patients in this population than BMI, which is widely used at present.

Systematic review of salutogenic-oriented lifestyle randomised controlled trials for adults with type 2 diabetes mellitus

OBJECTIVE

Describe the characteristics (development, intensity, deliverers, setting, strategies) and assess the effect of salutogenic-oriented lifestyle interventions on physical and psychosocial health outcomes in adults with type 2 diabetes mellitus (T2DM).

METHOD

PubMed, Scopus and PsycINFO were systematically searched for randomised controlled trials (RCTs) published up to August 2019 that complied with predefined salutogenic criteria: the participant as a whole, the participant's active involvement and the participant's individual learning process. Characteristics of the salutogenic-oriented interventions with and without significant results were compared and qualitatively summarised.

RESULTS

Twenty-eight RCTs were identified. Salutogenic oriented interventions that significantly improved both physical and psychosocial health were characterized by being based on formative research, culturally targeted, and delivered in 10-20 sessions in group settings, whereas salutogenic oriented interventions that neither improved physical or psychosocial health significantly were characterized by being individually tailored and delivered in less than 10 group sessions in individual settings.

CONCLUSIONS

This systematic review suggests that salutogenic-oriented lifestyle interventions are effective for physical and psychosocial health in the short term. More research is needed to determine how intervention characteristics moderate (long-term) effectiveness.

PRACTICE IMPLICATIONS

The results provide a basis for purposefully developing effective salutogenic interventions for adults with T2DM.

The role of physical activity in metabolic homeostasis before and after the onset of type 2 diabetes: an IMI DIRECT study

AIMS/HYPOTHESIS

It is well established that physical activity, abdominal ectopic fat and glycaemic regulation are related but the underlying structure of these relationships is unclear. The previously proposed twin-cycle hypothesis (TC) provides a mechanistic basis for impairment in glycaemic control through the interactions of substrate availability, substrate metabolism and abdominal ectopic fat accumulation. Here, we hypothesise that the effect of physical activity in glucose regulation is mediated by the twin-cycle. We aimed to examine this notion in the Innovative Medicines Initiative Diabetes Research on Patient Stratification (IMI DIRECT) Consortium cohorts comprised of participants with normal or impaired glucose regulation (cohort 1: N ≤ 920) or with recently diagnosed type 2 diabetes (cohort 2: N ≤ 435).

METHODS

We defined a structural equation model that describes the TC and fitted this within the IMI DIRECT dataset. A second model, twin-cycle plus physical activity (TC-PA), to assess the extent to which the effects of physical activity in glycaemic regulation are mediated by components in the twin-cycle, was also fitted. Beta cell function, insulin sensitivity and glycaemic control were modelled from frequently sampled 75 g OGTTs (fsOGTTs) and mixed-meal tolerance tests (MMTTs) in participants without and with diabetes, respectively. Abdominal fat distribution was assessed using MRI, and physical activity through wrist-worn triaxial accelerometry. Results are presented as standardised beta coefficients, SE and p values, respectively.

RESULTS

The TC and TC-PA models showed better fit than null models (TC: χ² = 242, p = 0.004 and χ² = 63, p = 0.001 in cohort 1 and 2, respectively; TC-PA: χ² = 180, p = 0.041 and χ² = 60, p = 0.008 in cohort 1 and 2, respectively). The association of physical activity with glycaemic control was primarily mediated by variables in the liver fat cycle.

CONCLUSIONS/INTERPRETATION

These analyses partially support the mechanisms proposed in the twin-cycle model and highlight mechanistic pathways through which insulin sensitivity and liver fat mediate the association between physical activity and glycaemic control.

Association between Food Label Unawareness and Loss of Renal Function in Diabetes: A Cross-Sectional Study in South Korea

Objectives: To examine sex differences in the association between food label unawareness and loss of renal function among South Korean diabetic patients aged ≥30 year and determine whether reading food labels when choosing which food products to consume plays a potential role in slowing the progression of renal disease. Methods: Data from the 2016–2017 Korea National Health and Nutrition Examination Survey were used for the analysis. Renal function was determined by the Modification of Diet in Renal Disease estimated glomerular filtration rate, and food label unawareness was defined as being unaware of the food label when choosing a food product for consumption. Multiple regression analysis was used to investigate the association between food label unawareness and loss of renal function among South Korean diabetic patients. Results: Four hundred and eighty-seven diabetic patients (men: 274; women: 213) were enrolled. Loss of renal function was associated with food label unawareness in only male diabetic patients (men: β = –10.01, standard error (SE) = 5.08, p = 0.0506; women: β = –0.30, SE = 5.14, p = 0.9528). A strong association was found between loss of renal function and food label unawareness among socially isolated male diabetic patients who lived in a one-generational household, did not have a spouse, and ate alone. Conclusion: Cultivating habits of reading food labels and inducing social facilitation may play a potential role in managing loss of renal function among male diabetic patients.

Glycemic control and use of glucose-lowering medications in hospital-admitted type 2 diabetes patients over 80 years

Treatment guidelines for type 2 diabetes (T2D) recommend avoidance of hypoglycemia and less stringent glycemic control in older patients. We examined the relation of glycemic control to glucose-lowering medications use in a cohort of patients aged>80 years with a diagnosis of T2D and a hospital admission in the Capital Region of Denmark in 2012-2016. We extracted data on medication use, diagnoses, and biochemistry from the hospitals' records. We identified 5,172 T2D patients with high degree of co-morbidity and where 17% had an HbA_1c in the range recommended for frail, comorbid, older patients with type 2 diabetes (58-75 mmol/mol (7.5-9%)). Half of the patients (n = 2,575) had an HbA_1c <48 mmol/mol (<6.5%), and a majority of these (36% of all patients) did not meet the diagnostic criteria for T2D. Of patients treated with one or more glucose-lowering medications (n = 1,758), 20% had HbA_1c-values <42 mmol/mol (<6%), and 1% had critically low Hba_1c values <30 mmol/mol (<4.9%), In conclusion, among these hospitalized T2D patients, few had an HbA_1c within the generally recommended glycemic targets. One third of patients did not meet the diagnostic criteria for T2D, and of the patients who were treated with glucose-lowering medications, one-fifth had HbA_1c-values suggesting overtreatment.

The correlation between the MRI-evaluated ectopic fat accumulation and the incidence of diabetes mellitus and hypertension depends on body mass index and waist circumference ratio

The widespread presence of overweight and obesity increases with every decade, and the number of people with body mass index (BMI) >30 kg/m² has doubled in the last 30 years. The aim of the study is to assess the correlation between MRI-evaluated ectopic fat accumulation in pancreas, skeletal muscles and liver and the incidence of type 2 diabetes and hypertension, depending on BMI and waist circumference ratio. This prospective study included 267 consecutive patients who were referred to abdominal MRI and underwent a standard clinical assessment with BMI and waist circumference ratio calculation. Ectopic fat accumulation in pancreas, skeletal muscles and liver was evaluated in magnetic resonance imaging using the fat-water separated Dixon imaging. There were statistically significant differences in mean steatosis of all assessed organs in the group of patients with type 2 diabetes or hypertension in comparison to the non-diabetic group as well as to the group without hypertension. It has been observed that pancreas and skeletal muscles are more susceptible to fat accumulation than liver. According to our results, there is a relation between the fat content in muscles, pancreas and liver, the incidence of type 2 diabetes and hypertension and also body mass index and waist circumference ratio. We believe that future studies should aim to determine whether the use of fat content measurement in certain organs could be used as a biomarker that can enable early detection of reversible metabolic changes, as well as their subsequent monitoring.

The impact of air pollution on the incidence of diabetes and survival among prevalent diabetes cases

PURPOSE

Growing evidence implicates ambient air pollutants in the development of major chronic diseases and premature mortality. However, epidemiologic evidence linking air pollution to diabetes remains inconclusive. This study sought to determine the relationships between selected air pollutants (nitrogen dioxide [NO₂], fine particulate matter [PM_2.5], ozone [O₃], and oxidant capacity [Ox; the redox-weighted average of O₃ and NO₂]) and the incidence of diabetes, as well as the risk of cardiovascular or diabetes mortality among individuals with prevalent diabetes.

RESEARCH DESIGN AND METHODS

We followed two cohorts, which included 4.8 million Ontario adults free of diabetes and 452,590 Ontario adults with prevalent diabetes, from 2001 to 2015. Area-level air pollution exposures were assigned to subjects' residential areas, and outcomes were ascertained using health administrative data with validated algorithms. We estimated hazard ratios for the association between each air pollutant and outcome using Cox proportional hazards models, and modelled the shape of the concentration-response relationships.

RESULTS

Over the study period, 790,461 individuals were diagnosed with diabetes. Among those with prevalent diabetes, 26,653 died from diabetes and 64,773 died from cardiovascular diseases. For incident diabetes, each IQR increase in NO₂ had a hazard ratio of 1.04 (95% CI: 1.03-1.05). This relationship was relatively robust to all sensitivity analyses considered, and exhibited a near-linear shape. There were also positive associations between incident diabetes and PM_2.5, O₃, and Ox, but these estimates were somewhat sensitive to different models considered. Among those with prevalent diabetes, almost all pollutants were associated with increased diabetes and cardiovascular mortality risk. The strongest association was observed between diabetes mortality and exposure to NO₂ (HR = 1.08, 95% CI: 1.02-1.13).

CONCLUSIONS

Selected air pollutants, especially NO₂, were linked to an increased risk of incident diabetes, as well as risk of cardiovascular or diabetes mortality among persons with prevalent diabetes. As NO₂ is frequently used as a proxy for road traffic exposures, this result may indicate that traffic-related air pollution has the strongest effect on diabetes etiology and survival after diabetes development.

Physical Activity and Sedentary Time: Association with Metabolic Health and Liver Fat

Introduction/Purpose

To investigate whether (a) lower levels of daily physical activity (PA) and greater sedentary time accounted for contrasting metabolic phenotypes (higher liver fat/presence of metabolic syndrome [METS+] vs lower liver fat/absence of metabolic syndrome [METS−]) in individuals of similar body mass index and (b) the association of sedentary time on metabolic health and liver fat.

Methods

Ninety-eight habitually active participants (53 female, 45 male; age, 39 ± 13 yr; body mass index 26.9 ± 5.1 kg·m⁻²), underwent assessments of PA (SenseWear armband; wear time ~98%), cardiorespiratory fitness (V˙O₂ peak), body composition (magnetic resonance imaging and magnetic resonance spectroscopy) and multiorgan insulin sensitivity (oral glucose tolerance test). We undertook a) cross-sectional analysis comparing four groups: nonobese or obese, with and without metabolic syndrome (METS+ vs METS−) and b) univariate and multivariate regression for sedentary time and other levels of PA in relation to liver fat.

Results

Light, moderate, and vigorous PA did not account for differences in metabolic health between individuals, whether nonobese or obese, although METS+ individuals were more sedentary, with a higher number, and prolonged bouts (~1–2 h). Overall, sedentary time, average daily METS and V˙O₂ peak were each independently associated with liver fat percentage. Each additional hour of daily sedentary time was associated with a 1.15% (95% confidence interval, 1.14%–1.50%) higher liver fat content.

Conclusions

Greater sedentary time, independent of other levels of PA, is associated with being metabolically unhealthy; even in habitually active people, lesser sedentary time, and higher cardiorespiratory fitness and average daily METS is associated with lower liver fat.

Functional Cereal Products in the Diet for Type 2 Diabetes Patients

Type 2 diabetes has become one of the major health problems of the modern world. It is assumed that environmental factors have a significant impact on the development of the disease, and great importance is ascribed to the diet, which can be modified accordingly. The diet can exert prophylactic and therapeutic effects; changes in the diet in advanced disease can improve the quality of life of diabetic patients and minimise the risk of complications, which are the direct cause of diabetes-related death. Functional food, which has a potentially health-enhancing effect in addition to its nutritional value, has been increasingly recognised and required. Cereal products are crucial in diabetic nutrition. Their function can additionally be enhanced by fortification with compounds with proven hypoglycaemic effects. Pasta has a low glycaemic index and is a good carrier of fortifying substances; hence, it can be highly recommended in diets for diabetic patients.

Understanding the mechanisms of reversal of type 2 diabetes

Clinical and pathophysiological studies have shown type 2 diabetes to be a condition mainly caused by excess, yet reversible, fat accumulation in the liver and pancreas. Within the liver, excess fat worsens hepatic responsiveness to insulin, leading to increased glucose production. Within the pancreas, the β cell seems to enter a survival mode and fails to function because of the fat-induced metabolic stress. Removal of excess fat from these organs via substantial weight loss can normalise hepatic insulin responsiveness and, in the early years post-diagnosis, is associated with β-cell recovery of acute insulin secretion in many individuals, possibly by redifferentiation. Collectively, these changes can normalise blood glucose levels. Importantly, the primary care-based Diabetes Remission Clinical Trial (DiRECT) showed that 46% of people with type 2 diabetes could achieve remission at 12 months, and 36% at 24 months, mediated by weight loss. This major change in our understanding of the underlying mechanisms of disease permits a reassessment of advice for people with type 2 diabetes.

Clinical characteristics and beta-cell function of Chinese children and adolescents with type 2 diabetes from 2009 to 2018

BACKGROUND

The limited available studies have unveiled different natural histories and prognosis associated with pediatric type 2 diabetes (T2D) and adult T2D. To date, data on the clinical features, metabolic profiles and beta-cell function characteristics are still limited in the Chinese pediatric T2D population.

METHODS

A total of 56 children with T2D, 31 with prediabetes and 159 with obesity were recruited. Clinical characteristics, metabolic profiles, beta-cell function and insulin resistance were analyzed.

RESULTS

The mean onset age of T2D was 12.35 ± 1.99 (7.9-17.8) years, and 7% of children were younger than 10 years; 55% of them were male, 57% had a family history of diabetes and 64% had classic symptoms, and 25% had a low or high birth weight. 89% of T2D patients were obese or overweight. A total of 58% of the patients with prediabetes were male. The fast serum C-peptide level was highest in the obesity group (P < 0.001), and there was no significant difference between the T2D and prediabetes groups. The mean homeostatic model of assessment of beta-cell function was the highest in the obesity group and was lowest in the T2D group (P < 0.001). The T2D group had the most serious lipid metabolism disorder, with the highest levels of total triglycerides, total cholesterol, and low density lipoprotein and the lowest high density lipoprotein level among the three groups.

CONCLUSIONS

A younger onset age and greater male susceptibility were found in Chinese pediatric T2D patients, and there was a stepwise deterioration trend in beta-cell function among patients with obesity, prediabetes and T2D. Based on our results, together with the SEARCH study results, an early screening and intervention program for T2D is recommended in high-risk or obese Chinese pediatric populations starting at 7 years.

Hypoglycemic effects of esculeoside A are mediated via activation of AMPK and upregulation of IRS-1

Background

Tomato fruit (Lycopersicon esculentum Mill.) has been suggested to be useful for the prevention of diabetes. Esculeoside A is the main saponin compounds in tomatoes. This study investigated the hypoglycemic effects and the underlying mechanism of esculeoside A in C57BLKS/Leprdb (db/db) mice.

Methods

Wild-type C57BLKS (db/dm) mice were used in the db/dm mouse group and db/db mice were randomly divided into 2 groups: untreated and treated db/db mouse groups. Esculeoside A (100 mg/kg) was administered by gavage for 56 days to the treated db/db mouse group. Distilled water was administered to the db/dm mouse group and the untreated db/db mouse group. The blood and liver biochemical parameters and the expression of liver insulin signaling-related proteins were examined.

Results

The results showed that esculeoside A reduced the fasting blood glucose (FBG) levels and improved the glucose tolerance. Further investigation revealed that hepatic protein expressions of total AMP-activated protein kinase (T-AMPK), phosphorylated AMP-activated protein kinase (p-AMPK), insulin receptor substrate-1 (IRS-1), and glucokinase (GCK) were significantly upregulated after esculeoside A treatment. In contrast, the hepatic protein expression of phosphoenolpyruvate carboxykinase (PEPCK) was significantly downregulated by esculeoside A treatment.

Conclusion

These findings suggested that esculeoside A has a potential of alleviating the metabolic abnormalities in db/db mice via regulation of AMPK/IRS-1 pathway. Our findings supported a possible application of esculeoside A as a functional supplement for diabetes treatment.

Long-Term Effects of a Novel Continuous Remote Care Intervention Including Nutritional Ketosis for the Management of Type 2 Diabetes: A 2-Year Non-randomized Clinical Trial

Purpose: Studies on long-term sustainability of low-carbohydrate approaches to treat diabetes are limited. We previously reported the effectiveness of a novel digitally-monitored continuous care intervention (CCI) including nutritional ketosis in improving weight, glycemic outcomes, lipid, and liver marker changes at 1 year. Here, we assess the effects of the CCI at 2 years. Materials and methods: An open label, non-randomized, controlled study with 262 and 87 participants with T2D were enrolled in the CCI and usual care (UC) groups, respectively. Primary outcomes were retention, glycemic control, and weight changes at 2 years. Secondary outcomes included changes in body composition, liver, cardiovascular, kidney, thyroid and inflammatory markers, diabetes medication use and disease status. Results: Reductions from baseline to 2 years in the CCI group resulting from intent-to-treat analyses included: HbA1c, fasting glucose, fasting insulin, weight, systolic blood pressure, diastolic blood pressure, triglycerides, and liver alanine transaminase, and HDL-C increased. Spine bone mineral density in the CCI group was unchanged. Use of any glycemic control medication (excluding metformin) among CCI participants declined (from 55.7 to 26.8%) including insulin (-62%) and sulfonylureas (-100%). The UC group had no changes in these parameters (except uric acid and anion gap) or diabetes medication use. There was also resolution of diabetes (reversal, 53.5%; remission, 17.6%) in the CCI group but not in UC. All the reported improvements had p < 0.00012. Conclusion: The CCI group sustained long-term beneficial effects on multiple clinical markers of diabetes and cardiometabolic health at 2 years while utilizing less medication. The intervention was also effective in the resolution of diabetes and visceral obesity with no adverse effect on bone health. Clinical Trial Registration: Clinicaltrials.gov NCT02519309.