Insulin resistance in type 1 diabetes: what is 'double diabetes' and what are the risks?

Lights and Shadows of Bariatric Surgery: Insights from a Nationwide Administrative Database of People Living with Type 1 Diabetes and Obesity

INTRODUCTION

The study aimed to describe the population of patients living with type 1 diabetes who had access to bariatric surgery (BS) in France, analyzing the changes in healthcare resource use and associated costs in the 3 years following this surgery.

METHODS

An observational longitudinal study based on the French national health insurance database was conducted on all adult patients that underwent a first BS from 2015 to 2020. Cost analyses were conducted on a sub-population who underwent BS from 2016 to 2017 for sufficient observation time using a pre-post methodology.

RESULTS

A total of 437 patients were identified as living with type 1 diabetes among the 234,077 patients who had undergone surgery over 6 years (2015-2020). The most frequently performed interventions were sleeve gastrectomy (n = 272; 62.2%) and gastric bypass (n = 154; 35.2%), with the majority of patients being women (77.8%) and an average age of 42.3 (± 12.0) years, consistent with the general population undergoing BS in France. While no significant differences were found in the overall healthcare costs when comparing the 3 years before and after BS, there was an increase in the frequency of biological measurements. Expenditures related to antidiabetic medications and insulin decreased significantly (p < 0.0001). The number of hospitalizations for severe hypoglycemia, coma, and ketoacidosis more than doubled in the 3 years following surgery compared with the period before (p = 0.04).

CONCLUSIONS

The risks of severe hypoglycemia or ketoacidosis in patients with type 1 diabetes undergoing BS remains a real concern and emphasizes the importance of involving the diabetologist in the operative decision with joint follow-up with the nutritionist.

The role of the farnesoid X receptor in diabetes and its complications

Diabetes is a metabolic disease in which tissues and organs are exposed to a hyperglycemic environment for a prolonged period. Long-term hyperglycemia can cause dysfunction of multiple organs and tissues in the body, leading to diabetic complications such as diabetic cardiomyopathy and diabetic nephropathy. Diabetes and its complications have become one of the key issues that seriously threaten the health of people worldwide. Farnesoid X receptor (FXR), as a metabolic regulator, has multiple functions in regulating insulin synthesis and secretion, insulin resistance, lipid metabolism, oxidative stress, inflammatory response, and fibrosis. It plays a key role in alleviating diabetes and its complications. In this review, we discuss the latest findings of FXR related to diabetes and its complications, focusing on its role in diabetes, diabetic nephropathy, diabetic cardiomyopathy, and diabetic liver injury. The aim is to better understand the role of FXR in diabetes and its complications and to provide new perspectives on the treatment of diabetes and its complications.

Hemoglobin glycation index among adults with type 1 diabetes: Association with double diabetes features

BACKGROUND

The hemoglobin glycation index (HGI) represents the discrepancy between the glucose management indicator (GMI) based on mean blood glucose levels and laboratory values of glycated hemoglobin (HbA1c). The HGI is a promising indicator for identifying individuals with excessive glycosylation, facilitating personalized evaluation and prediction of diabetic complications. However, the factors influencing the HGI in patients with type 1 diabetes (T1D) remain unclear. Autoimmune destruction of pancreatic β cells is central in T1D pathogenesis, yet insulin resistance can also be a feature of patients with T1D and their coexistence is called "double diabetes" (DD). However, knowledge regarding the relationship between DD features and the HGI in T1D is limited.

AIM

To assess the association between the HGI and DD features in adults with T1D.

METHODS

A total of 83 patients with T1D were recruited for this cross-sectional study. Laboratory HbA1c and GMI from continuous glucose monitoring data were collected to calculate the HGI. DD features included a family history of type 2 diabetes, overweight/obesity/central adiposity, hypertension, atherogenic dyslipidemia, an abnormal percentage of body fat (PBF) and/or visceral fat area (VFA) and decreased estimated insulin sensitivity. Skin autofluorescence of advanced glycation end products (SAF-AGEs), diabetic complications, and DD features were assessed, and their association with the HGI was analyzed.

RESULTS

A discrepancy was observed between HbA1c and GMI among patients with T1D and DD. A higher HGI was associated with an increased number of SAF-AGEs and a higher prevalence of diabetic microangiopathy (P = 0.030), particularly retinopathy (P = 0.031). Patients with three or more DD features exhibited an eight-fold increased risk of having a high HGI, compared with those without DD features (adjusted odds ratio = 8.12; 95% confidence interval: 1.52-43.47). Specifically, an elevated PBF and/or VFA and decreased estimated insulin sensitivity were associated with high HGI. Regression analysis identified estimated insulin sensitivity and VFA as factors independently associated with HGI.

CONCLUSION

In patients with T1D, DD features are associated with a higher HGI, which represents a trend toward excessive glycosylation and is associated with a higher prevalence of chronic diabetic complications.

Elevated triglyceride-glucose index is a risk factor for cardiovascular events in adults with type 1 diabetes: a cohort study

BACKGROUND

The triglyceride-glucose (TyG) index is recognized as an indicator of insulin resistance and is linked to cardiovascular disease (CVD) in patients with type 2 diabetes. However, its utility in patients with Type 1 diabetes (T1DM) has not been studied.

METHODS

In this nationwide cohort study, we enrolled 14,543 patients with T1DM between 2009 and 2015, with a median follow-up duration of 7.52 years. The primary outcome was the incidence of CVD, including myocardial infarction, ischemic stroke, and heart failure. The secondary outcome was the all-cause mortality. The risk of CVD across the TyG index quartiles was compared using the Cox proportional hazards model.

RESULTS

The cut-off points for the TyG quartiles were 8.46, 9.03, and 9.60. Patients in the highest TyG quartile exhibited a higher burden of cardiometabolic risk factors, including obesity, hypertension, dyslipidemia, and lower HDL cholesterol levels. Compared to the lowest quartile, the highest TyG quartile group showed a significantly increased risk of CVD (Composite CVD: adjusted hazard ratio [aHR] = 1.80; 95% confidence interval [CI] = 1.62-2.00, myocardial infarction: aHR = 1.70;95% CI = 1.38-2.10, ischemic stroke: aHR = 2.11; 95% CI = 1.78-2.50, heart failure: aHR = 1.65, 95% CI = 1.45-1.88) and all-cause mortality (aHR = 1.60, 95% CI = 1.41-1.81).

CONCLUSIONS

A higher TyG index was significantly associated with an increased risk of CVD and all-cause mortality in patients with T1DM.

RESEARCH INSIGHTS

What is currently known about this topic? 1. The TyG index is associated with insulin resistance and cardiovascular disease in both patients with type 2 diabetes and the general population. What is the key research question? 1. Could the TyG index also be utilized to assess insulin resistance and cardiovascular disease risk in patients with type 1 diabetes? What is new? 1. In patients with type 1 diabetes, those in the higher TyG quartile showed a higher prevalence of metabolic dysfunction such as obesity, hypertension and dyslipidemia. 2. A higher TyG index in patients with type 1 diabetes was associated with an increased risk of all-cause mortality and cardiovascular disease including myocardial infarction, heart failure and stroke. How might this study influence clinical practice? 1. The TyG index, a simple and non-invasive marker composed of triglycerides and fasting glucose, could be used to identify patients with type 1 diabetes who have high insulin resistance and cardiovascular disease risk.

Hyperinsulinemic male LEW.1WR1 rats show early signs of impaired liver metabolism

Weanling LEW.1WR1 (1WR1) rats are susceptible to type 1 diabetes (T1D) and hyperinsulinemic. Similar to human patients with T1D, these animals are susceptible to developing fatty liver infiltrates. Insulin resistance-related steatosis can lead to the development of severe forms of nonalcoholic fatty liver disease (NAFLD). Previous work in 1WR1 rats suggests that in the absence of T1D, they have increased body mass that is not reconciled by measuring their abdominal fat pads; this suggests 1WR1 rats have an underlying predisposition to store fat in the liver unrelated to diabetes status. We hypothesized that 1WR1 rats show early signs of NAFLD development. We assessed proteomics changes in the livers of glucose intolerant and hyperinsulinemic young adult 1WR1 rats to identify early detectable characteristics of NAFLD development. Our results show young adult 1WR1 rats have UBD/FAT10 gene over expression in the liver. Additionally, they have decreased mitochondrial protein levels, which may lead to lipid accumulation in the liver. A quantitative proteomic analysis showed protein expression related to branch chain fatty acid metabolism, fatty acid beta-oxidation, and oxidative phosphorylation in the liver is significantly different in 1WR1 rats compared to control LEW/SsNHsd (SsNHsd) rats. In summary, our study shows that 1WR1 rats developed early characteristics of mitochondrial dysfunction and insulin resistance in the liver independent of T1D, which are commonly observed with NAFLD development.

Unveiling the Therapeutic Potential of the Second-Generation Incretin Analogs Semaglutide and Tirzepatide in Type 1 Diabetes and Latent Autoimmune Diabetes in Adults

Type 1 diabetes mellitus (T1D) is a chronic autoimmune disease caused by the immune-mediated destruction of insulin-producing pancreatic beta cells, resulting in the lifelong need for exogenous insulin. Over the last few years, overweight and obesity have recently emerged as growing health issues also afflicting patients with T1D. In this context, the term "double diabetes" has been coined to indicate patients with T1D who have a family history of type 2 diabetes mellitus (T2D) and/or patients with T1D who are affected by insulin resistance and/or overweight/obesity and/or metabolic syndrome. At the same time, the use of second-generation incretin analogs semaglutide and tirzepatide has substantially increased on a global scale over the last few years, given the remarkable clinical benefits of these drugs (in terms of glucose control and weight loss) in patients with T2D and/or overweight/obesity. Although the glucagon-like peptide-1 (GLP-1) receptor agonists and the novel dual GIP (glucose-dependent insulinotropic polypeptide)/GLP-1 receptor agonist tirzepatide are currently not approved for the treatment of T1D, a growing body of evidence over the last few years has shown that these medications may serve as valid add-on treatments to insulin with substantial efficacy in improving glucose control, promoting weight loss, preserving residual beta-cell function and providing other beneficial metabolic effects in patients with T1D, double diabetes and latent autoimmune diabetes in adults (LADA). This manuscript aims to comprehensively review the currently available literature (mostly consisting of real-world studies) regarding the safety and therapeutic use (for different purposes) of semaglutide and tirzepatide in patients with T1D (at different stages of the disease), double diabetes and LADA.

Glucagon-like peptide-1 receptor agonists and type 1 diabetes: a potential game changer?

This mini review explores the increasing prevalence of obesity in type 1 diabetes (T1D) and the challenges patients face in achieving optimal glycemic control with current treatments. It discusses the evidence supporting the use of glucagon-like peptide-1 receptor agonists (GLP-1RA) as potential adjunctive therapy in T1D to reduce weight and improve insulin resistance. Potential benefits need to be weighed against the risk of hypoglycemia and lack of long-term data.

Evaluation of pharmacokinetic and pharmacodynamic similarity of an IDegAsp biosimilar versus the originator in healthy Chinese volunteers

OBJECTIVES

22011 is an insulin degludec/insulin aspart co-formulation (IDegAsp) that shares an identical amino acid sequence with Ryzodeg, the originator IDegAsp. This study aimed to compare the pharmacokinetics (PK), pharmacodynamics (PD), and safety of 22011 with Ryzodeg.

METHODS

In a single-center, randomized, open-label, two-treatment, two-period, two-sequence, crossover, euglycemic clamp study, healthy Chinese adults were randomized to receive 0.5 U/kg of 22011 and Ryzodeg under fasting conditions. PK was evaluated for up to 120 h and PD (represented by glucose infusion rate [GIR]) was assessed for up to 24 h.

RESULTS

Of 46 subjects randomized, all completed both treatment periods and were included in the PK/PD and safety analysis set. Insulin exposure (AUCIDeg, 0-24 h, AUCIAsp, 0-12 h, and Cmax, IAsp) and activity (GIRmax and AUCGIR, 0-24 h) were comparable (estimates of treatment ratios 0.916 ~ 1.076 for primary PK parameters and 0.946 ~ 1.037 for primary PD parameters), with 90% confidence intervals for the ratios of least square means falling within the range of 0.80 ~ 1.25. Adverse events were similar for both products and no significant safety concerns were noted in the laboratory results, vital signs, or electrocardiogram.

CONCLUSION

This study demonstrated the PK/PD similarity of 22011 to Ryzodeg with a comparable safety profile.Trial Registration: http://www.chinadrugtrials.org.cn/index.html with an identifier of CTR20230678, registered 15 March 2023.

Association of Insulin Resistance With Cardiovascular Disease and All-Cause Mortality in Type 1 Diabetes: Systematic Review and Meta-analysis

OBJECTIVE

The association of insulin resistance (IR) with cardiovascular disease (CVD) and all-cause mortality in type 1 diabetes (T1D) remains unclear.

PURPOSE

To investigate whether IR is associated with CVD and all-cause mortality among individuals with T1D.

DATA SOURCES

PubMed, Embase, and the Cochrane Library databases were searched from inception to 31 October 2023.

STUDY SELECTION

Observational studies reporting the associations between IR, as calculated by the estimated glucose disposal rate (eGDR), and the risk of CVD and all-cause mortality in individuals with T1D were eligible for inclusion.

DATA EXTRACTION

Data from eight selected studies were extracted, pooled by random-effects models, and results are presented as hazard ratios (95% CIs).

DATA SYNTHESIS

Eight studies involving 21,930 individuals were included, of which five studies involving 19,960 individuals with T1D reported the risk of CVD. During a median follow-up of 10 years, there were 2,149 cases of incident CVD. The pooled hazard ratio for composite CVD outcome per 1-unit increase in the eGDR index was 0.83 (95% CI 0.78-0.90, I2 = 58.9%). Five studies involving 19,403 individuals reported the risk of all-cause mortality. During a median follow-up of 10 years, 1,279 deaths were observed. The pooled hazard ratio for all-cause mortality per 1-unit increase in the eGDR index was 0.84 (95% CI 0.81-0.87, I2 = 0%).

LIMITATIONS

The small number of available studies restricted our ability to perform meta-regression analyses or more detailed subgroup analyses.

CONCLUSIONS

IR, as calculated by the eGDR, may be an additional risk factor for CVD and all-cause mortality in T1D.

Mechanisms of insulin resistance in type 1 diabetes mellitus: A case of glucolipotoxicity in skeletal muscle

Insulin resistance (IR), a hallmark of type 2 diabetes mellitus, develops in a significant number of patients with type 1 diabetes mellitus (T1DM) despite the use of insulin therapy to control glycemia. However, little is currently understood regarding the underlying mechanisms of IR in T1DM, especially within the context of chronic insulin treatment. Recent evidence suggests an important influence of glucolipotoxicity in skeletal muscle on insulin sensitivity in T1DM. Thus, this review summarizes our current knowledge regarding impairments in skeletal muscle lipid, glucose, and oxidative metabolism in the development of IR in insulin-treated T1DM.

Prevalence of obesity in people with and without type 1 diabetes across Belgium, Kuwait, and Mexico: an IMI2 SOPHIA study

Background

Individuals with type 1 diabetes (T1D) are traditionally perceived as lean, but recent evidence suggests an increasing trend of obesity. To provide global estimates, this study explored the prevalence of obesity among adults with and without T1D across three distinct global regions.

Methods

An observational, cross-sectional study was performed utilizing data from T1D registries and national health surveys to assess the prevalence of obesity (BMI ≥ 30 kg/m2) and the prevalence of overweight and obesity (BMI ≥ 25 kg/m2) across Belgium, Kuwait, and Mexico. Demographic and clinical characteristics of adults with and without T1D were assessed. Prevalence estimates were calculated through a binomial generalized linear mixed-effects model adjusting for age, sex, HbA1c, and survey year. As a sensitivity analysis, propensity score matching was performed for confounder adjustment of age and sex.

Findings

The study encompassed 3594 individuals with T1D (from 2003 to 2022) and 9898 without T1D (from 2014 to 2021). After model adjustment for confounders (age, sex, HbA1c% and data-collection year), individual obesity prevalence was lower in individuals with T1D in Kuwait and Mexico than among those without type 1 diabetes (Kuwait: 22% (CI: 18-26%) vs. 44% (CI: 41-48%); Mexico: 5% (CI: 3-7%) vs. 40% (CI: 38-42%)). In contrast, individuals with T1D in Belgium showed a more comparable proportions to those without T1D (12% (CI: 9-16%) vs. 16% (CI:11-22%)).

Interpretation

Our data reveal that obesity is prevalent among people with T1D. These findings underscore the need for targeted strategies in T1D care that address the growing concern of obesity.

Funding

This manuscript is part of the Stratification of Obesity Phenotypes to Optimize Future Obesity Therapy (SOPHIA) project (www.imisophia.eu). SOPHIA has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No. 875534. This Joint Undertaking support from the European Union's Horizon 2020 research and innovation program and EFPIA and type 1 diabetes Exchange, Breakthrough T1D, and Obesity Action Coalition.

Physical activity and sedentary behaviour in relation to body composition, estimated insulin sensitivity and arterial stiffness in adults with type 1 diabetes

AIMS

To examine the association of daily PA levels and sedentary behaviour with body composition, estimated insulin sensitivity, and arterial stiffness in adults with type 1 diabetes (T1D).

METHODS

Cross-sectional study in adults with T1D (n = 54). PA levels (daily steps, and time in moderate-to-vigorous intensity PA (MVPA)) and sedentary behaviour were measured using accelerometry for 7 days (McRoberts® DynaPort MoveMonitor). Cardiopulmonary exercise test for VO2max. Anthropometrics were collected, and body composition (total and % of fat mass (FMtot, FM%), total and % of lean mass (LMtot, LM%), and estimated visceral adipose tissue (VAT)) volume was assessed with dual energy X-ray-absorptiometry (DXA). Estimates of insulin sensitivity were determined (estimated glucose disposal rate (eGDR) and total daily insulin dose). Arterial stiffness was assessed with carotid-femoral pulse wave velocity (cf-PWV (m/s); SphygmoCor®).

RESULTS

Lower 10-years HbA1c associated moderately with all PA measures. Favourable moderate associations were also found between PA measures and BMI, waist, VAT but not FM and LM. PA measures were favourably associated with a lower total daily insulin dose and higher eGDR. All PA parameters associated moderately with cf-PWV however not independent from traditional risk factors. VO2max was inversely associated with cf-PWV independent of age, T1D duration and 24-hour mean blood pressure.

CONCLUSIONS

Higher levels of PA, lower sedentary behaviour and greater exercise capacity are favourably associated with long-term glycaemic control, body composition, insulin dosage, estimated insulin sensitivity and arterial stiffness in adults with T1D. Therefore, regular PA and limiting sedentary time should be encouraged to improve metabolic and cardiovascular health in this population. Future longitudinal studies should explore mutual interactions and synergistic effects of PA on these outcomes.

Insulin Resistance and CGM-Derived Parameters in People With Type 1 Diabetes: Are They Associated?

BACKGROUND

Insulin resistance (IR) is increasingly more prevalent in people with type 1 diabetes (T1D).

OBJECTIVE

We investigated whether IR is associated with continuous glucose monitor (CGM)-derived parameters (glucometrics), such as time in range (TIR), time above range (TAR), time below range (TBR), and glycemic variability (CV).

METHODS

This is a retrospective analysis of 2 databases: IR was quantified according to the estimated glucose disposal rate (eGDR) (NCT04664036) and by performing a hyperinsulinemic-euglycemic clamp (HEC) (NCT04623320). All glucometrics were calculated over 28 days.

RESULTS

A total of 287 subjects were included. Mean age was 46 ± 17 years, 55% were male, TIR was 57% ± 14%, and eGDR was 7.6 (5.6-9.3) mg/kg/min. The tertile of people with the lowest eGDR (highest level of IR) had a higher TAR compared to the tertile with the highest eGDR (39% ± 15% vs 33% ± 14%, P = .043). Using logistic regression, a higher eGDR was associated with a higher chance to fall in a higher TIR-tertile (odds ratio [OR] 1.251, P < .001), a lower TAR-tertile (OR 1.281, P < .001), and a higher TBR-tertile (OR 0.893, P = .039), adjusted for age, sex, diabetes duration, smoking status, and alcohol intake. In the 48 people undergoing a HEC, no significant association between glucometrics and the HEC-determined glucose disposal rate (M-value) was observed.

CONCLUSION

In people with T1D, an association between IR, measured by eGDR, and worse CGM profiles was observed.

The potential of glucose management indicator for the estimation of glucose disposal rate in people with type 1 diabetes

BACKGROUND AND AIMS

Insulin resistance is a growing feature in type 1 diabetes (T1D). It can be quantified by calculating the estimated glucose disposal rate (eGDR) with the Epstein's formula, which includes laboratory-measured glycated hemoglobin (HbA1c). We aimed the current research to assess the agreement between the conventional eGDR formula and an alternative one (eGDR-GMI) incorporating the glucose management indicator (GMI) derived from continuous glucose monitoring (CGM). We also explored the relationship between eGDR-GMI, cardiovascular risk factors, and the prevalence of diabetes-related complications.

METHODS AND RESULTS

We designed a cross-sectional study that included adults with T1D. eGDR-GMI and eGDR (mg/kg/min) were calculated using GMI or HbA1c, waist circumference, and hypertensive state. Clinical data were collected from electronic medical records. The analyses encompassed 158 participants with a mean age of 39 ± 13 years. The Bland-Altman analysis showed a good agreement between eGDR-GMI and eGDR. When we divided participants in eGDR-GMI tertiles we found a higher prevalence of diabetes-related complications and a less favorable metabolic profile in the lowest eGDR-GMI tertile. The relative risk of retinopathy, nephropathy, and neuropathy significantly increased by approximately 1 unit with each decrease in eGDR-GMI, regardless of age, sex, disease duration, lipids, and smoking habit.

CONCLUSIONS

eGDR-GMI represents a valid and robust alternative to the eGDR to assess insulin resistance in T1D. Low eGDR-GMI is associated with diabetes complications and a less favorable metabolic profile. Incorporating the eGDR-GMI into clinical practice can enhance the characterization of T1D people and allow for a more personalized treatment approach.

The gut microbiota intervenes in glucose tolerance and inflammation by regulating the biosynthesis of taurodeoxycholic acid and carnosine

Objective

This study aims to investigate the pathogenesis of hyperglycemia and its associated vasculopathy using multiomics analyses in diabetes and impaired glucose tolerance, and validate the mechanism using the cell experiments.

Methods

In this study, we conducted a comprehensive analysis of the metagenomic sequencing data of diabetes to explore the key genera related to its occurrence. Subsequently, participants diagnosed with impaired glucose tolerance (IGT), and healthy subjects, were recruited for fecal and blood sample collection. The dysbiosis of the gut microbiota (GM) and its associated metabolites were analyzed using 16S rDNA sequencing and liquid chromatograph mass spectrometry, respectively. The regulation of gene and protein expression was evaluated through mRNA sequencing and data-independent acquisition technology, respectively. The specific mechanism by which GM dysbiosis affects hyperglycemia and its related vasculopathy was investigated using real-time qPCR, Western blotting, and enzyme-linked immunosorbent assay techniques in HepG2 cells and neutrophils.

Results

Based on the published data, the key alterable genera in the GM associated with diabetes were identified as Blautia, Lactobacillus, Bacteroides, Prevotella, Faecalibacterium, Bifidobacterium, Ruminococcus, Clostridium, and Lachnoclostridium. The related metabolic pathways were identified as cholate degradation and L-histidine biosynthesis. Noteworthy, Blautia and Faecalibacterium displayed similar alterations in patients with IGT compared to those observed in patients with diabetes, and the GM metabolites, tauroursodeoxycholic acid (TUDCA) and carnosine (CARN, a downstream metabolite of histidine and alanine) were both found to be decreased, which in turn regulated the expression of proteins in plasma and mRNAs in neutrophils. Subsequent experiments focused on insulin-like growth factor-binding protein 3 and interleukin-6 due to their impact on blood glucose regulation and associated vascular inflammation. Both proteins were found to be suppressed by TUDCA and CARN in HepG2 cells and neutrophils.

Conclusion

Dysbiosis of the GM occurred throughout the entire progression from IGT to diabetes, characterized by an increase in Blautia and a decrease in Faecalibacterium, leading to reduced levels of TUDCA and CARN, which alleviated their inhibition on the expression of insulin-like growth factor-binding protein 3 and interleukin-6, contributing to the development of hyperglycemia and associated vasculopathy.

Unmet needs in the treatment of type 1 diabetes: why is it so difficult to achieve an improvement in metabolic control?

The development of advanced diabetes technology has permitted persons with type 1 diabetes mellitus to improve metabolic control significantly, particularly with the development of advanced hybrid closed-loop systems which have improved the quality of life by reducing hypoglycemia, decreasing macroangiopathy and microangiopathy-related complications, ameliorating HbA1c and improving glycemic variability. Despite the progression made over the past few decades, there is still significant margin for improvement to be made in terms of attaining appropriate metabolic control. Various factors are responsible for poor glycemic control including inappropriate carbohydrate counting, repeated bouts of hypoglycemia, hypoglycemia unawareness, cutaneous manifestations due to localized insulin use and prolonged use of diabetes technology, psychosocial comorbidities such as eating disorders or 'diabulimia', the coexistence of insulin resistance among people with type 1 diabetes and the inability to mirror physiological endogenous pancreatic insulin secretion appropriately. Hence, the aim of this review is to highlight and overcome the barriers in attaining appropriate metabolic control among people with type 1 diabetes by driving research into adjunctive treatment for coexistent insulin resistance and developing new advanced diabetic technologies to preserve β cell function and mirror as much as possible endogenous pancreatic functions.

True or false? Alzheimer's disease is type 3 diabetes: Evidences from bench to bedside

Globally, Alzheimer's disease (AD) is the most widespread chronic neurodegenerative disorder, leading to cognitive impairment, such as aphasia and agnosia, as well as mental symptoms, like behavioral abnormalities, that place a heavy psychological and financial burden on the families of the afflicted. Unfortunately, no particular medications exist to treat AD, as the current treatments only impede its progression.The link between AD and type 2 diabetes (T2D) has been increasingly revealed by research; the danger of developing both AD and T2D rises exponentially with age, with T2D being especially prone to AD. This has propelled researchers to investigate the mechanism(s) underlying this connection. A critical review of the relationship between insulin resistance, Aβ, oxidative stress, mitochondrial hypothesis, abnormal phosphorylation of Tau protein, inflammatory response, high blood glucose levels, neurotransmitters and signaling pathways, vascular issues in AD and diabetes, and the similarities between the two diseases, is presented in this review. Grasping the essential mechanisms behind this detrimental interaction may offer chances to devise successful therapeutic strategies.

Metformin beyond type 2 diabetes: Emerging and potential new indications

Metformin is best known as a foundational therapy for type 2 diabetes but is also used in other contexts in clinical medicine with a number of emerging and potential indications. Many of its beneficial effects may be mediated by modest effects on weight loss and insulin sensitivity, but it has multiple other known mechanisms of action. Current clinical uses beyond type 2 diabetes include: polycystic ovarian syndrome; diabetes in pregnancy/gestational diabetes; prevention of type 2 diabetes in prediabetes; and adjunct therapy in type 1 diabetes. As metformin has been in clinical use for almost 70 years, much of the underpinning evidence for its use in these conditions is, by definition, based on trials conducted before the advent of contemporary evidence-based medicine. As a result, some of the above-established uses are 'off-label' in many regulatory territories and their use varies accordingly in different countries. Going forward, several current 'repurposing' investigational uses of metformin are also being investigated: prevention of cancer (including in Li Fraumeni syndrome), renal protection, Alzheimer's disease, metabolic dysfunction-associated steatotic liver disease and promotion of healthy ageing. Despite the longevity of metformin and its important current roles beyond type 2 diabetes in clinical medicine, it has further potential and much research is ongoing.

Alternative therapeutic strategies in diabetes management

Diabetes is a heterogeneous metabolic disease characterized by elevated blood glucose levels resulting from the destruction or malfunction of pancreatic β cells, insulin resistance in peripheral tissues, or both, and results in a non-sufficient production of insulin. To adjust blood glucose levels, diabetic patients need exogenous insulin administration together with medical nutrition therapy and physical activity. With the aim of improving insulin availability in diabetic patients as well as ameliorating diabetes comorbidities, different strategies have been investigated. The first approaches included enhancing endogenous β cell activity or transplanting new islets. The protocol for this kind of intervention has recently been optimized, leading to standardized procedures. It is indicated for diabetic patients with severe hypoglycemia, complicated by impaired hypoglycemia awareness or exacerbated glycemic lability. Transplantation has been associated with improvement in all comorbidities associated with diabetes, quality of life, and survival. However, different trials are ongoing to further improve the beneficial effects of transplantation. Furthermore, to overcome some limitations associated with the availability of islets/pancreas, alternative therapeutic strategies are under evaluation, such as the use of mesenchymal stem cells (MSCs) or induced pluripotent stem cells for transplantation. The cotransplantation of MSCs with islets has been successful, thus providing protection against proinflammatory cytokines and hypoxia through different mechanisms, including exosome release. The use of induced pluripotent stem cells is recent and requires further investigation. The advantages of MSC implantation have also included the improvement of diabetes-related comorbidities, such as wound healing. Despite the number of advantages of the direct injection of MSCs, new strategies involving biomaterials and scaffolds have been developed to improve the efficacy of mesenchymal cell delivery with promising results. In conclusion, this paper offered an overview of new alternative strategies for diabetes management while highlighting some limitations that will need to be overcome by future approaches.

Life's essential 8 metrics and mortality outcomes in insulin resistance: The role of inflammation, vascular aging, and gender

BACKGROUND

Insulin resistance (IR) elevates cardiovascular disease (CVD) and mortality risks. Insulin resistance (IR) increases the risk of CVDs and mortality. Recently, the American Heart Association introduced the Life's Essential 8 (LE8) framework to assess cardiovascular health (CVH). However, its impact on mortality in IR populations is unknown.

METHODS

Analyzing 2005-2018 National Health and Nutrition Examination Survey data, we studied 5301 IR adults (≥20 years). LE8 scores were calculated and participants were categorized into low, moderate, and high CVH groups. Systemic immune-inflammation index (SII) and heart age/vascular age (HVA) were measured as potential mediators. Cox models estimated all-cause and CVD mortality hazard ratios (HRs), stratified by LE8 score and sex, and adjusted for covariates. Mediation analyses assessed SII and HVA's indirect effects. This study is an observational cohort study.

RESULTS

Over a 7.5-year median follow-up, 625 deaths occurred, including 159 CVD-related. Compared to low CVH, moderate and high CVH groups showed reduced all-cause (HR = 0.72, 95% CI 0.58-0.89; HR = 0.38, 95% CI 0.22-0.67) and CVD mortality (HR = 0.42, 95% CI 0.26-0.69; HR = 0.15, 95% CI 0.04-0.57). A 10-point LE8 increase correlated with 15% and 31% reductions in all-cause and CVD mortality, respectively. SII and HVA mediated up to 38% and 12% of these effects. The LE8's protective effect was more pronounced in men.

CONCLUSION

LE8 effectively evaluates CVH and lowers mortality risk in IR adults, partially mediated by SII and HVA. The findings inform clinical practice and public health strategies for CVD prevention in IR populations.

Comparison of Two Estimated Glucose Disposal Rate Methods for Detecting Insulin Resistance in Adults with Type 1 Diabetes Mellitus

Background: The presence of insulin resistance (IR) in patients with type 1 diabetes mellitus (T1DM) is a significant indicator of all chronic diabetic complications, independent of other risk factors. The estimated glucose disposal rate (eGDR) is a practical method that can be easily used in daily practice to determine IR. This study aimed to determine the cutoff values for two eGDR methods and compare their diagnostic value for determining IR in adult T1DM patients with metabolic syndrome (MetS). Methods: This cross-sectional study was performed on 184 adults admitted to the endocrinology outpatient clinic diagnosed with T1DM. Demographic characteristics, anthropometric measurements, and the presence of hypertension (HT) were recorded. The eGDR of all patients was calculated using two formulas based on HbA1c level, presence of HT, waist-to-hip ratio (WHR), or waist circumference (WC). Diagnostic cutoff values for both eGDRs were defined using receiver operating characteristic (ROC) analysis. Patients were divided into two groups according to the cutoff values. The accuracy of the diagnostic cutoffs for eGDRwhr and eGDRwc was compared using a Bland-Altman plot. Results: The cutoff value for eGDRwhr was 7.37 mg/(kg·min) with 83.3% specificity and 86.7% sensitivity [area under the curve (AUC) = 0.901; P < 0.001; 95% confidence interval (CI), 0.824-0.977] and for eGDRwc 7.50 mg/(kg·min) with 79.8% specificity and 83.3% sensitivity (AUC = 0.895; P < 0.001; 95% CI, 0.817-0.972) for the presence of MetS. Further ROC analysis showed that the difference between the two AUCs (0.901 and 0.895) was not significant (P = 0.923). Conclusion: Assessment of eGDR would lead to early prevention of diabetic complications. eGDR is measured using either WHR or WC. This study is the first to compare WHR and WC in calculating eGDR in adults. WHR and WC are not superior to each other for calculating eGDR in determining IR in T1DM.

Network pharmacology, molecular docking, and in vitro experimental verification of the mechanism of Guanxining in treating diabetic atherosclerosis

ETHNOPHARMACOLOGICAL RELEVANCE

Guanxinning(GXN) tablet is a patented traditional Chinese medicine widely used to prevent and treat cardiovascular diseases. However, its potential mechanism and target in anti-diabetic atherosclerosis have not been clarified.

AIM

The aim of this study was to investigate the underlying targets and mechanisms of action GXN in the treatment of diabetic atherosclerosis, employing a combination of network pharmacology, molecular docking, and in vitro experimental verification.

METHODS

We predicted the core components and targets of GXN in the treatment of diabetic atherosclerosis through various databases, and made analysis and molecular docking. In vitro, we induced injury in human umbilical vein endothelial cells using glucose/palmitate and observed the effects of GXN on cellular damage high-glucose and high-fat conditions, subsequently elucidating its molecular mechanisms.

RESULTS

A total of 14 active components and 157 targets of GXN were identified. Using the PPI network, we selected 9 core active components and 20 targets of GXN. GO functional analysis revealed that these targets were primarily associated with apoptosis signaling pathways in response to endoplasmic reticulum stress and reactive oxygen species responses. Molecular docking confirmed the strong binding affinities of the primary active components of GXN with ERN1, MAPK1 and BECN1. In vitro experiments demonstrated the ability of GXN to restore endothelial cell activity, enhance cell migration and inhibit sICAM secretion, and upregulate the expression of endoplasmic reticulum stress-related proteins (IRE1, XBP1) and autophagy-related proteins (Beclin1, LC3A, and LC3B), while simultaneously inhibiting endothelial cell apoptosis under high-glucose and high-fat conditions.

CONCLUSIONS

Our findings suggest that GXN can potentially safeguard endothelial cells from the adverse effects of high-glucose and high-fat by modulating the interactions between endoplasmic reticulum stress and autophagy. Therefore, GXN is a promising candidate for the prevention and treatment of diabetic atherosclerosis.

The Effects of Resistance Exercise Training on Skeletal Muscle Metabolism and Insulin Resistance Development in Female Rodents with Type 1 Diabetes

The etiology of insulin resistance (IR) development in type 1 diabetes mellitus (T1DM) remains unclear; however, impaired skeletal muscle metabolism may play a role. While IR development has been established in male T1DM rodents, female rodents have yet to be examined in this context. Resistance exercise training (RT) has been shown to improve IR and is associated with a lower risk of hypoglycemia onset in T1DM compared to aerobic exercise. The purpose of this study was to investigate the effects of RT on IR development in female T1DM rodents. Forty Sprague Dawley eight-week-old female rats were divided into four groups: control sedentary (CS; n = 10), control trained (CT; n = 10), T1DM sedentary (DS; n = 10), and T1DM trained (DT; n = 10). Multiple low-dose streptozotocin injections were used to induce T1DM. Blood glucose levels were maintained in the 4-9 mmol/l range with intensive insulin therapy. CT and DT underwent weighted ladder climbing 5 days/week for six weeks. Intravenous glucose tolerance tests (IVGTT) were conducted on all animals following the six-week period. Results demonstrate that DS animals exhibited significantly increased weekly blood glucose measures compared to all groups including DT (p < 0.0001), despite similar insulin dosage levels. This was concomitant with a significant increase in insulin-adjusted area under the curve following IVGTT in DS (p < 0.05), indicative of a reduction in insulin sensitivity. Both DT and DS exhibited greater serum insulin concentrations compared to CT and CS (p < 0.05). DS animals also exhibited significantly greater glycogen content in white gastrocnemius muscle compared to CS and DT (p < 0.05), whereas DT and DS animals exhibited greater p-Akt: Akt ratio in the white vastus lateralis muscle and citrate synthase activity in the red vastus lateralis muscle compared to CS and CT (p < 0.05). These results indicate that female rodents with T1DM develop poor glycemic control and IR which can be attenuated with RT, possibly related to differences in intramyocellular glycogen content.

Lower left atrial function in young individuals with type 1 diabetes mellitus compared to healthy controls: an echocardiographic study

In adulthood, individuals with type 1 diabetes mellitus may develop a condition of heart failure with preserved ejection fraction. However, subclinical changes to the heart in diabetes are likely to occur prior to the clinical presentation. This cross-sectional study aimed to compare left atrial function by echocardiography between 43 individuals with type 1 diabetes and 43 healthy controls, aged 10-30 years. All participants underwent echocardiography and 2D speckle tracking measurements for left atrial phase function parameters. Physical capacity was assessed by exercise test on a bicycle. Results showed that participants with type 1 diabetes had significantly lower left atrial function parameters than healthy controls (p < 0.05). There was a significant negative correlation between HbA1c means and reservoir and conduit strain (p < 0.05) and individuals with BMI < 30 showed a lower left atrial stiffness (p < 0.05). Individuals with type 1 diabetes and a higher physical capacity did not differ from their healthy peers. Results indicate that lower HbA1c levels, BMI < 30 and a higher physical capacity are favourable in terms of left atrial function in children and young adults with type 1 diabetes mellitus. Left atrial strain by echocardiography might become a new important tool in assessing heart function in T1DM.

Double diabetes-when type 1 diabetes meets type 2 diabetes: definition, pathogenesis and recognition

Currently, the differentiation between type 1 diabetes (T1D) and type 2 diabetes (T2D) is not straightforward, and the features of both types of diabetes coexist in one subject. This situation triggered the need to discriminate so-called double diabetes (DD), hybrid diabetes or type 1.5 diabetes, which is generally described as the presence of the insulin resistance characteristic of metabolic syndrome in individuals diagnosed with T1D. DD not only raises the question of proper classification of diabetes but is also associated with a significantly greater risk of developing micro- and macroangiopathic complications, which was independent of glycaemic control. When considering the global obesity pandemic and increasing incidence of T1D, the prevalence of DD may also presumably increase. Therefore, it is of the highest priority to discover the mechanisms underlying the development of DD and to identify appropriate methods to prevent or treat DD. In this article, we describe how the definition of double diabetes has changed over the years and how it is currently defined. We discuss the accuracy of including metabolic syndrome in the DD definition. We also present possible hypotheses connecting insulin resistance with T1D and propose possible methods to identify individuals with double diabetes based on indirect insulin resistance markers, which are easily assessed in everyday clinical practice. Moreover, we discuss adjuvant therapy which may be considered in double diabetic patients.

Insulin resistance-related features are associated with cognitive decline: a cross-sectional study in adult patients with type 1 diabetes

BACKGROUND

To investigate the associations between insulin resistance (IR)-related features and cognitive function in type 1 diabetes (T1D).

METHODS

A total of 117 adult patients with T1D were recruited in this cross-sectional study. IR-related features include overweight/obesity/central obesity, hypertension, atherogenic dyslipidemia, and decreased estimated insulin sensitivity (eIS). The Wechsler Memory Scale-Chinese Revision, Wisconsin Card Sorting Test, and Sustained Attention to Response Task was used to assess memory, executive function and sustained attention, respectively. A z-score was generated from each test, and a composite measure of global cognitive performance was calculated by averaging the z-scores of all tests. Cognitive differences were measured between T1D patients with and without IR-related features. The associations between IR-related features and and cognitive performance were analyzed using: logistic regression, partial correlation, and multivariate linear regression analysis.

RESULTS

A total of 53 (45.3%) T1D patients were defined as having IR-related features. Individuals with IR-related features displayed worse overall cognitive scores compared to those without and had a 4-fold increase in the risk for having global cognitive z-score < 0. Among the IR-related features, higher triglyceride (TG) and lower eIS showed linear correlation with lower global cognitive performance. And the subsequent regression analysis identified eIS as the factor independently associated with global cognitive performance.

CONCLUSIONS

We have provided evidence linking IR-related features to deteriorated cognitive function in adult patients with T1D. And eIS showed an independent positive correlation with global cognitive performance. Although no causal relationship can be drawn, IR emerges as an important factor reflecting cognitive function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03610984.

Evaluation of Effects of Continuous Glucose Monitoring on Physical Activity Habits and Blood Lipid Levels in Persons With Type 1 Diabetes Managed With Multiple Daily Insulin Injections: An Analysis Based on the GOLD Randomized Trial (GOLD 8)

BACKGROUND

People with type 1 diabetes generally view it easier to exercise when having continuous information of the glucose levels. We evaluated whether patients with type 1 diabetes managed with multiple daily insulin injections (MDI) exercised more after initiating continuous glucose monitoring (CGM) and whether the improved glycemic control and well-being associated with CGM translates into improved blood lipids and markers of inflammation.

METHOD

The GOLD trial was a randomized cross-over trial over 16 months where patients used either CGM or capillary self-monitoring of blood glucose (SMBG) over six months, with a four-month wash-out period between the two treatment periods. We compared grade of physical activity, blood lipids, apolipoproteins, and high-sensitivity C-reactive protein (hsCRP) levels during CGM and SMBG.

RESULTS

There were 116 patients with information of physical activity estimated by the International Physical Activity Questionnaire (IPAQ) during both CGM and SMBG. No changes were found during CGM or SMBG, IPAQ scores 3305 versus 3878 (P = .16). In 136 participants with information of blood lipid levels with no change in lipid-lowering medication during the two treatment periods, HbA1c differed by 4.2 mmol/mol (NGSP 0.39%) between SMBG and CGM treatment (P < .001). No significant changes existed in low-density lipoprotein, high-density lipoprotein, triglycerides, total cholesterol, apolipoprotein A1, apolipoprotein B1, or hsCRP, during CGM and SMBG.

CONCLUSION

Although many patients experience it easier to perform physical activity when monitoring glucose levels with CGM, it does not influence the amount of physical activity in persons with type 1 diabetes. Blood lipids, apolipoprotein, and hsCRP levels were similar during CGM and SMBG.

Liraglutide Improves Diabetic Cardiomyopathy by Downregulation of Cardiac Inflammatory and Apoptosis Markers

BACKGROUND

Diabetic cardiomyopathy is one of the leading causes of mortality for people with diabetes worldwide. The majority of the formalistic alterations in the heart associated with diabetic cardiomyopathy have been found to be primarily caused by the ongoing oxidative stress brought on by hyperglycemia, which leads to the dysfunctional reactions of apoptosis and inflammation. Liraglutide, a long-acting counterpart of glucagon-like peptide-1, has been demonstrated to have a number of therapeutic applications in medicine and other biological processes.

METHODS

The PubMed database was searched using the terms liraglutide, DCM, and all associated inflammatory markers.

RESULTS

There has been a lot of research on liraglutide's potential to protect the heart from cardiomyopathy brought on by diabetes. Liraglutide's therapeutic actions as an antioxidant, antihyperglycemic, anti-apoptotic, and anti-inflammatory medicine may help to lessen diabetic cardiomyopathy.

CONCLUSION

The most recent studies on the effects of liraglutide therapy on DCM are presented in this review, along with an explanation of the underlying mechanisms.

Impact of lockdown on children with type-1 diabetes: returning to the community was associated with a decrease in HbA1c

Background

In March 2020, a 2-month lockdown of the entire population has been declared in France to limit the spread of COVID-19. Sudden changes in daily life can impact the glycemic control of patients with type 1 diabetes (T1D), especially children and adolescents. We aimed to assess the impact of the lockdown on glycemic control in children and adolescents with T1D.

Methods

Children with T1D were prospectively recruited in two pediatric centers from May 11 to August 1, 2020. At inclusion, patients and/or parents were asked to fill in a form assessing the patient's lifestyle during the lockdown and a medical case report form was filled in by clinician. The mean of the three last glycated hemoglobin (HbA1c) values obtained before lockdown (HbA1c_mean; before March 17, 2020) was compared to the first HbA1c value measured after the lockdown (HbA1c_after; from May 11 to August 1, 2020). Univariable and multivariable analyses were performed, as appropriate, to identify factors associated with glycemic changes during lockdown.

Results

One-hundred-and-eighteen children and adolescents (median age was 14.1 years, 50% males) with T1D (median time from diagnosis was 4.1 years) were enrolled in the study. No significant difference was observed between medians of HbA1c_mean and HbA1c_after values (8.37% [7.88; 9.32%] vs. 8.50% [7.70; 9.50%], respectively; p = 0.391). Returning to the community was a protective factor [OR 0.31 (0.09-0.94); p = 0.045]. Patients having increased HbA1c were more frequently in contact with a suspected case of COVID-19 [OR 9.07 (2.15-53.66); p = 0.006], whereas patients having decreased HbA1c had the feeling of increase number of hypoglycemia [OR 0.19 (0.05-0.57); p = 0.006].

Conclusion

In our patients, HbA1c before and after the lockdown was stable. In subgroup analysis, returning to the community was a protective factor. In addition, feeling of hypoglycemia was more frequent in the patients with decreased HbA1c.

The role of captopril in leukotriene deficient type 1 diabetic mice

T1D can be associated with metabolic disorders and several impaired pathways, including insulin signaling, and development of insulin resistance through the renin-angiotensin system (RAS). The main precursor of RAS is angiotensinogen (Agt) and this system is often linked to autophagy dysregulation. Dysregulated autophagy has been described in T1D and linked to impairments in both glucose metabolism, and leukotrienes (LTs) production. Here, we have investigated the role of RAS and LTs in both muscle and liver from T1D mice, and its effects on insulin and autophagy pathways. We have chemically induced T1D in 129sve and 129sve 5LO-/- mice (lacking LTs) with streptozotocin (STZ). To further inhibit ACE activity, mice were treated with captopril (Cap). In muscle of T1D mice, treatment with Cap increased the expression of RAS (angiotensinogen and angiotensin II receptor), insulin signaling, and autophagy markers, regardless of the genotype. In the liver of T1D mice, the treatment with Cap increased the expression of RAS and insulin signaling markers, mostly when LTs were absent. 5LO-/- T1D mice showed increased insulin sensitivity, and decreased NEFA, after the Cap treatment. Cap treatment impacted both insulin signaling and autophagy pathways at the mRNA levels in muscle and liver, indicating the potential role of ACE inhibition on insulin sensitivity and autophagy in T1D.

Emerging therapeutic options in the management of diabetes: recent trends, challenges and future directions

Diabetes is a serious health issue that causes a progressive dysregulation of carbohydrate metabolism due to insufficient insulin hormone, leading to consistently high blood glucose levels. According to the epidemiological data, the prevalence of diabetes has been increasing globally, affecting millions of individuals. It is a long-term condition that increases the risk of various diseases caused by damage to small and large blood vessels. There are two main subtypes of diabetes: type 1 and type 2, with type 2 being the most prevalent. Genetic and molecular studies have identified several genetic variants and metabolic pathways that contribute to the development and progression of diabetes. Current treatments include gene therapy, stem cell therapy, statin therapy, and other drugs. Moreover, recent advancements in therapeutics have also focused on developing novel drugs targeting these pathways, including incretin mimetics, SGLT2 inhibitors, and GLP-1 receptor agonists, which have shown promising results in improving glycemic control and reducing the risk of complications. However, these treatments are often expensive, inaccessible to patients in underdeveloped countries, and can have severe side effects. Peptides, such as glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1), are being explored as a potential therapy for diabetes. These peptides are postprandial glucose-dependent pancreatic beta-cell insulin secretagogues and have received much attention as a possible treatment option. Despite these advances, diabetes remains a major health challenge, and further research is needed to develop effective treatments and prevent its complications. This review covers various aspects of diabetes, including epidemiology, genetic and molecular basis, and recent advancements in therapeutics including herbal and synthetic peptides.

Genetic evidence for the causal association between type 1 diabetes and the risk of polycystic ovary syndrome

BACKGROUND

Accumulating observational studies have identified associations between type 1 diabetes (T1D) and polycystic ovary syndrome (PCOS). Still, the evidence about the causal effect of this association is uncertain.

METHODS

We performed a two-sample Mendelian randomization (MR) analysis to test for the causal association between T1D and PCOS using data from a large-scale biopsy-confirmed genome-wide association study (GWAS) in European ancestries. We innovatively divided T1D into nine subgroups to be analyzed separately, including: type1 diabetes wide definition, type1 diabetes early onset, type 1 diabetes with coma, type 1 diabetes with ketoacidosis, type 1 diabetes with neurological complications, type 1 diabetes with ophthalmic complications, type 1 diabetes with peripheral circulatory complications, type 1 diabetes with renal complications, and type 1 diabetes with other specified/multiple/unspecified complications. GWAS data for PCOS were obtained from a large-scale GWAS (10,074 cases and 103,164 controls) for primary analysis and the IEU consortium for replication and meta-analysis. Sensitivity analyses were conducted to evaluate heterogeneity and pleiotropy.

RESULTS

Following rigorous instrument selection steps, the number of SNPs finally used for T1D nine subgroups varying from 6 to 36 was retained in MR estimation. However, we did not observe evidence of causal association between type 1 diabetes nine subgroups and PCOS using the IVW analysis, MR-Egger regression, and weighted median approaches, and all P values were > 0.05 with ORs near 1. Subsequent replicates and meta-analyses also yielded consistent results. A number of sensitivity analyses also did not reveal heterogeneity and pleiotropy, including Cochran's Q test, MR-Egger intercept test, MR-PRESSO global test, leave-one-out analysis, and funnel plot analysis.

CONCLUSION

This is the first MR study to investigate the causal relationship between type 1 diabetes and PCOS. Our findings failed to find substantial causal effect of type 1 diabetes on risk of PCOS. Further randomized controlled studies and MR studies are necessary.

Double diabetes as an effect modifier for adverse perinatal outcome in pregnant women with type 1 diabetes mellitus - a retrospective multicenter cohort study

Introduction

Double diabetes (DDiab) is defined as T1DM coexisting with insulin resistance (IR), metabolic syndrome (MetS), and/or obesity. Little evidence is available regarding how frequent DDiab is among T1DM pregnancies and whether it affects the perinatal outcome in this population.

Aims of the study

To explore the prevalence of DDiab in early pregnancy in the cohort of pregnant women with T1DM and to examine the association between an early-pregnancy DDiab status and fetomaternal complications characteristic for T1DM in pregnancy.

Material and methods

A retrospective data analysis of the multicenter cohort of N=495 pregnant women in singleton pregnancy complicated with T1DM followed from early pregnancy until delivery in three tertiary referral centers. DDiab status was defined as T1DM plus pre-pregnancy obesity defined as BMI≥30 kg/m2 measured at the first antenatal visit (DDiabOb), or T1DM plus pre-pregnancy IR defined as eGDR (estimated Glucose Disposal Rate) below the 25th centile for the cohort measured at the first antenatal visit (DDiabIR). Proportions of the adverse pregnancy outcomes were compared between DDiabOb and Non-DDiabOb and between DDiabIR and Non-DDiabIR patients.

Characteristics of the study group

(data presented as mean(SD) or percentage): age: 30.0(5.1) years; age when T1DM diagnosed: 17.5(8.5) years; T1DM duration: 12.0(7,9) years; microvascular complications (White classes R,F,RF): 11.9%, pre-pregnancy counselling: 26.6%, baseline gestational age: 10.5(4.3) weeks, pre-pregnancy BMI: 23.7(4.3) kg/m2; chronic hypertension: 9.1%, gestational hypertension (PIH) 10.7%, preeclampsia (PET): 3.2%; nulliparity 53.8%, smoking in pregnancy: 4.8%, eGWG: 22.4%, DDiabOB: 10.1%; DdiabIR: 25.2%; LGA: 44.0%, and NICU admission: 20.8%.

Results

(data from the univariate analysis given as OR(95%CI)): both DDiabOB and DDiabIR status increased the risk for eGWG [23.15 (10.82; 55.59); 3.03 (1.80; 5.08), respectively]. DDiabIR status increased the risk for PET [4.79 (1.68;14.6)], preterm delivery [1.84 (1.13; 3.21)], congenital malformation [2.15 (1.07;4.25)], and NICU hospitalization [2.2 (1.20;4.01)]. Both DDiabOB and DDiabIR accurately ruled out PET (NPV 97.3%/98.3%, accuracy: 88.3%/75.6%, respectively), congenital malformation (NPV 85.6%/88.4%, accuracy: 78.9/69.8, respectively), and perinatal mortality (NPV 98.7%/99.2%, accuracy: 88.8%/74.5%, respectively).

Conclusions

Double diabetes became a frequent complication in T1DM pregnant population. Double diabetes diagnosed in early pregnancy allows for further stratification of the T1DM pregnant population for additional maternal risk.

Insulin resistance and hepatic steatosis in type 1 diabetes mellitus and their association with diabetic chronic complications

BACKGROUND

The aim of this study was to evaluate insulin resistance and hepatic steatosis and their association with diabetes duration, control and chronic complications in patients with type 1 diabetes.

METHODS

We studied medical records of 181 consecutive hospitalized adult patients with type 1 diabetes. Estimated glucose disposal rate (eGDR), Insulin Sensitivity Score (ISS), Fatty Liver Index (FLI) and Hepatic Steatosis Index (HSI) were calculated.

RESULTS

Patients in the 1st tertile of eGDR (<4.1 mg/kg-1-min-1) and ISS (<4.8) had higher prevalence of ischemic cardiovascular disease (ICVD) (P<0.001), hepatic steatosis, higher gamma glutamyl transpeptidase, HSI, FLI compared with participants from the 2nd and 3rd tertile of eGDR and ISS. Compared with those without steatosis, patients with ultrasound-diagnosed steatosis (30.5%) had a lower ISS (4.4±1.9 vs. 6.3±2.4, P<0.001), eGDR (4.5±3.0 vs. 5.8±2.7, P=0.01), higher FLI (72.5±25.1 vs. 51.0±27.2, P<0.001), HSI (37.5±6.1 vs. 35.2±4.7, P=0.03) and prevalence of ICVD (71.7 vs. 45.7%, P=0.004) and retinopathy (69.6 vs. 52.4%, P=0.03). Factors independently associated with hepatic steatosis were only ICVD (OR=2.584, P=0.029), ISS (OR 0.148, P<0.001), aspartate aminotransferase (OR=1.025, P=0.038) and male gender (OR=2.726, P=0.016).

CONCLUSIONS

Insulin resistance and hepatic steatosis are common in type 1 diabetes and have a significant association with ICVD, independently of diabetes duration, control and insulin doses.

Cerebral tuberculoma and convulsion in infants: A case report

Tuberculosis of the central nervous system is the second most common site after tuberculous meningitis. It represents 0.2% of intracranial expansive lesions in some Western countries compared to 10%-30% in developing countries. We report the case of an infant of 1 year and 2 months old who presented for 15 days with convulsions with asthenia, hypotonia, without fever. The clinical examination and laboratory workup were without abnormalities. His father had ongoing pulmonary tuberculosis, but the infant had no clinical or radiological signs of pulmonary tuberculosis. A brain MRI was showed multiple punctiform brain lesions, suggesting intracerebral tuberculomas in the first place, given the clinical and radiological appearance and the father's history of tuberculosis. The patient was put on anti-convulsant and antibacillary treatment. Through this case, we can see the clinical and radiological polymorphism of cerebral tuberculoma. The diagnosis of certainty remains anatomopathological. The prognosis is poor when it is detected late.

Impact of overweight and obesity on epicardial adipose tissue in children with type 1 diabetes

OBJECTIVES

Epicardial adipose tissue (EAT) thickness, a novel marker of cardiovascular disease (CVD), is increased in children with a healthy weight and type 1 diabetes (T1D). The prevalence of obesity has increased in children with T1D and may confer additional CVD risk. The purpose of this study was to examine EAT thickness in youth with and without T1D in the setting of overweight/obesity.

METHODS

Youth with overweight/obesity and T1D (n=38) or without T1D (n=34) between the ages of 6-18 years were included in this study. Echocardiogram using spectral and color flow Doppler was used to measure EAT and cardiac function. Waist circumference, blood pressure, and HbA_1c, were used to calculate estimated glucose disposal rate (eGDR) to estimate insulin resistance in children with T1D.

RESULTS

EAT thickness was not significantly different in youth with T1D compared to controls (2.10 ± 0.67 mm vs. 1.90 ± 0.59 mm, p=0.19). When groups were combined, EAT significantly correlated with age (r=0.449, p≤0.001), BMI (r=0.538, p≤0.001), waist circumference (r=0.552, p≤0.001), systolic BP (r=0.247, p=0.036), myocardial performance index (r=-0.287, p=0.015), ejection fraction (r=-0.442, p≤0.001), and cardiac output index (r=-0.306, p=0.009). In the group with T1D, diastolic BP (r=0.39, p=0.02) and eGDR (r=-0.48, p=0.002) correlated with EAT.

CONCLUSIONS

EAT was associated with measures of adiposity and insulin resistance but does not differ by diabetes status among youth with overweight/obesity. These findings suggest that adiposity rather than glycemia is the main driver of EAT thickness among youth with T1D.

Comparison of Insulin-Treated Patients with Ambiguous Diabetes Type with Definite Type 1 and Type 2 Diabetes Mellitus Subjects: A Clinical Perspective

In clinical practice, the distinction between type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) can be challenging, leaving patients with "ambiguous" diabetes type. Insulin-treated patients (n=115) previously diagnosed with T2DM had to be re-classified based on clinical phenotype and laboratory results, and were operationally defined as having an ambiguous diabetes type. They were compared against patients with definite T1DM and T2DM regarding 12 clinical and laboratory features typically different between diabetes types. Characteristics of patients with ambiguous diabetes type, representing approximately 6% of all patients with T1DM or T2DM seen at our specialized clinic, fell in between those of patients with definite T1DM and T2DM, both regarding individual features and with respect to a novel classification based on multi-variable regression analysis (P<0.0001). In conclusion, a substantial proportion of diabetes patients in a tertiary care centre presented with an "ambiguous" diabetes type. Their clinical characteristics fall in between those of definite T1DM or T2DM patients.

Clinical characteristics and cardiovascular risk profile in children and adolescents with latent autoimmune diabetes: Results from the German/Austrian prospective diabetes follow-up registry

AIMS

To characterize children and adolescents with latent autoimmune diabetes of the young (LADY), and to assess the utility of classifying individuals as LADYs regarding their cardiovascular (CV) risk factors.

METHODS

Data from 25,520 individuals (age at diagnosis <18 years) of the Prospective Diabetes Follow-up Registry Diabetes-Patienten Verlaufsdokumentation (DPV) were analyzed. LADY was defined as positivity of ≥one islet autoantibody (iAb+) and an insulin-free interval of ≥6 months upon diabetes diagnosis. LADYs were compared to iAb+ individuals immediately requiring insulin ("immunologically confirmed" type 1 diabetes, T1DM), iAb-/Ins- individuals ("classical" T2DM) and to those clinically defined as T2DM (iAbs not measured).

RESULTS

Clinical characteristics of LADYs (n = 299) fell in between those with T1DM (n = 24,932) and T2DM (iAb-/Ins-, n = 152) or suspected T2DM (iAB not measured, n = 137). Stratifying LADYs according to their clinical diagnosis however revealed two distinct populations, highly resembling either T1DM or T2DM. Particularly, CV risk profile, precisely prevalence rates of arterial hypertension and dyslipidemia, was significantly higher in LADYs clinically classified as T2DM compared to LADYs classified as T1DM, and did not differ from those with "classical" T2DM.

CONCLUSIONS

In terms of CV risk, classifying children and adolescents with diabetes as LADYs provides no additional benefit. Instead, clinical diagnosis seems to better assign individuals to appropriate risk groups for increased CV risk profiles.

Recent developments in adjunct therapies for type 1 diabetes

INTRODUCTION

There have been many recent advances in the treatment of type 1 diabetes (T1D) including in insulin formulations, continuous glucose monitoring (CGM) technology and automated insulin delivery. However, long-term optimal glycemic control is still only achieved in a minority.

AREAS COVERED

Adjunct therapy - the use of therapeutic agents other than insulin - is one strategy aimed at improving outcomes. An ideal adjunct agent would improve glycemic control, reduce weight (or weight gain), reduce insulin requirement and prevent complications (e.g. cardiorenal) without increasing hypoglycemia. The amylin analogue pramlintide has been licensed in the USA, while the sodium glucose co-transporter-2 inhibitor (SGLT2i) dapagliflozin, was briefly (2019 - 2021) licensed for type 1 diabetes in Europe and the UK. However, other agents from the type 2 diabetes (T2D) arena including metformin, other SGLT2is, glucagon-like peptide-1 receptor agonists (GLP-1RA) and dipeptidyl peptidase-IV (DPP-4) inhibitors have been investigated.

EXPERT OPINION

As evidence emerges for cardiorenal protection by SGLT2is and GLP-1RAs in T2D, it has become increasingly important to know whether people with T1D can also benefit. Here, we review recent trials of adjunct agents in T1D and discuss the efficacy and safety of these agents (alone and in combination) in an era in which continuous glucose monitoring is becoming standard of care.

Impact of glycemic variability on cognitive impairment, disordered eating behaviors and self-management skills in patients with type 1 diabetes: study protocol for a cross-sectional online study, the Sugar Swing study

BACKGROUND

People living with type 1 diabetes (PWT1D) are at increased risk for impairments in brain function, which may impact on daily life. Cognitive impairments in PWT1D might contribute to increasing eating disorders, reducing self-management skills, and deteriorating glycemic control. Glycemic variability may be a key determinant of disordered eating behaviors, as well as of cognitive impairments. The main objective of this study is to better understand the impact of glycemic variability in disordered eating behaviors and cognitive impairment, and its consequences on self-management skills in PWT1D.

METHOD

We aim to recruit 150 PWT1D with 50% of men and women in this cross-sectional study. Participants will record their glycemic variability over a 10-day period using a continuous glucose monitoring system (CGMS) and track their dietary intakes using image-assisted food tracking mobile application (2 days). Over four online visits, eating behaviors, diabetes self-management's skills, anxiety disorders, depression disorder, diabetes literacy and numeracy skills, cognitive flexibility, attention deficit, level of interoception, and impulsivity behaviors will be assessed using self-reported questionnaires. Cognitive functions (i.e., attention, executive functions, impulsivity, inhibition and temporal discounting), will be measured. Finally, medical, biological and sociodemographic data will be collected. To further our understanding of the PWT1D experience and factors impacting glycemic self-management, 50 PWT1D will also participate in the qualitative phase of the protocol which consist of individual in-depth face-to-face (virtual) interviews, led by a trained investigator using a semi-structured interview.

DISCUSSION

This study will contribute to highlighting the consequences of blood sugar fluctuations (i.e., "sugar swings"), in daily life, especially how they disrupt eating behaviors and brain functioning. A better understanding of the mechanisms involved could eventually allow for early detection and management of these problems. Our study will also seek to understand the patients' point of view, which will allow the design of appropriate and meaningful recommendations.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05487534. Registered 4 August 2022.

Body Composition Characteristics of Type 1 Diabetes Children and Adolescents: A Hospital-Based Case-Control Study in Uganda

Background: Changes in body composition have been suggested as an intractable effect of Type 1 Diabetes Mellitus and its management. This study aims to compare body composition characteristics in a sample of young children and adolescents with Type 1 Diabetes Mellitus with healthy controls. Methods: In this case−control study, body composition was assessed using bioelectrical impedance among 328 participants. Anthropometric measurements included weight, height, upper arm, hip, and waist, circumferences; biceps; triceps; and subscapular and suprailiac skinfolds. From raw Bioelectrical impedance data, we calculated the impedance, phase angle, and height normalised resistance and reactance to assess body composition. Analysis of variance accounting for paired blocks was used to compare the two matched groups, while an independent Student’s t-test was used for intragroup comparisons among cases. Results: Waist Hip Ratio, biceps, triceps, subscapular and suprailiac skinfolds were higher among cases than in controls. Cases showed a higher Fat Mass Index, higher fasting blood glucose and higher glycated haemoglobin. Cases also had a higher mean value of resistance (p = 0.0133), and a lower mean value of reactance (p = 0.0329). Phase angle was lower among cases than in controls (p < 0.001). Conclusion: Our diabetic children showed higher levels of adiposity than controls. The observed differences in body composition are explained by differences in the fat-mass index. Abdominal fat accumulation was associated with poor glycaemic control and a lower phase angle.

The Effects of Exercise Training on Glucose Homeostasis and Muscle Metabolism in Type 1 Diabetic Female Mice

Although exercise training is an important recommendation for the management of type 1 diabetes (T1D), most of the available research studies predominantly focus on male subjects. Given the importance of sex as a biological variable, additional studies are required to improve the knowledge gap regarding sex differences in T1D research. Therefore, the purpose of this study was to examine the role of exercise training in mediating changes in glucose homeostasis and skeletal muscle metabolism in T1D female mice. Female mice were injected with streptozotocin (STZ) to induce T1D. Two weeks after STZ injection, control (CON) and STZ mice were exercise trained on a treadmill for 4 weeks. Aerobic exercise training failed to improve glucose tolerance, prevent the decrease in body weight and adipose tissue mass, or attenuate muscle atrophy in T1D female mice. However, insulin sensitivity was improved in T1D female mice after exercise training. Aerobic exercise training maintained skeletal muscle triglyceride content but did not prevent depletion of skeletal muscle or liver glycogen in T1D mice. Gene expression analysis suggested that T1D resulted in decreased glucose transport, decreased ketone body oxidation, and increased fatty acid metabolism in the skeletal muscle, which was not altered by exercise training. These data demonstrate that 4 weeks of aerobic exercise training of a moderate intensity is insufficient to counteract the negative effects of T1D in female mice, but does lead to an improvement in insulin sensitivity.

A combination of metformin and insulin improve cardiovascular and cerebrovascular risk factors in individuals with type 1 diabetes mellitus

BACKGROUND

This study aims to further clarify whether the addition of metformin to insulin treatment improve cardiovascular and cerebrovascular risk factors in individuals with T1DM.

METHODS

Electronic databases were searched for randomized controlled trials in which the efficacy and safety of metformin were compared with those of a placebo for risk factors of cardiovascular and cerebrovascular disease among individuals with T1DM, and a meta-analysis was conducted.

RESULTS

Thirteen cardiovascular studies were identified. In the metformin group, mean carotid intimal media thickness was significantly reduced by 0.03 mm, ascending aortic pulse wave velocity by 6.3 m/s, descending aortic wall shear stress by 1.77 dyn/cm² (P = 0.02), insulin daily dose by 0.05 U/kg/d, body weight by 2.27 kg, fat-free mass by 1.32 kg, body mass index by 0.58 kg/m², hip circumference by 0.29 m, and low-density lipoprotein by 0.16 mmol/L, all above are P < 0.05. In the metformin group, flow-mediated dilation was increased by 1.29 %, glucose infusion rate/insulin by 18.22 mg/(kg⋅min)/μIU/μL, and waist-to-hip ratio by 0.02, all above are P < 0.00001. The metformin group showed no differences in blood pressure, reactive hyperemia index, waist circumference, triglyceride, total cholesterol, high-density lipoprotein cholesterol, or body mass index Z score. For cerebrovascular studies were identified. But none of them had a risk factor assessment.

CONCLUSIONS

Metformin can ameliorate cardiovascular and cerebrovascular risk factors through non-hypoglycemic multiple pathways in individuals with T1DM.

Comparison of insulin sensitivity indices for detection of double diabetes in Indian adolescents with type 1 diabetes

OBJECTIVES

The role of insulin sensitivity (IS) in the development and progression of metabolic syndrome (MS) in subjects with type-1 diabetes (T1D) is being increasingly recognized. As patients with T1D lack endogenous insulin secretion, measurement of insulin concentration by immunoassay or by indices such as homeostasis model of assessment for insulin resistance (HOMA-IR) is not helpful in assessing IS. Hence, some equations have been developed and validated against data from euglycemic-hyper-insulinemic clamp tests (the gold standard) to estimate IS. 1) To assess IS using available equations (EDC, SEARCH and CACTI) and relationship of IS with MS and microalbuminuria in adolescents with T1D, (2) To compare the predictive value of these equations for detection of MS and derive a cut-off to predict the future risk of development of MS and microalbuminuria and (3) To identify the most accurate non-invasive and easy-to-use equation for detecting patients with double diabetes (DD) in a clinical setting.

METHODS

This cross-sectional study included 181 adolescents aged 12-18 years with T1D. Demographic data and laboratory measurements were performed using standard protocols. IS was calculated using following equations:(1) EDC=24.31-12.22×(WHR)-3.29×(hypertension)-0.57×(HbA1c), (2) SEARCH=exp(4.64725-0.02032(waist)-0.09779(HbA1c)-0.00235(Triglycerides), (3)CACTI-exA=exp(4.1075-0.01299×(waist)-1.05819×(insulin dose)-0.00354×(Triglycerides)-0.00802×(DBP)).

RESULTS

IS determined by all three methods had significant negative correlation (p<0.05) with MS as well as with microalbuminuria. The cut-off value of 5.485 mg/kg/min by SEARCH method for determining IS had the highest sensitivity and specificity in identifying MS.

CONCLUSIONS

IS by SEARCH equation may be used in routine clinical practice to detect DD in Indian adolescents with T1D at risk of developing metabolic as well as microvascular complications.

How to Achieve Sufficient Endogenous Insulin Suppression in Euglycemic Clamps Assessing the Pharmacokinetics and Pharmacodynamics of Long-Acting Insulin Preparations Employing Healthy Volunteers

The therapeutic effect of basal insulin analogs will be sustained at a rather low insulin level. When employing healthy volunteers to assess the pharmacokinetics (PK) and pharmacodynamics (PD) of long-acting insulin preparations by euglycemic clamp techniques, endogenous insulin cannot be ignored and sufficient endogenous insulin inhibition is crucial for the PD and/or PK assessment. This study aimed to explore a way to sufficiently inhibit endogenous insulin secretion. Healthy Chinese male and female volunteers were enrolled. After a subcutaneous injection of insulin glargine (IGlar) (LY2963016 or Lantus) (0.5 IU/kg), they underwent a manual euglycemic clamp for up to 24 h where the target blood glucose (BG) was set as 0.28 mmol/L below the individual’s baseline. Blood samples were collected for analysis of PK/PD and C-peptide. The subjects fell into two groups according to the reduction extent of postdose C-peptide from baseline. After matching for the dosage proportion of Lantus, there were 52 subjects in group A (C-peptide reduction&lt;50%) and 26 in group B (C-peptide reduction≥50%), respectively. No significant difference was detected in age, body mass index, the proportion of Latus treatment and female participants. A lower basal BG was observed in group B compared to group A (4.35 ± 0.26 vs. 4.59 ± 0.22 mmol/L, p &lt; 0.05). The clamp studies were all conducted with high quality (where BG was consistently maintained around the target and exhibited a low variety). The binary logistic regression analysis indicated low basal BG as an independent factor for the success of sufficient endogenous insulin suppression. In conclusion, setting a lower sub-baseline target BG (e.g., 10% instead of 5% below baseline) might be an approach to help achieve sufficient endogenous insulin suppression in euglycemic clamps with higher basal BG levels (e.g., beyond 4.60 mmol/L).

The role of pancreas to improve hyperglycemia in STZ-induced diabetic rats by thiamine disulfide

Background

The present study investigated the effect of thiamine disulfide (TD) on the pancreas in terms of hyperglycemia improvement and insulin sensitivity increase in diabetic male rats. We also aimed to study the function of Pdx1 (pancreatic and duodenal homeobox 1) and Glut2 (glucose transporter 2) genes in pancreatic tissue.

Methods

Type 1 diabetes was induced through injection of 60 mg/kg streptozotocin (STZ). The diabetic rats were divided into four groups, namely diabetic control (DC), diabetic treated with thiamine disulfide (D-TD), diabetic treated with insulin (D-insulin), and diabetic treated with TD and insulin (D-insulin+TD). The non-diabetic (NDC) and diabetic groups received a normal diet (14 weeks). Blood glucose level and body weight were measured weekly; insulin tolerance test (ITT) and glucagon tolerance test (GTT) were performed in the last month of the study. The level of serum insulin and glucagon were measured monthly and a hyperglycemic clamp (Insulin Infusion rate (IIR)) was done for all the groups. Pancreas tissue was isolated so that Pdx1and Glut2 genes expression could be measured.

Results

We observed that TD therapy decreased blood glucose level, ITT, and serum glucagon levels in comparison with those of the DC group; it also increased serum insulin levels, IIR, and expression of Pdx1 and Glut2 genes in comparison with those of the DC group.

Conclusion

Administration of TD could improve hyperglycemia in type 1 diabetic animals through improved pancreas function. Therefore, not only does TD have a significant effect on controlling and reducing hyperglycemia in diabetes, but it also has the potential to decrease the dose of insulin administration.

Impact of excluding hyperglycemia from international diabetes federation metabolic syndrome diagnostic criteria on prevalence of the syndrome and its association with microvascular complications, in adult patients with type 1 diabetes

BACKGROUND

We aimed to determine, in patients with type 1 diabetes (T1DM), the impact of excluding hyperglycemia as a criterion from the International Diabetes Federation (IDF) definition of the metabolic syndrome (MetS), both on its prevalence and on its association with micro and macrovascular complications and markers of subclinical inflammation.

METHODS

A cross-sectional design, including 280 patients with T1DM. We defined MetS by three different models: (i) the standard IDF criteria, (ii) a modification consisting of excluding of hyperglycemia as a criterion (modified IDF criteria) and (iii) a modification consisting in changing the hyperglycemia by insulin resistance (MetS + IR model) defined by the estimated glucose disposal rate. Microvascular complications and cardioautonomic neuropathy were assessed. We measured an inflammatory panel including high sensitivity C reactive protein, erythrocyte sedimentation rate, homocysteine, and fibrinogen concentrations.

RESULTS

After excluding hyperglycemia, the prevalence of MetS was 6.4% (95%CI: 4.1 to 9.9) compared with 20.7% (95%CI: 16.3 to 25.8) using standard IDF criteria. After adjusting for duration of diabetes, all three MetS definitions increased the odds for having microvascular complications [OR: 6.012 (2.208-16.307) for modified definition; OR: 5.176 (2.555-10.486) for standard definition and [OR: 3.374 (1.649-8.456) for MetS+IR model]. However, the both modified IDF models for MetS showed better predictive performance than standard criteria for suffering from neuropathy, nephropathy, cardiovascular disease and were associated with markers of subclinical inflammation.

CONCLUSIONS

The prevalence of MetS significantly varies as a function whether or not hyperglycemia is included as a diagnostic criterion. The subset of patients fulfilling the modified MetS definitions may reflect better the concept of metabolic syndrome in T1DM. These modified definitions were accompanied by a poorer metabolic control and lipid profile, showing the worse inflammatory biomarker profiles and higher odds for micro- and macrovascular complications. In patients with T1DM, the inclusion of insulin resistance instead of hyperglycemia as a criterion of MetS may be of interest in routine clinical practice.

Insulin Resistance in Experimental Type 1 Diabetes Mellitus

Experimental type 1 diabetes mellitus (T1DM) was induced in rats by daily intraperitoneal injections of alloxan in a dose of 90 mg/kg for 4 days. For verification of insulin resistance, insulin tolerance test was performed in 2 weeks and the glucose utilization rate constant (K_ITT) was calculated. The rats demonstrated the main symptoms of T1DM: hypoinsulinemia, hyperglycemia, ketonemia, glucosuria, ketonuria, polydipsia, polyphagia, weight loss, and insulin resistance, as evidenced by a decrease in K_ITT. The serum content of free fatty acids and triacylglycerols significantly increased. The content of triacylglycerols increased in skeletal muscles and decreased in the liver. A negative linear correlation was found between K_ITT and triacylglycerol content in muscles. Thus, the development of insulin resistance in experimental T1DM in rats is associated with accumulation of triacylglycerols in skeletal muscles.

Capturing the real-world benefit of residual β-cell function during clinically important time-periods in established Type 1 diabetes

AIMS

Many individuals with type 1 diabetes retain residual β-cell function, with increased endogenous insulin secretion associated with reduced hyperglycaemia, hypoglycaemia and glycaemic variability. However, it is unknown when these improvements occur during the day. Dysglycaemia is common in overnight and postprandial periods and associated with diabetes complications. Therefore, this study aimed to determine the influence of residual β-cell function upon nocturnal and postprandial glycaemic control in established type 1 diabetes.

METHODS

Under free-living conditions, 66 participants wore a blinded continuous glucose monitor (CGM), kept a food diary, and completed a stimulated urine C-peptide creatinine (UCPCR) test. Nocturnal, and postprandial CGM outcomes (participant means and discrete event analysis) were compared between UCPCR groups: undetectable (Cpep_und ), low (Cpep_low : 0.001-0.19 nmol/mmol) and high (Cpep_high : ≥0.2 nmol/mmol).

RESULTS

Greater β-cell function was associated with incremental improvements in glycaemia. Cpep_high spent significantly greater time in normoglycaemia than Cpep_und overnight (76 ± 20% vs. 58 ± 20%, p = 0.005) and 0-300 mins postprandially (68 ± 22% vs. 51 ± 22%, p = 0.045), while also having reducing nocturnal variability (SD 1.12 ± 0.41 vs. 1.52 ± 0.43 mmol/L, p = 0.010). Analysis of individual events, controlling for diabetes duration, BMI, basal insulin, use of a continuous or flash glucose monitor and (for postprandial) meal type, carbohydrate and bolus insulin intake, replicated the group findings, additionally demonstrating Cpep_und had increased hyperglycaemia versus Cpep_low overnight and increased postprandial hypoglycaemic events compared with Cpep_high . For all participants, breakfast had a significantly higher incremental area under the curve than lunch and dinner.

CONCLUSIONS

Residual β-cell function is associated with improved nocturnal and postprandial glycaemic control. These data may be of clinical importance for identifying specific periods and individuals where further glycaemic management strategies would be beneficial.