Document on a comprehensive approach to type 2 diabetes mellitus

Multidisciplinary Panel Consensus for the Management of Patients with Type 2 Diabetes: A Delphi Study

AIM

To reach a multidisciplinary consensus on managing patients with type 2 diabetes among specialists in family medicine, cardiology, endocrinology, internal medicine, and nephrology.

METHODS

A two-round Delphi study was conducted using a questionnaire with 68 positive/negative statements distributed in four thematic blocks on diabetes management: early diagnosis and prediabetes, referral criteria, treatment and comorbidities, and clinical management. The expert panel was composed of 105 physicians from different specialties (family medicine, cardiology, endocrinology, internal medicine, and nephrology) with experience in managing patients with diabetes and who were members of a diabetes-related society.

RESULTS

Response rates for the first and second rounds were 86.7 and 75.2%, respectively. After both rounds, a consensus was reached on 52 (76.5%) items. The recommendations with the highest degree of consensus (median = 10, IQR = 0.00) were related to anti-smoking education, cardiovascular risk factor target control, and diabetic kidney disease. There were significant differences between family physicians and other specialties for some items.

CONCLUSIONS

This study provides a set of recommendations for diabetes management agreed upon by specialists from different healthcare settings.

Agreement between tele-assessment and face-to-face assessment of 30-s sit-to-stand test in patients with type 2 diabetes mellitus

BACKGROUND

The globalization of healthcare systems, and the aim to lower healthcare costs have all contributed to the growth of telehealth technology in recent years. However, before these systems are put into use, their efficacy should be verified. To the best of our knowledge, this is the first study focusing on the evaluation of functional exercise capacity using the 30-s sit-to-stand (30-s STS) test as a tele-assessment method in patients with type 2 diabetes mellitus (T2DM).

AIMS

The purpose of the study is to investigate the level of agreement between tele-assessment and face-to-face assessment of 30-s STS test in patients with T2DM.

METHODS

Fifty participants performed two times 30-s STS tests separated by 1 h: a face-to-face and an Internet-connected video call examination (tele-assessment). Two physiotherapists conduct these evaluations; each was blinded to the other. The order of the evaluations was designated at random for each participant and physiotherapist.

RESULTS

There was a good level of agreement between tele-assessment and face-to-face assessment of the 30-s STS test (mean differences = 0.20 ± 0.88, limits of agreement = 1.93 to - 1.53). Excellent interrater reliability was found for scores of the 30-s STS test [ICC = 0.93 (95% CI: 0.88; 0.96)]. In addition, all before and after test parameters show that there was a very good interrater reliability (ρ ≥ 0.75).

CONCLUSIONS

This study shows a good level of agreement between tele-assessment and face-to-face assessment of the 30-s STS test. Our study's findings indicate that tele-assessment is a potential application to determine the level of physical capacity remotely in patients with T2DM.

Effectiveness and safety of Daixie Decoction granules combined with metformin for the treatment of T2DM patients with obesity: study protocol for a randomized, double-blinded, placebo-controlled, multicentre clinical trial

BACKGROUND

Type 2 diabetes mellitus (T2DM) with obesity is a glycolipid metabolism disorder, which makes hypoglycaemic treatment more complex and increases the proportion of multidrug combinations. In addition, patients are more prone to adverse reactions and gradually lose compliance with treatment. Previous clinical trials have demonstrated that Daixie Decoction granules (DDG) can reduce body weight and blood lipids and improve the quality of life of T2DM with obesity. But there are a lack of further evaluations for the efficacy and safety of DDG combined with metformin.

METHODS/DESIGN

The study is designed as a multicentre, randomized, double-blind, placebo-controlled clinical trial. Participants who meet the Nathrow criteria will be randomly assigned to the intervention group and control group (n ₁ = n ₂ = 133). Based on a unified diet control and exercise therapy, the intervention group will be treated with DDG and metformin, and the control group will be treated with DDG placebo and metformin. All subjects will receive a 6-month treatment followed by a 6-month follow-up. Effective rate of a 1% decrease in HbA1c and 3% decrease in body weight will serve as the primary outcome. The secondary outcome include fasting plasma glucose, blood lipids, C-peptides, insulin, inflammatory factors, insulin resistance index (HOMA-IR) and the subcutaneous and visceral fat content in the upper abdomen measured by MRI. Blood routine, urine routine, stool routine, liver and kidney function, EKG and other safety indicators and major adverse reactions were monitored during total treatment and follow-up time.

DISCUSSION

We aimed to determine the efficacy and safety of DDG combined with metformin for the treatment of T2DM patients with obesity.

TRIAL REGISTRATION

Trial registration: ChiCTR, ChiCTR2000036290. Registered 22 August 2014,  http://www.chictr.org.cn/showprojen.aspx? proj=59001.

Daily phytate intake increases adiponectin levels among patients with diabetes type 2: a randomized crossover trial

AIM

Adiponectin, a major adipokine secreted by adipose tissue, has been shown to improve insulin sensitivity. Myo-inositol hexaphosphate (phytate; InsP6) is a natural compound that is abundant in cereals, legumes, and nuts that has demonstrated to have different beneficial properties in patients with diabetes type 2.

METHODS

We performed a randomized crossover trial to investigate the impact of daily consumption of InsP6 on serum levels of adiponectin, TNF-alpha, IL-6, and IL-1beta in patients with type 2 diabetes mellitus (T2DM; n = 39). Thus, we measure serum levels of these inflammatory markers, classic vascular risk factors, and urinary InsP6 at baseline and at the end of the intervention period.

RESULTS

Patients who consumed InsP6 supplements for 3 months had higher levels of adiponectin and lower HbA1c than those who did not consume InsP6. No differences were found in TNF-alpha, IL-6, and IL-1beta.

CONCLUSION

This is the first report to show that consumption of InsP6 increases plasma adiponectin concentration in patients with T2DM. Consequently, our findings indicate that following a phytate-rich diet has beneficial effects on adiponectin and HbA1c concentrations and it could help to prevent or minimize diabetic-related complications.

COVID-19 and Diabetes

Diabetes mellitus (DM) is one of the most common comorbid conditions in persons with COVID-19 and a risk factor for poor prognosis. The reasons why COVID-19 is more severe in persons with DM are currently unknown although the scarce data available on patients with DM hospitalized because of COVID-19 show that glycemic control is inadequate. The fact that patients with COVID-19 are usually cared for by health professionals with limited experience in the management of diabetes and the need to prevent exposure to the virus may also be obstacles to glycemic control in patients with COVID-19. Effective clinical care should consider various aspects, including screening for the disease in at-risk persons, education, and monitoring of control and complications. We examine the effect of COVID-19 on DM in terms of glycemic control and the restrictions arising from the pandemic and assess management of diabetes and drug therapy in various scenarios, taking into account factors such as physical exercise, diet, blood glucose monitoring, and pharmacological treatment. Specific attention is given to patients who have been admitted to hospital and critically ill patients. Finally, we consider the role of telemedicine in the management of DM patients with COVID-19 during the pandemic and in the future.

Factors Associated with Adherence to Clinical Practice Guidelines for Patients with Type 2 Diabetes Mellitus: Results of a Spanish Delphi Consensus

OBJECTIVE

To assess factors associated with adherence to clinical practice guidelines (CPGs) for type 2 diabetes mellitus (T2DM).

METHODS

A cross-sectional multicenter study based on a two-round Delphi survey was designed. A total of 98 endocrinologists (mean age 45 years) involved in the care of T2DM patients completed a 43-item questionnaire assessing different aspects of adherence related to CPGs.

RESULTS

Most participants worked in tertiary care public hospitals. All participants used CPGs, with ADA/EASD as the most common (99%). The lack of time, establishment of an individualized management of patients, insufficient human resources, and therapeutic inertia were scored as the main reasons for not following CPGs recommendations. Participants agreed that insufficient material resources and limitations established by the healthcare system prevent adherence to CPGs. The risk of hypoglycemia was considered to be limiting factor for the patients' integral control. Also, there was consensus on the need to have the support of nursing personnel with specific training in diabetes as well as dietitians and podiatrists. There was disagreement regarding the influence on adherence to CPGs of patient's characteristics not matching those of CPGs, patient's preferences, tolerability of the action recommended, concomitant comorbidities, or pluripathological conditions. Differences according to the participant's age (≤40 years vs. >40 years) were not found. Therapeutic inertia and lack of time did not show a significant correlation.

CONCLUSIONS

Nonadherence to CPGs on T2DM is a multifactorial problem but the existence multiple CPGs, the lack of time, the therapeutic inertia, and insufficient human resources have been identified as factors limiting adherence. Hypoglycemia continues to be a barrier for achievement of targets recommended by CPGs.

Anti-diabetic properties of genistein-chromium (III) complex in db/db diabetic mice and its sub-acute toxicity evaluation in normal mice

BACKGROUND

In this study, chromium (III) complex was synthesized from genistein (GEN) which had good hypoglycemic activity and inorganic chromium (III) element, and its hypoglycemic activity and sub-acute toxicity were studied.

METHODS

The genistein-chromium (III) complex was synthesized by chelating chromium with genistein in ethanol and its structure was determined by LC-MS, atomic absorption spectroscopy, UV-vis spectroscopy, infrared spectroscopy, elemental and thermodynamic analysis. The anti-diabetic activity of the complex was assessed in db/db mice and C57 mice by daily oral gavage for 4 weeks. The sub-acute toxicity test was carried out on KM mice with this complex.

RESULTS

The molecular structure of this complex was inferred as a complex [CrGEN₃] formed by three ligands and one chromium element. The complex could significantly improve the body weight of db/db mice, fasting blood glucose, random blood glucose, organ index, glycogen levels and the performance of OGTT (Oral Glucose Tolerance Test) and ITT (Insulin Tolerance Test) in db/db mice (p < 0.05). The morphology of liver, kidney, pancreas and skeletal muscle also had obviously improvement and repairment. Effects on serum indices and antioxidant enzymes activities of db/db mice showed that the serum profiles and antioxidant ability of complex group had significant improvement compared with the diabetic control group (p < 0.05 or p < 0.01), and some indices even returned to normal levels. In addition, this complex did not produce any hazardous symptoms or deaths in sub-acute toxicity test. High dose of [CrGEN₃] had no significant influence on serum indices and antioxidant capacity in normal mice, and the organ tissues maintained organized and integrity in the sub-acute toxicity study.

CONCLUSION

The study of the genistein-chromium (III) complex showed that the complex had good hypoglycemic activity in vivo, and did not have the potential toxicity. These results would provide an important reference for the development of functional hypoglycemic foods or pharmaceuticals.

Incidence and costs of cardiovascular events in Spanish patients with type 2 diabetes mellitus: a comparison with general population, 2015

INTRODUCTION

Cardiovascular (CV) disease affects a high percentage of patients with type 2 diabetes mellitus (T2DM), especially in the hospital setting, impacting on mortality, complications, quality of life and use of health resources. The aim of this study was to estimate the incidence, mean length of hospital stay (LOHS) and costs attributable to hospital admissions due to CV events in patients with T2DM versus patients without diabetes mellitus (non-DM) in Spain.

RESEARCH DESIGN AND METHODS

Retrospective observational study based on the Spanish National Hospital Discharge Database for 2015. Hospital admissions for patients aged ≥35 years with a diagnosis of CV death, non-fatal acute myocardial infarction (AMI), non-fatal stroke, unstable angina, heart failure and revascularization were evaluated. The International Classification of Diseases, Ninth Revision (250.x0 or 250.x2) coding was used to classify records of patients with T2DM. For each CV complication, the hospital discharges of the two groups, T2DM and non-DM, were precisely matched and the number of hospital discharges, patients, LOHS and mean cost were quantified. Additional analyses assessed the robustness of the results.

RESULTS

Of the 276 925 hospital discharges analyzed, 34.71% corresponded to patients with T2DM. A higher incidence was observed in all the CV complications studied in the T2DM population, with a relative risk exceeding 2 in all cases. The mean LOHS (days) was longer in the T2DM versus the non-DM group for: non-fatal AMI (7.63 vs 7.02, p<0.001), unstable angina (5.11 vs 4.78, p=0.009) and revascularization (7.96 vs 7.57, p<0.001). The mean cost per hospital discharge was higher in the T2DM versus the non-DM group for non-fatal AMI (€6891 vs €6876, p=0.029) and unstable angina (€3386 vs €3304, p<0.001).

CONCLUSIONS

Patients with T2DM had a higher incidence and number of hospital admissions per patient due to CV events versus the non-DM population. This generates a significant clinical and economic burden given the longer admission stay and higher costs associated with some of these complications.

The burden of type 2 diabetes in Europe: Current and future aspects of insulin treatment from patient and healthcare spending perspectives

Due to the progressive nature of type 2 diabetes (T2DM), initiation of insulin therapy is very likely in the disease continuum. This article aims at highlighting the current situation with regard to insulin therapy in people with T2DM in Europe and at presenting the associated unmet need. Challenges for both people with T2DM and healthcare professionals include clinical inertia also derived from fear of hypoglycaemia, weight gain and injections as well as increased need for a comprehensive diabetes management. We compare national and international guidelines and recommendations for the initiation and intensification of insulin therapy with the real-world situation in six European countries, demonstrating that glycaemic targets are only met in a minority of people with T2DM on insulin therapy. Furthermore, this work evaluates currently recorded numbers of people with T2DM treated with insulin in Europe, the proportion not achieving the stated glycaemic targets and thus in need to enhance insulin therapy e.g. by a change in means of insulin delivery including, but not limited to, insulin pens, wearable mealtime insulin delivery patches, patch pumps, and conventional insulin pumps with continuous subcutaneous insulin infusion.

Reliability of 30-s Chair Stand Test with and without Cognitive Task in People with Type-2 Diabetes Mellitus

Background: Reliability refers to the precision of an assessment, so it is a critical topic to take the right decisions related to health management. People usually perform several tasks at the same time in their daily life. The aim of this study was to examine the reliability of the 30-s chair stand test in people with type 2 Diabetes Mellitus (T2DM) with test–retest, with and without dual-task (motor + cognitive task). Methods: Twenty-six subjects with T2DM and 30 subjects without T2DM performed the 30-s Chair Stand Test (30sCST) in which they must sit and stand as many times as possible in 30 s. They performed the test in the usual way (30sCST) and also with an additional cognitive task (30sCST-DT). A retest was conducted 7–14 days later. Results: Relative reliability was excellent in both groups (intraclass correlation coefficient > 0.9). In 30sCST-DT, relative reliability was high in the T2DM group (intraclass correlation coefficient > 0.7) and excellent in subjects without T2DM (intraclass correlation coefficient > 0.9). Conclusions: The 30sCST and the 30sCST-DT tests are reliable tools for people with T2DM to measure changes after an intervention. The smallest real difference was 15% and 20% upper in the T2DM group in the 30sCST and 30sCST-DT tests, respectively.