Effect of BMI, insulin dose and number of injections on glycaemic control in insulin-using diabetic patients. Studygroup Diabetes Rijnmond (SDR)

Weight and glycaemic control in type 2 diabetes: what is the outcome of insulin initiation?

AIMS

Little information is available on the association between obesity at time of insulin initiation and attainment of glycaemic targets in type 2 diabetic (T2DM) patients. This study describes changes in HbA1c, weight and body mass index (BMI) over 24 months postinsulin initiation.

METHODS

First-time insulin users with T2DM were selected from the UK General Practice Research Database for the period 1st January 2002 to 31st March 2008. The cohort was stratified into BMI categories (kg/m(2) ) at the time of insulin initiation. Data were reviewed at 6-monthly intervals. A multivariate repeated-measures linear model was fitted assessing weight change over 12 months.

RESULTS

3783 patients were included (normal weight, n = 672; overweight, n = 1259; obese, n = 1070; clinically obese, n = 480; morbidly obese, n = 302). The largest reductions in HbA1c were observed 6 months postinsulin initiation and were greatest in lower BMI categories: median observed HbA1c at initiation and 6 months was 9.7 and 7.9% in normal weight patients and 9.6 and 8.2% in the clinically obese, respectively. A minority of patients achieved HbA1c ≤ 7.5% and by 24 months the proportion achieving this was: normal weight 41%; overweight 34%; obese 30%; clinically obese 26%; morbidly obese 31%; trend p < 0.001. The greatest weight gain occured by 6 months and multivariate adjusted models showed that normal weight patients had the highest gains 5.07 kg (95% CI: 3.35, 6.79), as did those with HbA1c ≥ 12.1%-5.55 kg (95% CI: 3.81, 7.28).

CONCLUSION

Obesity is associated with a poorer response to insulin illustrated by higher HbA1c values and lower achievement of targets.

Intensive diabetes therapy and body weight: focus on insulin detemir

Weight gain can be a significant barrier to the treatment of diabetes. Insulin detemir is a basal insulin analog that can help patients move safely toward glycemic targets with less weight gain. This review discusses the potential adverse effects of, and hypothesis for, weight gain resulting from intensive insulin management of diabetes. In addition, an assessment of all weight change data from clinical trials and observational studies involving insulin detemir are presented. Finally, we discuss how the ability of insulin detemir to closely mimic endogenous insulin secretion leads to more predictable glycemic control with reduced weight gain and provides patients with a more acceptable method of achieving glycemic control.

Glycemic and risk factor control in type 1 diabetes: results from 13,612 patients in a national diabetes register

OBJECTIVE

This study was designed to investigate the clinical characteristics of a large type 1 diabetic population and to evaluate the degree of fulfillment of recently updated treatment goals.

RESEARCH DESIGN AND METHODS

The Swedish National Diabetes Register was initiated in 1996 as a tool for quality assurance in diabetes care. A1C levels, treatment, and risk factors were analyzed in two cross-sectional samples of 9,424 patients in 1997 and 13,612 patients in 2004 and in a smaller longitudinal sample from 1997 to 2004.

RESULTS

Mean A1C decreased from 8.2 +/- 1.3% in 1997 to 8.0 +/- 1.2% in 2004 (P < 0.001). The proportion of patients reaching A1C <7.0% increased from 17.4 to 21.2% in 2004. A slow but significant improvement in blood pressure levels was seen, but only 61.3% reached the blood pressure goal of <130/80 mmHg in 2004. Lipid control improved, and the use of lipid-lowering drugs increased. Among patients treated with lipid-lowering agents, 38% reached the goal of total cholesterol <4.5 mmol/l, and 48% reached the goal of LDL cholesterol <2.5 mmol/l. Successful long-term glycemic and blood pressure control were both independently predicted by low BMI and the absence of microalbuminuria in 1997.

CONCLUSIONS

In this large cohort of type 1 diabetic patients, there was a slow improvement in glycemic and risk factor control from 1997 to 2004, although the gap between the clinical results and current Swedish and American treatment goals is still unsatisfactory. It is crucial that additional measures be taken to improve risk factor control in type 1 diabetic patients.

Continuous perioperative insulin infusion therapy for patients with type 2 diabetes undergoing bariatric surgery

BACKGROUND

Continuous insulin infusion (CII) is proven to decrease morbidity and mortality in surgical critical care patients. This study compared standard insulin therapy with CII in type 2 diabetes patients undergoing elective bariatric surgical procedures in a community hospital.

METHODS

A retrospective review investigated 350 bariatric surgical patients with type 2 diabetes who underwent perioperative treatment of hyperglycemia using either standard insulin therapy or CII. The 182 patients in group 1 underwent glucose monitoring and subcutaneous insulin treatment every 6 h, whereas the 168 patients in group 2 had CII treatment beginning in the preoperative holding area and monitored hourly for the next 24 h. The two groups were similar in demographic characteristics.

RESULTS

There were no significant hypoglycemic episodes with perioperative CII. The mean perioperative insulin required was 5.8 U/h. The patients receiving CII had fewer postprocedure cholecystectomies, but a higher number of port-site infections.

CONCLUSIONS

Perioperative CII can be administered safely to diabetic patients undergoing bariatric surgery. The insulin requirements in this population are higher than expected. Our study showed a decrease in the number of postoperative cholecystectomies in the CII group, but no effect on the stricture rate and an increase in the number of patients with postoperative port-site infections.

At last, a weight neutral insulin?

In the treatment of diabetes, the positive correlation between weight gain and glycaemic control is well known. Inappropriate weight gain has been demonstrated in landmark diabetes studies, with insulin or oral antidiabetic drugs. Weight increase is associated with accelerated deterioration in beta-cell function in type II diabetes, and increases in hypertension and lipid levels in both type I and type II diabetes. Concerns about increasing weight may be a barrier to initiation or to intensification of insulin therapy. Insulin introduction may be delayed in type II diabetes, and patients may under-dose their insulin to avoid gaining weight. Insulin detemir is a new long-acting soluble insulin analogue where protraction is achieved by reversible binding to albumin. As a result, it has consistent absorption and low variability from injection to injection. Studies of insulin detemir in basal-bolus regimens in type I and type II diabetes have shown significantly less weight gain compared with NPH. There is speculation about potential mechanisms for these outcomes and results from ongoing investigations are awaited. The insulin detemir data suggest that weight gain with insulin therapy is not inevitable. The potential therefore exists for improving glycaemic control while maintaining weight stability, resulting in immediate and long-term benefits for patients.

Day-to-day consistency in amount and source of carbohydrate intake associated with improved blood glucose control in type 1 diabetes

OBJECTIVE

To determine if a relationship exists between blood glucose control and variability in nutrient intake from day-to-day in subjects with type 1 diabetes.

METHODS

Two three-day diet records and one measurement of glycated hemoglobin (HbA1c) were obtained from 272 subjects with type 1 diabetes treated with a mixture of regular and NPH insulins before breakfast and supper and using a standardized algorithm to adjust insulin dose according to the results of self-monitoring of blood glucose two to four times daily. Day-to-day variation in nutrient intake was expressed as the coefficient of variation (CV = SDx100/mean).

RESULTS

Nutrient intakes in the study population (mean +/- SD) were energy 8.35+/-2.43 MJ, fat 81+/-30 g, protein 94+/-28 g, carbohydrate 227+/-68 g, starch 126+/-38 g and dietary fiber 20+/-6 g with diet glycemic index being 84.2+/-7.4. Neither energy, nutrient intakes nor insulin dose was significantly related to HbA1c. Day-to-day variation of carbohydrate (p = 0.0097) and starch (p = 0.0016) intakes and diet glycemic index (p = 0.033) was positively related to HbA1c, and the associations remained significant when adjusted for age, sex, duration of diabetes and BMI. Day-to-day variation in energy, protein or fat intakes was not related to HbA1c.

CONCLUSIONS

Consistency in the amount and source of carbohydrate intake from day-to-day is associated with improved blood glucose control in people with type 1 diabetes, a result which supports continued educational efforts to achieve adherence to a diabetes diet plan. This conclusion may not apply to people on intensified insulin therapy who adjust their insulin dose based on their actual carbohydrate intake at each meal.