The WHO Global Diabetes Compact: a new initiative to support people living with diabetes

Effect of a multicomponent quality improvement strategy on sustained achievement of diabetes care goals and macrovascular and microvascular complications in South Asia at 6.5 years follow-up: Post hoc analyses of the CARRS randomized clinical trial

BACKGROUND

Diabetes control is poor globally and leads to burdensome microvascular and macrovascular complications. We aimed to assess post hoc between-group differences in sustained risk factor control and macrovascular and microvascular endpoints at 6.5 years in the Center for cArdiovascular Risk Reduction in South Asia (CARRS) randomized trial.

METHODS AND FINDINGS

This parallel group individual randomized clinical trial was performed at 10 outpatient diabetes clinics in India and Pakistan from January 2011 through September 2019. A total of 1,146 patients with poorly controlled type 2 diabetes (HbA1c ≥8% and systolic BP ≥140 mm Hg and/or LDL-cholesterol ≥130 mg/dl) were randomized to a multicomponent quality improvement (QI) strategy (trained nonphysician care coordinator to facilitate care for patients and clinical decision support system for physicians) or usual care. At 2.5 years, compared to usual care, those receiving the QI strategy were significantly more likely to achieve multiple risk factor control. Six clinics continued, while 4 clinics discontinued implementing the QI strategy for an additional 4-year follow-up (overall median 6.5 years follow-up). In this post hoc analysis, using intention-to-treat, we examined between-group differences in multiple risk factor control (HbA1c <7% plus systolic BP <130 mm Hg and/or LDL-cholesterol <100 mg/dl) and first macrovascular endpoints (nonfatal myocardial infarction, nonfatal stroke, death, revascularization [angioplasty or coronary artery bypass graft]), which were coprimary outcomes. We also examined secondary outcomes, namely, single risk factor control, first microvascular endpoints (retinopathy, nephropathy, neuropathy), and composite first macrovascular plus microvascular events (which also included amputation and all-cause mortality) by treatment group and whether QI strategy implementation was continued over 6.5 years. At 6.5 years, assessment data were available for 854 participants (74.5%; n = 417 [intervention]; n = 437 [usual care]). In terms of sociodemographic and clinical characteristics, participants in the intervention and usual care groups were similar and participants at sites that continued were no different to participants at sites that discontinued intervention implementation. Patients in the intervention arm were more likely to exhibit sustained multiple risk factor control than usual care (relative risk: 1.79; 95% confidence interval [CI], 1.45, 2.20), p < 0.001. Cumulatively, there were 233 (40.5%) first microvascular and macrovascular events in intervention and 274 (48.0%) in usual care patients (absolute risk reduction: 7.5% [95% CI: -13.2, -1.7], p = 0.01; hazard ratio [HR] = 0.72 [95% CI: 0.61, 0.86]), p < 0.001. Patients in the intervention arm experienced lower incidence of first microvascular endpoints (HR = 0.68 [95% CI: 0.56, 0.83), p < 0.001, but there was no evidence of between-group differences in first macrovascular events. Beneficial effects on microvascular and composite vascular outcomes were observed in sites that continued, but not sites that discontinued the intervention.

CONCLUSIONS

In urban South Asian clinics, a multicomponent QI strategy led to sustained multiple risk factor control and between-group differences in microvascular, but not macrovascular, endpoints. Between-group reductions in vascular outcomes at 6.5 years were observed only at sites that continued the QI intervention, suggesting that practice change needs to be maintained for better population health of people with diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01212328.

Type 1 and type 2 diabetes mortality burden: Predictions for 2030 based on Bayesian age-period-cohort analysis of China and global mortality burden from 1990 to 2019

AIMS

This study assessed diabetes (type 1 and type 2) mortality in China and globally from 1990 to 2019, predicting the next decade's trends.

MATERIALS AND METHODS

Data came from the Global Burden of Disease (GBD) database. The annual percentage change (AAPC) in age-standardized mortality rates (ASMR) for diabetes (type 1 and type 2) during 1990-2019 was calculated. A Bayesian age-period-cohort (BAPC) model predicted diabetes (type 1 and type 2) mortality from 2020 to 2030.

RESULTS

In China, type 1 diabetes deaths declined from 6,005 to 4,504 cases (AAPC -2.827), while type 2 diabetes deaths rose from 64,084 to 168,388 cases (AAPC -0.763) from 1990 to 2019. Globally, type 1 diabetes deaths increased from 55,417 to 78,236 cases (AAPC 0.223), and type 2 diabetes deaths increased from 606,407 to 1,472,934 cases (AAPC 0.365). Both China and global trends showed declining type 1 diabetes ASMR. However, female type 2 diabetes ASMR in China initially increased and then decreased, while males had a rebound trend. Peak type 1 diabetes deaths were in the 40-44 age group, and type 2 diabetes peaked in those over 70. BAPC predicted declining diabetes (type 1 and type 2) mortality burden in China and globally over the next 10 years.

CONCLUSIONS

Type 2 diabetes mortality remained high in China and globally despite decreasing type 1 diabetes mortality over 30 years. Predictions suggest a gradual decrease in diabetes mortality over the next decade, highlighting the need for continued focus on type 2 diabetes prevention and treatment.

New advances in type 1 diabetes

Type 1 diabetes is an autoimmune condition resulting in insulin deficiency and eventual loss of pancreatic β cell function requiring lifelong insulin therapy. Since the discovery of insulin more than 100 years ago, vast advances in treatments have improved care for many people with type 1 diabetes. Ongoing research on the genetics and immunology of type 1 diabetes and on interventions to modify disease course and preserve β cell function have expanded our broad understanding of this condition. Biomarkers of type 1 diabetes are detectable months to years before development of overt disease, and three stages of diabetes are now recognized. The advent of continuous glucose monitoring and the newer automated insulin delivery systems have changed the landscape of type 1 diabetes management and are associated with improved glycated hemoglobin and decreased hypoglycemia. Adjunctive therapies such as sodium glucose cotransporter-1 inhibitors and glucagon-like peptide 1 receptor agonists may find use in management in the future. Despite these rapid advances in the field, people living in under-resourced parts of the world struggle to obtain necessities such as insulin, syringes, and blood glucose monitoring essential for managing this condition. This review covers recent developments in diagnosis and treatment and future directions in the broad field of type 1 diabetes.

The diabetes care continuum in Venezuela: Cross-sectional and longitudinal analyses to evaluate engagement and retention in care

The impact of the humanitarian crisis in Venezuela on care for noncommunicable diseases (NCDs) such as diabetes is unknown. This study aims to document health system performance for diabetes management in Venezuela during the humanitarian crisis. This longitudinal study on NCDs is nationally representative at baseline (2014-2017) and has follow-up (2018-2020) data on 35% of participants. Separate analyses of the baseline population with diabetes (n = 585) and the longitudinal population with diabetes (n = 210) were conducted. Baseline analyses constructed a weighted care continuum: all diabetes; diagnosed; treated; achieved glycaemic control; achieved blood pressure, cholesterol, and glycaemic control; and achieved aforementioned control plus non-smoking. Weighted multinomial regression models controlling for region were used to estimate the association between socio-demographic characteristics and care continuum stage. Longitudinal analyses constructed an unweighted care continuum: all diabetes; diagnosed; treated; and achieved glycaemic control. Unweighted multinomial regression models controlling for region were used to estimate the association between socio-demographic characteristics and changes in care continuum stage. Among 585 participants with diabetes at baseline, 71% were diagnosed, 51% were on treatment, and 32% had achieved glycaemic control. Among 210 participants with diabetes in the longitudinal population, 50 (24%) participants' diabetes management worsened, while 40 (19%) participants improved. Specifically, the proportion of those treated decreased (60% in 2014-2017 to 51% in 2018-2020), while the proportion of participants achieving glycaemic control did not change. Although treatment rates have declined substantially among people with diabetes in Venezuela, management changed less than expected during the crisis.

Prevalence of Chronic Kidney Disease in Individuals With Type 2 Diabetes Within Primary Care: A Cross-Sectional Study

AIMS

To assess the prevalence and risk factors for chronic kidney disease (CKD) among adults with type 2 diabetes within primary care.

METHODS

This cross-sectional study evaluated 1319 individuals receiving standard care across 26 primary units from July 2017 to January 2023. The estimated glomerular filtration rate (eGFR) and albuminuria were used for the diagnosis of CKD. CKD was defined by eGFR values of <60 mL/min/1.73 m2 and/or albumin-to-creatine ratio ≥30 mg/g. Logistic regression was applied to identify factors associated with CKD and study variables.

RESULTS

The median age of participants (60.6% females) was 55 years and the median diabetes duration was 10 years. The overall CKD prevalence in the study population was 39.2%. Within the CKD group, the prevalence rates of albuminuria, albuminuria coupled with low eGFR and isolated low eGFR were 72.1%, 19%, and 8.9%, respectively. The prevalence of CKD was 30.6% among participants under 40 years old and a higher value was observed in middle-aged adults with early-onset diabetes (at age <40 years) compared with the later-onset group. Multivariable analyses identified associations between CKD and factors such as age, the male sex, diabetes duration, hypertension, retinopathy, and metformin use.

CONCLUSION

A relatively high prevalence of CKD, especially in non-elderly adults, was revealed in this primary care study. Early recognition strategies for CKD are crucial for timely prevention within primary care.

Budget impact analysis for three glucagon-like peptide-1 receptor agonist-based therapies for type 2 diabetes mellitus management in Saudi Arabia

BACKGROUND AND OBJECTIVES

This study presents a budget impact analysis (BIA) conducted in Saudi Arabia, evaluating the cost implications of adopting semaglutide, tirzepatide, or dulaglutide in the management of type 2 diabetes mellitus (T2DM) patients. The analysis aims to assess the individual budgetary impact of these treatment options on healthcare budgets and provide insights for decision-makers.

METHODS

A prevalence-based BIA was developed using real-world and clinical trials data. The model considered disease epidemiology, medication prices, diabetes management expenses, cardiovascular (CV) complications costs, and weight reduction savings over a 5-year time horizon. One-way and probabilistic sensitivity analyses (OWSA, PSA) were performed to assess the robustness of the results.

RESULTS

Over a 5-year period, the cumulative budget impact for semaglutide, tirzepatide, and dulaglutide were 85,923,089 USD, 169,790,195 USD, and 94,558,356 USD, respectively. Hypothetical scenarios considering price parity between semaglutide and tirzepatide are associated with financial impacts of 85,923,091 USD and 86,475,335 USD, respectively. In the public sector, semaglutide showed the lowest incidence of 3-point major adverse CV events (3P-MACE), with tirzepatide leading in weight loss and HbA1c reduction, and dulaglutide presenting the highest 3P-MACE rates and least improvements in HbA1c and weight. A breakeven analysis suggested that tirzepatide's list price would need to be $199.91 lower than its current list price to achieve budget impact parity with semaglutide based on currently available evidence. Results from the OWSA suggested that risk reductions for CV events were key drivers of budget impact. PSA results were confirmatory of base-case analyses.

CONCLUSIONS

CV cost-offsets and drug acquisition considerations may make semaglutide a favorable use of resources for Saudi budget planners and decision-makers. These results were robust to assumptions regarding the list price of tirzepatide.

Identifying the necessary capacities for the adaptation of a diabetes phenotyping algorithm in countries of differing economic development status

BACKGROUND

In 2019, the World Health Organization recognised diabetes as a clinically and pathophysiologically heterogeneous set of related diseases. Little is currently known about the diabetes phenotypes in the population of low- and middle-income countries (LMICs), yet identifying their different risks and aetiology has great potential to guide the development of more effective, tailored prevention and treatment.

OBJECTIVES

This study reviewed the scope of diabetes datasets, health information ecosystems, and human resource capacity in four countries to assess whether a diabetes phenotyping algorithm (developed under a companion study) could be successfully applied.

METHODS

The capacity assessment was undertaken with four countries: Trinidad, Malaysia, Kenya, and Rwanda. Diabetes programme staff completed a checklist of available diabetes data variables and then participated in semi-structured interviews about Health Information System (HIS) ecosystem conditions, diabetes programme context, and human resource needs. Descriptive analysis was undertaken.

RESULTS

Only Malaysia collected the full set of the required diabetes data for the diabetes algorithm, although all countries did collect the required diabetes complication data. An HIS ecosystem existed in all settings, with variations in data hosting and sharing. All countries had access to HIS or ICT support, and epidemiologists or biostatisticians to support dataset preparation and algorithm application.

CONCLUSIONS

Malaysia was found to be most ready to apply the phenotyping algorithm. A fundamental impediment in the other settings was the absence of several core diabetes data variables. Additionally, if countries digitise diabetes data collection and centralise diabetes data hosting, this will simplify dataset preparation for algorithm application. These issues reflect common LMIC health systems' weaknesses in relation to diabetes care, and specifically highlight the importance of investment in improving diabetes data, which can guide population-tailored prevention and management approaches.

Type 2 diabetes in the Democratic Republic of Congo: an urgent need for a management framework

Glycaemic control is of one the main goals for managing type 2 diabetes. In sub-Saharan Africa and the Democratic Republic of the Congo, studies have reported alarming poor control rates. Patients with poor glycaemic control are exposed to complications leading to high cost of care and deteriorated quality of life. In recent studies by our group, we have demonstrated that poor glycaemic control is high and driven by proximal (individual) and distal (structural) factors in Kinshasa, Democratic Republic of the Congo. Financial constraints impacted many aspects of care at multiple levels from the Government to persons living with diabetes. Financial constraints prevented good preparation, organization and access to diabetes care. Difficulties in implementing lifestyle changes, lack of health literacy and limited healthcare support were also contributing to poor glycaemic control. Through a Delphi study, a group of experts reached a consensus on five potential strategies for improving glycaemic control in the Democratic Republic of Congo as follows: changing the healthcare system for better diabetes care extended to other noncommunicable diseases, ensuring consistent financing of the healthcare, augmenting the awareness of diabetes among the general population and the persons living with diabetes, easing the adoption of lifestyle modifications and reducing the burden of undiagnosed diabetes. This paper reflects on the urgent need for an improved management framework for diabetes care in the Democratic Republic of the Congo. Specifically, the Government needs to increase the investment in the prevention and treatment of noncommunicable diseases including diabetes.

Optimization of nutritional strategies using a mechanistic computational model in prediabetes: Application to the J-DOIT1 study data

Lifestyle interventions have been shown to prevent or delay the onset of diabetes; however, inter-individual variability in responses to such interventions makes lifestyle recommendations challenging. We analyzed the Japan Diabetes Outcome Intervention Trial-1 (J-DOIT1) study data using a previously published mechanistic simulation model of type 2 diabetes onset and progression to understand the causes of inter-individual variability and to optimize dietary intervention strategies at an individual level. J-DOIT1, a large-scale lifestyle intervention study, involved 2607 subjects with a 4.2-year median follow-up period. We selected 112 individuals from the J-DOIT1 study and calibrated the mechanistic model to each participant's body weight and HbA1c time courses. We evaluated the relationship of physiological (e.g., insulin sensitivity) and lifestyle (e.g., dietary intake) parameters with variability in outcome. Finally, we used simulation analyses to predict individually optimized diets for weight reduction. The model predicted individual body weight and HbA1c time courses with a mean (±SD) prediction error of 1.0 kg (±1.2) and 0.14% (±0.18), respectively. Individuals with the most and least improved biomarkers showed no significant differences in model-estimated energy balance. A wide range of weight changes was observed for similar model-estimated caloric changes, indicating that caloric balance alone may not be a good predictor of body weight. The model suggests that a set of optimal diets exists to achieve a defined weight reduction, and this set of diets is unique to each individual. Our diabetes model can simulate changes in body weight and glycemic control as a result of lifestyle interventions. Moreover, this model could help dieticians and physicians to optimize personalized nutritional strategies according to their patients' goals.

Identifying sex-specific anthropometric measures and thresholds for dysglycemia screening in an HIV-endemic rural South African population

Valid screening and diagnostic algorithms are needed to achieve 2030 targets proposed by the WHO's Global Diabetes Compact. We explored anthropometric thresholds to optimally screen and refer individuals for diabetes testing in rural South Africa. We evaluated screening thresholds for waist circumference (WC), body mass index (BMI), and waist-hip ratio (WHR) to detect dysglycemia based on a glycated hemoglobin (HbA1C) ≥6.5% among adults in a population-based study in South Africa using weighted, non-parametric ROC regression analyses. We then assessed the diagnostic validity of traditional obesity thresholds, explored optimal thresholds for this population, and fit models stratified by sex, age, and HIV status. The prevalence of dysglycemia in the total study population (n = 17,846) was 7.7%. WC had greater discriminatory capacity than WHR to detect dysglycemia in men (p-value<0.001) and women (p<0.001). WC had greater discriminatory capacity than BMI to detect dysglycemia in women (p<0.001). However, BMI and WC performed similarly for men (p = 0.589). Whereas traditional WC thresholds for women (>81cm) performed well (sensitivity 91%, positive predictive value [PPV] 14.9%), substantially lower thresholds were needed to achieve acceptable sensitivity and PPV among men (traditional >94cm, derived >79.5cm). WC outperforms BMI as an anthropometric screening measure for dysglycemia in rural South Africa. Whereas WC guideline thresholds are appropriate for women, male-derived WC cutoffs performed better at lower thresholds. In this rural South African population, thresholds that maximize specificity and PPV for efficient resource allocation may be preferred.

The role of structural racism and geographical inequity in diabetes outcomes

Diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally. In this Series paper, we use new theoretical frameworks and a narrative review of existing literature to show how structural inequity (structural racism and geographical inequity) has accelerated rates of diabetes disease, morbidity, and mortality globally. We discuss how structural inequity leads to large, fixed differences in key, upstream social determinants of health, which influence downstream social determinants of health and resultant diabetes outcomes in a cascade of widening inequity. We review categories of social determinants of health with known effects on diabetes outcomes, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. We also provide regional perspectives, grounded in our theoretical framework, to highlight prominent, real-world challenges.

Interventions to address global inequity in diabetes: international progress

Diabetes is a serious chronic disease with high associated burden and disproportionate costs to communities based on socioeconomic, gender, racial, and ethnic status. Addressing the complex challenges of global inequity in diabetes will require intentional efforts to focus on broader social contexts and systems that supersede individual-level interventions. We codify and highlight best practice approaches to achieve equity in diabetes care and outcomes on a global scale. We outline action plans to target diabetes equity on the basis of the recommendations established by The Lancet Commission on Diabetes, organising interventions by their effect on changing the ecosystem, building capacity, or improving the clinical practice environment. We present international examples of how to address diabetes inequity in the real world to show that approaches addressing the individual within a larger social context, in addition to addressing structural inequity, hold the greatest promise for creating sustainable and equitable change that curbs the global diabetes crisis.

Improving health outcomes of people with diabetes: target setting for the WHO Global Diabetes Compact

The Global Diabetes Compact is a WHO-driven initiative uniting stakeholders around goals of reducing diabetes risk and ensuring that people with diabetes have equitable access to comprehensive, affordable care and prevention. In this report we describe the development and scientific basis for key health metrics, coverage, and treatment targets accompanying the Compact. We considered metrics across four domains: factors at a structural, system, or policy level; processes of care; behaviours and biomarkers such as glycated haemoglobin (HbA1c); and health events and outcomes; and three risk tiers (diagnosed diabetes, high risk, or whole population), and reviewed and prioritised them according to their health importance, modifiability, data availability, and global inequality. We reviewed the global distribution of each metric to set targets for future attainment. This process led to five core national metrics and target levels for UN member states: (1) of all people with diabetes, at least 80% have been clinically diagnosed; and, for people with diagnosed diabetes, (2) 80% have HbA1c concentrations below 8·0% (63·9 mmol/mol); (3) 80% have blood pressure lower than 140/90 mm Hg; (4) at least 60% of people 40 years or older are receiving therapy with statins; and (5) each person with type 1 diabetes has continuous access to insulin, blood glucose meters, and test strips. We also propose several complementary metrics that currently have limited global coverage, but warrant scale-up in population-based surveillance systems. These include estimation of cause-specific mortality, and incidence of end-stage kidney disease, lower-extremity amputations, and incidence of diabetes. Primary prevention of diabetes and integrated care to prevent long-term complications remain important areas for the development of new metrics and targets. These metrics and targets are intended to drive multisectoral action applied to individuals, health systems, policies, and national health-care access to achieve the goals of the Global Diabetes Compact. Although ambitious, their achievement can result in broad health benefits for people with diabetes.

Exploring Probenecid Derived 1,3,4-Oxadiazole-Phthalimide Hybrid as α-Amylase Inhibitor: Synthesis, Structural Investigation, and Molecular Modeling

1,3,4-Oxadiazole moiety is a crucial pharmacophore in many biologically active compounds. In a typical synthesis, probenecid was subjected to a sequence of reactions to obtain a 1,3,4-oxadiazole–phthalimide hybrid (PESMP) in high yields. The NMR (1H and 13C) spectroscopic analysis initially confirmed the structure of PESMP. Further spectral aspects were validated based on a single-crystal XRD analysis. Experimental findings were confirmed afterwards by executing a Hirshfeld surface (HS) analysis and quantum mechanical computations. The HS analysis showed the role of the π⋯π stacking interactions in PESMP. PESMP was found to have a high stability and lower reactivity in terms of global reactivity parameters. α-Amylase inhibition studies revealed that the PESMP was a good inhibitor of α-amylase with an s value of 10.60 ± 0.16 μg/mL compared with that of standard acarbose (IC50 = 8.80 ± 0.21 μg/mL). Molecular docking was also utilized to reveal the binding pose and features of PESMP against the α-amylase enzyme. Via docking computations, the high potency of PESMP and acarbose towards the α-amylase enzyme was unveiled and confirmed by docking scores of −7.4 and −9.4 kcal/mol, respectively. These findings shine a new light on the potential of PESMP compounds as α-amylase inhibitors.

Socioeconomic inequality in awareness, treatment and control of diabetes among adults in India: Evidence from National Family Health Survey of India (NFHS), 2019-2021

Diabetes is a growing epidemic and a major threat to most of the households in India. Yet, there is little evidence on the extent of awareness, treatment, and control (ATC) among adults in the country. In this study, we estimate the prevalence and ATC of diabetes among adults across various sociodemographic groups and states of India. We used data on 2,078,315 individuals aged 15 years and over from the recent fifth round, the most recent one, of the National Family Health Survey (NFHS-5), 2019-2021, that was carried out across all the states of India. Diabetic individuals were identified as those who had random blood glucose above 140 mg/dL or were taking diabetes medication or has doctor-diagnosed diabetes. Diabetic individuals who reported diagnosis were labelled as aware, those who reported taking medication for controlling blood glucose levels were labelled as treated and those whose blood glucose levels were < 140 mg/dL were labelled as controlled. The estimates of prevalence of diabetes, and ATC were age-sex adjusted and disaggregated by household wealth quintile, education, age, sex, urban-rural residence, caste, religion, marital status, household size, and state. Concentration index was used to quantify socioeconomic inequalities and multivariable logistic regression was used to estimate the adjusted differences in those outcomes. We estimated diabetes prevalence to be 16.1% (15.9-16.1%). Among those with diabetes, 27.5% (27.1-27.9%) were aware, 21.5% (21.1-21.7%) were taking treatment and 7% (6.8-7.1%) had their diabetes under control. Across the states of India, the adjusted rates of awareness varied from 14.4% (12.1-16.8%) to 54.4% (40.3-68.4%), of treatment from 9.3% (7.5-11.1%) to 41.2% (39.9-42.6%), and of control from 2.7% (1.6-3.7%) to 11.9% (9.7-14.0%). The age-sex adjusted rates were lower (p < 0.001) among the poorer and less educated individuals as well as among males, residents of rural areas, and those from the socially backward groups Among individuals with diabetes, the richest fifth were respectively 12.4 percentage points (pp) (11.3-13.4; p < 0.001), 10.5 pp (9.7-11.4; p < 0.001), and 2.3 pp (1.6-3.0; p < 0.001) more likely to be aware, getting treated, and having diabetes under control, than the poorest fifth. The concentration indices of ATC were 0.089 (0.085-0.092), 0.083 (0.079-0.085) and 0.017 (0.015-0.018) respectively. Overall, the ATC of diabetes is low in India. It is especially low the poorer and the less educated individuals. Targeted interventions and management can reduce the diabetes burden in India.

An Innovative Teaching Approach for Diabetes Mellitus in Laboratory Medicine Uses the Clinical Laboratory Diagnostic Pathway

Objectives

The routine teaching mode of diabetes mellitus (DM) is divided into various sub-majors of medical laboratory, which is not conducive to clinical laboratory physicians quickly mastering relevant knowledge. A novel DM laboratory testing pathway is established to improve teaching efficiency and enhance the effects of talent cultivation in laboratory medicine.

Methods

The guidelines and expert consensuses of DM were gathered from professional websites and databases. The clinical laboratory diagnostic pathway was formulated, and the questionnaire and mutual evaluation were used to evaluate the teaching effectiveness of 8-year undergraduate students enrolled in 2018 and enrolled in 2019, respectively.

Results

Clinical laboratory physicians developed and approved the DM clinical laboratory diagnostic pathway, which included the entire process of DM diagnosis and differential diagnosis, drug selection, treatment impact monitoring, prognosis evaluation, etc. The results of the questionnaires showed that, in comparison to the teaching mode used with the students enrolled in 2018 and enrolled in 2019, the percentages of more improvement and significant improvement were significantly increased (P < 0.01) and the percentages of no improvement and slight improvement were significantly decreased (P < 0.01). Following the instruction of the DM clinical laboratory diagnostic route, the results were greatly improved, including points emphasized and the accuracy of responding to questions, among other things, according to the teachers' and students' mutual evaluation (P < 0.05).

Conclusions

To enhance the teaching quality in laboratory medicine, it is required to build the disease clinical laboratory diagnostic pathway for a novel teaching method. This may boost teachers' and students' confidence and broaden their knowledge.

Effectiveness of the chronic care model for adults with type 2 diabetes in primary care: a systematic review and meta-analysis

BACKGROUND

Mixed evidence exists regarding the effectiveness of the Chronic Care Model (CCM) with patient outcomes. The aim of this review is to examine the effectiveness of CCM interventions on hemoglobin A1c (HbA_1c), systolic BP (SBP), diastolic BP (DBP), LDL cholesterol and body mass index (BMI) among primary care adults with type 2 diabetes.

METHODS

PubMed, Embase, CINAHL, Cochrane Central Registry of Controlled Trials, Scopus and Web of Science were searched from January 1990 to June 2021 for randomized controlled trials (RCTs) comparing CCM interventions against usual care among adults with type 2 diabetes mellitus in primary care with HbA_1c, SBP, DBP, LDL cholesterol and BMI as outcomes. An abbreviated search was performed from 2021 to April 2022. This study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for data extraction and Cochrane risk of bias assessment. Two reviewers independently extracted the data. Meta-analysis was performed using Review Manager software. Heterogeneity was evaluated using χ² and I² test statistics. Overall effects were evaluated using Z statistic.

RESULTS

A total of 17 studies involving 16485 patients were identified. Most studies had low risks of bias. Meta-analysis of all 17 studies revealed that CCM interventions significantly decreased HbA_1c levels compared to usual care, with a mean difference (MD) of -0.21%, 95% CI -0.30, -0.13; Z = 5.07, p<0.00001. Larger effects were experienced among adults with baseline HbA_1c ≥8% (MD -0.36%, 95% CI -0.51, -0.21; Z = 5.05, p<0.00001) and when four or more CCM elements were present in the interventions (MD -0.25%, 95% CI -0.35, -0.15; Z = 4.85, p<0.00001). Interventions with CCM decreased SBP (MD -2.93 mmHg, 95% CI -4.46, -1.40, Z = 3.75, p=0.0002) and DBP (MD -1.35 mmHg, 95% CI -2.05, -0.65, Z = 3.79, p=0.0002) compared to usual care but there was no impact on LDL cholesterol levels or BMI.

CONCLUSIONS

CCM interventions, compared to usual care, improve glycaemic control among adults with type 2 diabetes in primary care, with greater reductions when the mean baseline HbA_1c is ≥8% and with interventions containing four or more CCM elements.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO  CRD42021273959.

A WHO key informant language survey of people with lived experiences of diabetes: Media misconceptions, values-based messaging, stigma, framings and communications considerations

AIMS

This study aimed to learn from people with lived experiences of diabetes to raise the quality of diabetes communications.

METHODS

An online key informant survey for people (18+) with a direct and/or adjacent (caregiver, friend, family-member etc.,) lived experience of diabetes. Through thematic analysis, we gathered insights on perceptions of media reporting on diabetes and communicating with accuracy, impact and without stigma. Descriptive analysis also investigated effective values for WHO to communicate diabetes with key audiences of policy-makers, funding partners and the general public.

RESULTS

918 respondents in 58 WHO Member States were analysed. Participants identified five key themes requiring more appropriate consideration in the media: accurately defining diabetes types, over-emphasis on sugar and lifestyle, negative impacts of diabetes stigma, burden of costs (financial, personal and interpersonal) and mental health. Irrespective of audience, key values-based messages identified as important for WHO to convey included: 'urgency', 'preventing suffering', 'improving wellbeing' and 'meaningful engagement' of people with lived experience.

CONCLUSION

Learning from people with lived experience of diabetes identifies key diabetes communication considerations. Continued meaningful engagement of this group, including in WHO's work and the multistakeholder diffusion of this methodology to local contexts, could improve public discourse on diabetes and related policies.

The continuum of insulin development viewed in the context of a collaborative process toward leveraging science to save lives: Following the trail of publications and patents one century after insulin's first use in humans

Nearly 100 years ago, diabetes, a disease expected to reach global prevalence of at least 10% within the decade, was a fatal diagnosis. This year of 2022 marks a century since insulin, a lifesaving treatment for those living with diabetes, was purified, tested in humans, and brought to the bedside through widespread commercial production, thus saving countless lives. Insulin's arrival to the world stage was acknowledged with the 1923 Nobel Prize in Physiology or Medicine for "the discovery of insulin", the first among several Prizes awarded to honor scientific work on insulin. This initial awarding has been the subject of significant controversy since, as numerous other scientists paved the way towards the ultimate success, and priority for the true "discovery of insulin" has been argued for many other scientists. The intention and regulations around the Nobel Prize nomination and award process presented herein offer insight into the 1923 Nobel prize designation for the Toronto group, which distinguished itself in the accomplishment by their success in purifying insulin from pancreatic extract and in bringing insulin to worldwide production and the homes of those who needed it. However, a continuous, collaborative process involving contributors spanning centuries and continents was required for the development, rather than discovery, of insulin therapy and its benefits to humanity. This should be the story's enduring legacy. The prior 100 years have witnessed a series of significant innovations in insulin development and therapeutics, but both a cure for diabetes and equitable insulin access remain out of reach and require inspired attention and continuous diligent efforts.

Rural-Urban Differences in Diabetes Care and Control in 42 Low- and Middle-Income Countries: A Cross-sectional Study of Nationally Representative Individual-Level Data

OBJECTIVE

Diabetes prevalence is increasing rapidly in rural areas of low- and middle-income countries (LMICs), but there are limited data on the performance of health systems in delivering equitable and effective care to rural populations. We therefore assessed rural-urban differences in diabetes care and control in LMICs.

RESEARCH DESIGN AND METHODS

We pooled individual-level data from nationally representative health surveys in 42 countries. We used Poisson regression models to estimate age-adjusted differences in the proportion of individuals with diabetes in rural versus urban areas achieving performance measures for the diagnosis, treatment, and control of diabetes and associated cardiovascular risk factors. We examined differences across the pooled sample, by sex, and by country.

RESULTS

The pooled sample from 42 countries included 840,110 individuals (35,404 with diabetes). Compared with urban populations with diabetes, rural populations had ∼15-30% lower relative risk of achieving performance measures for diabetes diagnosis and treatment. Rural populations with diagnosed diabetes had a 14% (95% CI 5-22%) lower relative risk of glycemic control, 6% (95% CI -5 to 16%) lower relative risk of blood pressure control, and 23% (95% CI 2-39%) lower relative risk of cholesterol control. Rural women with diabetes had lower achievement of performance measures relating to control than urban women, whereas among men, differences were small.

CONCLUSIONS

Rural populations with diabetes experience substantial inequities in the achievement of diabetes performance measures in LMICs. Programs and policies aiming to strengthen global diabetes care must consider the unique challenges experienced by rural populations.

Diet-induced weight loss in obese/diabetic mice normalizes glucose metabolism and promotes functional recovery after stroke

BACKGROUND

Post-stroke functional recovery is severely impaired by type 2 diabetes (T2D). This is an important clinical problem since T2D is one of the most common diseases. Because weight loss-based strategies have been shown to decrease stroke risk in people with T2D, we aimed to investigate whether diet-induced weight loss can also improve post-stroke functional recovery and identify some of the underlying mechanisms.

METHODS

T2D/obesity was induced by 6 months of high-fat diet (HFD). Weight loss was achieved by a short- or long-term dietary change, replacing HFD with standard diet for 2 or 4 months, respectively. Stroke was induced by middle cerebral artery occlusion and post-stroke recovery was assessed by sensorimotor tests. Mechanisms involved in neurovascular damage in the post-stroke recovery phase, i.e. neuroinflammation, impaired angiogenesis and cellular atrophy of GABAergic parvalbumin (PV)+ interneurons were assessed by immunohistochemistry/quantitative microscopy.

RESULTS

Both short- and long-term dietary change led to similar weight loss. However, only the latter enhanced functional recovery after stroke. This effect was associated with pre-stroke normalization of fasting glucose and insulin resistance, and with the reduction of T2D-induced cellular atrophy of PV+ interneurons. Moreover, stroke recovery was associated with decreased T2D-induced neuroinflammation and reduced astrocyte reactivity in the contralateral striatum.

CONCLUSION

The global diabetes epidemic will dramatically increase the number of people in need of post-stroke treatment and care. Our results suggest that diet-induced weight loss leading to pre-stroke normalization of glucose metabolism has great potential to reduce the sequelae of stroke in the diabetic population.

A century past the discovery of insulin: global progress and challenges for type 1 diabetes among children and adolescents in low-income and middle-income countries

Type 1 diabetes is on the rise globally; however, the burden of mortality remains disproportionate in low-income and middle-income countries (LMICs). As 2021 marks 100 years since the discovery of insulin, we revisit progress, global burden of type 1 diabetes trends, and understanding of the pathogenesis and management practices related to the disease. Despite much progress, inequities in access and availability of insulin formulations persist and are reflected in differences in survival and morbidity patterns related to the disease. Some of these inequities have also been exacerbated by health-system challenges during the COVID-19 pandemic. There is a clear opportunity to improve access to insulin and related essential technologies for improved management of type 1 diabetes in LMICs, especially as a part of universal health coverage. These improvements will require concerted action and investments in human resources, community engagement, and education for the timely diagnosis and management of type 1 diabetes, as well as adequate health-care financing. Further research in LMICs, especially those in Africa, is needed to improve our understanding of the burden, risk factors, and implementation strategies for managing type 1 diabetes.