Meeting the Challenge of Diabetes in Ageing and Diverse Populations: A Review of the Literature from the UK

Recent advance in preparation of lignin nanoparticles and their medical applications: A review

BACKGROUND

Lignin has attracted a lot of attention because it is non-toxic, renewable and biodegradable. Lignin nanoparticles (LNPs) have high specific surface area and specific surface charges. It provides LNPs with good antibacterial and antioxidant properties. LNPs preparation has become clear, however, the application remains in the early stages.

PURPOSE

A review centric research has been conducted, reviewing existing literature to accomplish a basic understanding of the medical applications of LNPs.

METHODS

Initially, we extensively counseled the heterogeneity of lignin from various sources. The size and morphology of LNPs from different preparation process were then discussed. Subsequently, we focused on the potential medical applications of LNPs, including drug delivery, wound healing, tissue engineering, and antibacterial agents. Lastly, we explained the significance of LNPs in terms of antibacterial, antioxidant and biocompatibility, especially highlighting the need for an integrated framework to understand a diverse range of medical applications of LNPs.

RESULTS

We outlined the chemical structure of different type of lignin, and highlighted the advanced methods for lignin nanoparticles preparation. Moreover, we provided an in-depth review of the potential applications of lignin nanoparticles in various medical fields, especially in drug carriers, wound dressings, tissue engineering components, and antimicrobial agents.

CONCLUSION

This review provides a detailed overview on the current state and progression of lignin nanoparticles for medical applications.

Current evidence for designing self-management support for underserved populations: an integrative review using the example of diabetes

AIMS

With numerous and continuing attempts at adapting diabetes self-management support programmes to better account for underserved populations, its important that the lessons being learned are understood and shared. The work we present here reviews the latest evidence and best practice in designing and embedding culturally and socially sensitive, self-management support programmes.

METHODS

We explored the literature with regard to four key design considerations of diabetes self-management support programmes: Composition - the design and content of written materials and digital tools and interfaces; Structure - the combination of individual and group sessions, their frequency, and the overall duration of programmes; Facilitators - the combination of individuals used to deliver the programme; and Context - the influence and mitigation of a range of individual, socio-cultural, and environmental factors.

RESULTS

We found useful and recent examples of design innovation within a variety of countries and models of health care delivery including Brazil, Mexico, Netherlands, Spain, United Kingdom, and United States of America. Within Composition we confirmed the importance of retaining best practice in creating readily understood written information and intuitive digital interfaces; Structure the need to offer group, individual, and remote learning options in programmes of flexible duration and frequency; Facilitators where the benefits of using culturally concordant peers and community-based providers were described; and finally in Context the need to integrate self-management support programmes within existing health systems, and tailor their various constituent elements according to the language, resources, and beliefs of individuals and their communities.

CONCLUSIONS

A number of design principles across the four design considerations were identified that together offer a promising means of creating the next generation of self-management support programme more readily accessible for underserved communities. Ultimately, we recommend that the precise configuration should be co-produced by all relevant service and patient stakeholders and its delivery embedded in local health systems.

Impact of Voluntary, Community and Social Enterprise (VCSE) Organisations Working with Underserved Communities with Type 2 Diabetes Mellitus in England

The Voluntary, Community and Social Enterprise (VCSE) sector offers services and leadership within the health and care system in England and has a specialist role in working with underserved, deprived communities. This evaluation aims to identify best practices in self-management support for those living with type 2 diabetes mellitus (T2DM) and to develop a theory of change (TofC) through understanding the impact of VCSE organisations on diabetes management. An appreciative inquiry (AI) was carried out and co-delivered using qualitative interviews and an embedded analysis with VCSE partners. A voluntary service coordinated seven VCSE organisations who assisted with recruiting their service users and undertook interviews to identify the impact of existing activities and programmes. People living with T2DM were interviewed about services. Themes were as follows: (a) individual and group activities; (b) trusted services and relationships across the community; (c) long-term engagement; (d) sociocultural context of diet and nutritional choices; (e) experience of adaptation; and (f) culturally appropriate advice and independent VCSE organisations. The structured educational approach (DESMOND) for T2DM was accessed variably, despite these services being recommended by NICE guidelines as a standard intervention. The VCSE offered continuity and culturally appropriate services to more marginalised groups. This evaluation highlights the importance of targeted engagement with underserved communities, particularly where primary care services are more limited. The TofC is a unique insight into the impact of VCSE services, offering bespoke support to manage T2DM, suggesting areas for improvements in capacity and offering the capability to sustain the VCSE sector as an essential element of the T2DM care pathway in England.

Taking a "Care Pathway/Whole Systems" Approach to Equality Diversity Inclusion (EDI) in Organ Donation and Transplantation in Relation to the Needs of "Ethnic/Racial/Migrant" Minority Communities: A Statement and a Call for Action

International evidence shows variation in organ donation and transplantation (ODT) based upon a range of patient characteristics. What is less well understood is the impact of patient "ethnicity/race/immigration background," as these terms are defined and intended differently across countries. We also know that these characteristics do not operate in isolation but intersect with a range of factors. In this paper, we propose a framework that seeks to clarify the definition of the key terms "ethnicity/race/migrant" and to review how these communities are operationalized across European studies about inequities in ODT. Further, patients and the public wish to see Equality Diversity Inclusion (EDI) approaches in their everyday lives, not just in relation to ODT. We propose a 'care pathway/whole-systems' approach to ODT encompassing culturally competent public health interventions for a) the prevention and management of chronic diseases, b) improvements in public engagement for the promotion of the culture of ODT and enhancements in end-of-life care, through to c) enhanced likelihood of successful transplant among migrant/ethnic minority communities. Our framework recognizes that if we truly wish to take an EDI approach to ODT, we need to adopt a more social, human and holistic approach to examining questions around patient ethnicity.

Frameworks for Implementation, Uptake, and Use of Cardiometabolic Disease-Related Digital Health Interventions in Ethnic Minority Populations: Scoping Review

BACKGROUND

Digital health interventions have become increasingly common across health care, both before and during the COVID-19 pandemic. Health inequalities, particularly with respect to ethnicity, may not be considered in frameworks that address the implementation of digital health interventions. We considered frameworks to include any models, theories, or taxonomies that describe or predict implementation, uptake, and use of digital health interventions.

OBJECTIVE

We aimed to assess how health inequalities are addressed in frameworks relevant to the implementation, uptake, and use of digital health interventions; health and ethnic inequalities; and interventions for cardiometabolic disease.

METHODS

SCOPUS, PubMed, EMBASE, Google Scholar, and gray literature were searched to identify papers on frameworks relevant to the implementation, uptake, and use of digital health interventions; ethnically or culturally diverse populations and health inequalities; and interventions for cardiometabolic disease. We assessed the extent to which frameworks address health inequalities, specifically ethnic inequalities; explored how they were addressed; and developed recommendations for good practice.

RESULTS

Of 58 relevant papers, 22 (38%) included frameworks that referred to health inequalities. Inequalities were conceptualized as society-level, system-level, intervention-level, and individual. Only 5 frameworks considered all levels. Three frameworks considered how digital health interventions might interact with or exacerbate existing health inequalities, and 3 considered the process of health technology implementation, uptake, and use and suggested opportunities to improve equity in digital health. When ethnicity was considered, it was often within the broader concepts of social determinants of health. Only 3 frameworks explicitly addressed ethnicity: one focused on culturally tailoring digital health interventions, and 2 were applied to management of cardiometabolic disease.

CONCLUSIONS

Existing frameworks evaluate implementation, uptake, and use of digital health interventions, but to consider factors related to ethnicity, it is necessary to look across frameworks. We have developed a visual guide of the key constructs across the 4 potential levels of action for digital health inequalities, which can be used to support future research and inform digital health policies.

Mitochondrially targeted tamoxifen alleviates markers of obesity and type 2 diabetes mellitus in mice

Type 2 diabetes mellitus represents a major health problem with increasing prevalence worldwide. Limited efficacy of current therapies has prompted a search for novel therapeutic options. Here we show that treatment of pre-diabetic mice with mitochondrially targeted tamoxifen, a potential anti-cancer agent with senolytic activity, improves glucose tolerance and reduces body weight with most pronounced reduction of visceral adipose tissue due to reduced food intake, suppressed adipogenesis and elimination of senescent cells. Glucose-lowering effect of mitochondrially targeted tamoxifen is linked to improvement of type 2 diabetes mellitus-related hormones profile and is accompanied by reduced lipid accumulation in liver. Lower senescent cell burden in various tissues, as well as its inhibitory effect on pre-adipocyte differentiation, results in lower level of circulating inflammatory mediators that typically enhance metabolic dysfunction. Targeting senescence with mitochodrially targeted tamoxifen thus represents an approach to the treatment of type 2 diabetes mellitus and its related comorbidities, promising a complex impact on senescence-related pathologies in aging population of patients with type 2 diabetes mellitus with potential translation into the clinic.

Changes in objectively-measured physical capability over 4-year, risk of diabetes, and glycemic control in older adults: The China Health and Retirement Longitudinal study

AIMS

High physical capability reduces risk of diabetes, but the association of its changes with risk of diabetes and glycemic control is unclear in older adults. This study aimed to quantify their association.

METHODS

A total of 1,667 participants without diabetes and aged ≥ 60 years from the China Health and Retirement Longitudinal Study were included and followed over 4 years. Physical capability was objectively measured at baseline and 4-year later. Logistic regression models were used to assess the association of changes in physical capability with risk of diabetes.

RESULTS

During follow-up, 160 participants developed diabetes. None of the changes in physical capability expressed in continuous scales or in tertiles was associated with risk of diabetes in unadjusted or adjusted models (all P > 0.05), and no favorable joint effects were observed. Changes in physical capability were not associated with changes in fasting plasma glucose or hemoglobin A1c. Yet increases in walking speed or grip strength were related to reduced metabolic score for insulin resistance (both P ≤ 0.03).

CONCLUSIONS

Increases in objectively-measured physical capability were not associated with reduced risk of diabetes but may ameliorate insulin resistance in older adults. Studies with longer follow-up periods are required to confirm these findings.

Developing a realist informed framework for cultural adaptation of lifestyle interventions for the prevention of type 2 diabetes in South Asian populations in Europe

AIMS

Selected lifestyle interventions proven effective for White-European populations have been culturally adapted for South Asian populations living in Europe, who are at higher risk of type 2 diabetes. However, a limited theoretical basis underpins how cultural adaptations are believed to augment intervention effectiveness. We undertook a realist review to synthesise existing literature on culturally adapted type 2 diabetes prevention interventions, to develop a framework that shows 'how' cultural adaptation works, for 'whom' and in 'what contexts'.

METHODS

We followed the stepped methodological approach of realist review. Our work concluded a European-wide project (EuroDHYAN), and core studies were identified from the preceding EuroDHYAN reviews. Data were extracted, coded into themes and synthesised to create 'Context-Mechanism-Outcome' configurations and to generate a refined explanatory framework.

RESULTS

We identified eight core intervention papers. From this evidence, and supporting literature, we examined the 'Team' domain of cultural adaptation and identified a mechanism of shared cultural identity which we theorised as contributing to strong team-participant relationships. We also identified four key contexts which influenced intervention outcomes: 'research setting' and 'heterogeneous populations' (intrinsic to the intervention) and 'broader environment' and 'socio-cultural stress' (extrinsic barriers).

CONCLUSIONS

This work instigates research into the mechanisms of cultural adaptation which, if pursued, will allow a more nuanced understanding of how to apply adaptations, and for whom. In practice we recommend greater consideration of heterogeneous and intersecting population characteristics; how intervention design can safeguard sustainability; and how the four key contexts identified influence how, and whether, these interventions work.

QardioArm Blood Pressure Monitoring in a Population With Type 2 Diabetes: Validation Study

BACKGROUND

Home blood pressure monitoring has many benefits, even more so, in populations prone to high blood pressure, such as persons with diabetes.

OBJECTIVE

The purpose of this research was to validate the QardioArm mobile device in a sample of individuals with noninsulin-dependent type 2 diabetes in accordance with the guidelines of the second International Protocol of the European Society of Hypertension.

METHODS

The sample consisted of 33 patients with type 2 diabetes. To evaluate the validity of QardioArm by comparing its data with that obtained with a digital sphygmomanometer (Omron M3 Intellisense), two nurses collected diastolic blood pressure, systolic blood pressure, and heart rate with both devices.

RESULTS

The analysis indicated that the test device QardioArm met all the validation requirements using a sample population with type 2 diabetes.

CONCLUSIONS

This paper reports the first validation of QardioArm in a population of individuals with noninsulin-dependent type 2 diabetes. QardioArm for home monitoring of blood pressure and heart rate met the requirements of the second International Protocol of the European Society of Hypertension.

Ethnic disparities in initiation and intensification of diabetes treatment in adults with type 2 diabetes in the UK, 1990-2017: A cohort study

BACKGROUND

Type 2 diabetes mellitus (T2DM) disproportionately affects individuals of nonwhite ethnic origin. Timely and appropriate initiation and intensification of glucose-lowering therapy is key to reducing the risk of major vascular outcomes. Given that ethnic inequalities in outcomes may stem from differences in therapeutic management, the aim of this study was to identify ethnic differences in the timeliness of initiation and intensification of glucose-lowering therapy in individuals newly diagnosed with T2DM in the United Kingdom.

METHODS AND FINDINGS

An observational cohort study using the Clinical Practice Research Datalink was conducted using 162,238 adults aged 18 and over diagnosed with T2DM between 1990 and 2017 (mean age 62.7 years, 55.2% male); 93% were of white ethnicity (n = 150,754), 5% were South Asian (n = 8,139), and 2.1% were black (n = 3,345). Ethnic differences in time to initiation and intensification of diabetes treatment were estimated at three time points (initiation of noninsulin monotherapy, intensification to noninsulin combination therapy, and intensification to insulin therapy) using multivariable Cox proportional hazards regression adjusted for factors a priori hypothesised to be associated with initiation and intensification: age, sex, deprivation, glycated haemoglobin (HbA1c), body mass index (BMI), smoking status, comorbidities, consultations, medications, calendar year, and clustering by practice. Odds of experiencing therapeutic inertia (failure to intensify treatment within 12 months of HbA1c >7.5% [58 mmol/mol]), were estimated using multivariable logistic regression adjusted for the same hypothesised confounders. Noninsulin monotherapy was initiated earlier in South Asian and black groups (South Asian HR 1.21, 95% CI 1.08-1.36, p < 0.001; black HR 1.29, 95% CI 1.05-1.59, p = 0.017). Correspondingly, no ethnic differences in therapeutic inertia were evident at initiation. Intensification with noninsulin combination therapy was slower in both nonwhite ethnic groups relative to white (South Asian HR 0.80, 95% CI 0.74-0.87, p < 0.001; black HR 0.79, 95% CI 0.70-0.90, p < 0.001); treatment inertia at this stage was greater in nonwhite groups relative to white (South Asian odds ratio [OR] 1.45, 95% CI 1.23-1.70, p < 0.001; black OR 1.43, 95% CI 1.09-1.87, p = 0.010). Intensification to insulin therapy was slower again for black groups relative to white groups (South Asian HR 0.49, 95% CI 0.41-0.58, p < 0.001; black HR 0.69, 95% CI 0.53-0.89, p = 0.012); correspondingly, treatment inertia was significantly higher in nonwhite groups at this stage relative to white groups (South Asian OR 2.68, 95% CI 1.89-3.80 p < 0.001; black OR 1.82, 95% CI 1.13-2.79, p = 0.013). At both stages of treatment intensification, nonwhite groups had fewer HbA1c measurements than white groups. Limitations included variable quality and completeness of routinely recorded data and a lack of information on medication adherence.

CONCLUSIONS

In this large UK cohort, we found persuasive evidence that South Asian and black groups intensified to noninsulin combination therapy and insulin therapy more slowly than white groups and experienced greater therapeutic inertia following identification of uncontrolled HbA1c. Reasons for delays are multifactorial and may, in part, be related to poorer long-term monitoring of risk factors in nonwhite groups. Initiatives to improve timely and appropriate intensification of diabetes treatment are key to reducing disparities in downstream vascular outcomes in these populations.

Managing patients with prediabetes and type 2 diabetes after coronary events: individual tailoring needed - a cross-sectional study

BACKGROUND

Understanding the determinants associated with prediabetes and type 2 diabetes in coronary patients may help to individualize treatment and modelling interventions. We sought to identify sociodemographic, medical and psychosocial factors associated with normal blood glucose (HbA1c < 5.7%), prediabetes (HbA1c 5.7-6.4%), and type 2 diabetes.

METHODS

A cross-sectional explorative study applied regression analyses to investigate the factors associated with glycaemic status and control (HbA_1c level) in 1083 patients with myocardial infarction and/or a coronary revascularization procedure. Data were collected from hospital records at the index event and from a self-report questionnaire and clinical examination with blood samples at 2-36 months follow-up.

RESULTS

In all, 23% had type 2 diabetes, 44% had prediabetes, and 33% had normal blood glucose at follow-up. In adjusted analyses, type 2 diabetes was associated with larger waist circumference (Odds Ratio 1.03 per 1.0 cm, p = 0.001), hypertension (Odds Ratio 2.7, p < 0.001), lower high-density lipoprotein cholesterol (Odds Ratio 0.3 per1.0 mmol/L, p = 0.002) and insomnia (Odds Ratio 2.0, p = 0.002). In adjusted analyses, prediabetes was associated with smoking (Odds Ratio 3.3, p = 0.001), hypertension (Odds Ratio 1.5, p = 0.03), and non-participation in cardiac rehabilitation (Odds Ratio 1.7, p = 0.003). In patients with type 2 diabetes, a higher HbA_1c level was associated with ethnic minority background (standardized beta [β] 0.19, p = 0.005) and low drug adherence (β 0.17, p = 0.01). In patients with prediabetes or normal blood glucose, a higher HbA_1c was associated with larger waist circumference (β 0.13, p < 0.001), smoking (β 0.18, p < 0.001), hypertension (β 0.08, p = 0.04), older age (β 0.16, p < 0.001), and non-participation in cardiac rehabilitation (β 0.11, p = 0.005).

CONCLUSIONS

Along with obesity and hypertension, insomnia and low drug adherence were the major modifiable factors associated with type 2 diabetes, whereas smoking and non-participation in cardiac rehabilitation were the factors associated with prediabetes. Further research on the effect of individual tailoring, addressing the reported significant predictors of failure, is needed to improve glycaemic control.

TRIAL REGISTRATION

Retrospectively registered at ClinicalTrials.gov: NCT02309255 , December 5th 2014.

Validation of BP devices QardioArm® in the general population and Omron M6 Comfort® in type II diabetic patients according to the European Society of Hypertension International Protocol (ESH-IP)

BACKGROUND

Following the European Society of Hypertension International Protocol (ESH-IP) Revision 2010, QardioArm® and Omron M6 Comfort IT® oscillometric devices were evaluated in the general population and in patients with type II diabetes, respectively, for self-blood pressure (BP) measurement.

METHODS

Both devices, QardioArm® and Omron M6 Comfort®, measure BP at the brachial level. The ESH-IP Revision 2010 includes a total number of 33 subjects. For each measure, the difference between observer and device BP values was calculated. In all, 99 pairs of BP differences are classified into three categories (≤5, ≤10, and ≤15 mmHg). The protocol procedures were followed precisely.

RESULTS

QardioArm® and Omron M6 Comfort® fulfilled the requirements of the ESH-IP and passed the validation process successfully. For QardioArm®, a total of 69 out of 99 comparisons for systolic blood pressure (SBP) showed an absolute difference within 5 mmHg and 82 out of 99 for diastolic blood pressure (DBP). As for Omron M6 Comfort®, a total of 83 out of 99 comparisons for SBP showed an absolute difference within 5 mmHg and 77 out of 99 for DBP. The mean differences between the device and mercury readings were 0.7±5.9 mmHg for SBP and 0.3±4.1 mmHg for DBP for QardioArm® and -1.4±4.7 mmHg for SBP and -2.1±4.3 mmHg for DBP for Omron M6 Comfort®. With regard to part 2 of ESH-IP 2010, 27 out of 33 subjects had a minimum of two out of three measurements within 5 mmHg difference for SBP and 31 out of 33 subjects for DBP for the QardioArm®, and 29 out of 33 patients had a minimum of two out of three measurements within 5 mmHg difference for SBP and 26 out of 33 patients for DBP for Omron M6 Comfort®.

CONCLUSION

QardioArm® and Omron M6 Comfort® readings differing from the mercury standard by <5, 10, and 15 mmHg fulfill the ESH-IP Revision 2010 requirements. Consequently, these two devices are suitable for use in the general population and non-insulin-dependent type II diabetic patients, respectively.