Banting Lecture. From the triumvirate to the ominous octet: a new paradigm for the treatment of type 2 diabetes mellitus

Effects of a protein kinase C epsilon inhibitor on insulin signalling in lipid-treated HepG2 hepatocytes and glucose tolerance in fat-fed mice

AIMS

Protein kinase C epsilon (PKCε) plays a causative role in the development of glucose intolerance, and is a potential target for the treatment of type 2 diabetes. Here, we examined the effects of the PKCε inhibitor CIDD-0150612 (CP612) on insulin action in palmitate-treated HepG2 hepatocytes in vitro and on glucose homeostasis in fat-fed mice in vivo.

METHODS

HepG2 cells were treated with palmitate and CP612 and stimulated with insulin. Insulin signalling was examined by immunoblotting and glucose incorporation into glycogen was measured using glucose tracer. Mice were fed a high-fat diet and treated with CP612 prior to glucose tolerance tests and tissue harvest. Proteomic analysis of liver was carried out by mass spectrometry.

RESULTS

CP612 promoted Akt phosphorylation in a highly insulin-dependent manner and reversed the inhibition of insulin-stimulated Akt phosphorylation and glucose incorporation into glycogen by palmitate. Fat-fed mice treated with CP612 had reduced fat mass, but not lean mass, compared with vehicle-treated littermates. Mice treated acutely with CP612 exhibited elevated fasting blood glucose. However, mice studied 24h after the last dose had lower fasting glucose and improved glucose tolerance with a lower insulin excursion. Proteomic analysis of liver from CP612-treated fat-fed mice indicated a reduction in gluconeogenic gene expression and decreased phosphorylation of the transcription factor Foxk1.

CONCLUSIONS

The PKCε inhibitor CP612 had beneficial effects on insulin action in hepatocytes and on fat mass and glucose homeostasis in mice. Because certain effects were not previously observed in genetically PKCε-deficient mice, off-target effects may be partly responsible.

Metabolic and vascular insulin resistance: partners in the pathogenesis of cardiovascular disease in diabetes

Vascular insulin resistance has emerged as a pivotal factor in the genesis of cardiovascular disease (CVD) in people with diabetes. It forms a complex pathogenic partnership with metabolic insulin resistance to significantly amplify the CVD risk of diabetes and other affected populations. Metabolic insulin resistance (characterized by quantitatively diminished insulin action on glucose metabolism in skeletal muscle, liver, and adipose tissue) is a hallmark of diabetes, obesity, and related conditions. In contrast, vascular insulin resistance is a less appreciated and not well-quantified complication of these conditions. Importantly, an impaired vascular response to insulin contributes directly to vascular dysfunction and over 40 years of research has convincingly shown that vascular and metabolic insulin resistance synergize to create an environment that predisposes individuals to CVD. In this review, we examine the multifaceted vascular actions of insulin, including its roles in regulating blood pressure, blood flow, endothelial health, and arterial stiffness. We also examine how these processes become disrupted in the setting of vascular insulin resistance, which subsequently undermines endothelial function, compromises tissue microvascular perfusion, and promotes vascular rigidity and atherosclerosis. We then highlight potential therapeutic strategies with demonstrated efficacy to improve vascular insulin sensitivity in people with diabetes and suggest that targeting disordered vascular insulin signaling holds promise not only for refining the functional understanding of vascular insulin resistance but also for developing innovative treatments with potential to reduce CVD risk and improve cardiovascular outcomes in people with diabetes.

Effects of reducing sedentary behavior on liver insulin sensitivity, liver fat content, and liver enzyme levels: a six-month randomized controlled trial

Metabolic syndrome increases the risk of developing noncommunicable diseases such as metabolic dysfunction-associated steatotic liver disease. The aim was to investigate the effects of sedentary behavior (SB) reduction on liver glucose uptake (LGU), endogenous glucose production (EGP), liver fat content (LFC), and liver enzyme levels [alanine aminotransferase (ALT), aspartate aminotransferase, and γ-glutamyltransferase]. Forty-four sedentary (daily SB time ≥ 10 h), physically inactive middle-aged adults with metabolic syndrome were randomized into intervention (INT; n = 23, 21 completed) and control (CON; n = 21, 19 completed) groups. For 6 mo, INT aimed to limit SB by 1 h/day, whereas CON aimed to maintain usual habits. SB and physical activity (PA) were measured continuously with hip-worn accelerometers. Before and at the end of the intervention, LGU was measured using positron emission tomography during the hyperinsulinemic-euglycemic clamp. EGP was calculated, and LFC was measured by magnetic resonance spectroscopy. INT reduced SB by 51 [95% confidence interval (CI): 22, 78] min/day and increased moderate-to-vigorous physical activity (MVPA) by 22 (95% CI: 12, 33) min/day, with no significant change in CON. Differences in liver health markers between the groups were not significant. However, according to the exploratory analyses among participants who successfully reduced SB, ALT decreased (-1.1 [95% CI: 0.93, 1.36] U/L) compared with the continuously sedentary participants (+0.8 [95% CI: 0.65, 1.05] U/L) (group × time, P = 0.006). To enhance liver health, reducing SB for longer durations and/or increasing the intensity of PA may be necessary. However, successfully reducing SB may lead to better levels of circulating ALT liver enzymes.NEW & NOTEWORTHY Aiming to reduce sedentary behavior (SB) by 1 h/day did not significantly influence liver health markers, suggesting that more substantial reductions or a different approach might be necessary to see improvements. However, achieving the desired behavioral change could lead to improvements in ALT levels. This study is the first to analyze how reducing SB and replacing it with nonguided physical activity impacts liver health in adults with metabolic syndrome, offering insights for future intervention strategies.

Obesity and type 2 diabetes mellitus: insights from skeletal muscle extracellular matrix remodeling

Obesity and type 2 diabetes mellitus (T2DM) are metabolic diseases at epidemic proportions. The economic burden for these diseases is at an all-time high, and as such, there is an urgent need for advancements in identifying targets for treating these complex disorders. The extracellular matrix (ECM), comprising collagen, fibronectin, laminin, elastin, and proteoglycan, surrounds skeletal muscles and plays a critical role in maintaining tissue homeostasis by providing structural support and facilitating cell-to-cell communication. Disruption of the ECM signaling results in changes to its micro/macroenvironment, thereby modifying tissue homeostasis. Skeletal muscle ECM remodeling has been shown to be associated with insulin resistance, an underlying feature of obesity and T2DM. This narrative review explores the critical components of skeletal muscle ECM and its accumulation and remodeling in metabolic diseases. In addition, we discuss potential treatments to mitigate the effects of ECM remodeling in skeletal muscle. We conclude that targeting ECM remodeling in skeletal muscle represents a promising yet underexplored therapeutic avenue in the management of metabolic disorders.

Associations between triglyceride-glucose body mass index and all-cause mortality in ICU patients with sepsis and acute heart failure

BACKGROUND

The triglyceride‒glucose body mass index (TyG-BMI) has been recognized as a significant predictor of cardiovascular disease risk and plays a crucial role in assessing insulin resistance. However, the correlation between the TyG-BMI and clinical outcomes in patients with sepsis and acute heart failure (AHF) has not been sufficiently explored. This study aimed to investigate the associations between TyG-BMI and clinical outcomes in patients with sepsis and AHF.

METHODS

We conducted a retrospective analysis of ICU-admitted patients via data from the MIMIC-IV database. Multivariable logistic regression, sensitivity analysis, and restricted cubic spline (RCS) models were used to assess the relationship between TyG-BMI and all-cause mortality. K‒M survival analysis and Boruta analysis were employed to evaluate the predictive value of the TyG-BMI. Subgroup analyses considered the effects of age, sex, ethnicity, and comorbidities.

RESULTS

Among the 1,729 patients, a higher TyG-BMI was associated with lower all-cause mortality at 90 and 180 days. Each standard deviation increase in the TyG-BMI was linked to 0.2% and 0.3% reductions in 90-day and 180-day all-cause mortality, respectively. Kaplan‒Meier analysis revealed significantly lower all-cause mortality in patients with higher TyG-BMIs (P < 0.0001). The RCS model revealed a nonlinear relationship between the TyG-BMI and mortality. Boruta analysis identified the TyG-BMI as an important clinical feature. Sensitivity analyses revealed that the association remained significant after patients with myocardial infarction, malignancies, or missing data were excluded. The subgroup analysis revealed that for the 90-day and 180-day mortality rates, significant interactions were found only in the subgroup of patients with kidney diseases (P < 0.05).

CONCLUSION

The TyG-BMI may have potential value in predicting mortality in ICU patients with sepsis and AHF, supporting early risk assessment and clinical intervention. This study provides critical insights into patient prognosis.

Clinical staging to guide management of metabolic disorders and their sequelae: a European Atherosclerosis Society consensus statement

Obesity rates have surged since 1990 worldwide. This rise is paralleled by increases in pathological processes affecting organs such as the heart, liver, and kidneys, here termed systemic metabolic disorders (SMDs). For clinical management of SMD, the European Atherosclerosis Society proposes a pathophysiology-based system comprising three stages: Stage 1, where metabolic abnormalities such as dysfunctional adiposity and dyslipidaemia occur without detectable organ damage; Stage 2, which involves early organ damage manifested as Type 2 diabetes, asymptomatic diastolic dysfunction, metabolic-associated steatohepatitis (MASH), and chronic kidney disease (CKD); and Stage 3, characterized by more advanced organ damage affecting multiple organs. Various forms of high-risk obesity, driven by maintained positive energy balance, are the most common cause of SMD, leading to ectopic lipid accumulation and insulin resistance. This progression affects various organs, promoting comorbidities such as hypertension and atherogenic dyslipidaemia. Genetic factors influence SMD susceptibility, and ethnic disparities in SMD are attributable to genetic and socioeconomic factors. Key SMD features include insulin resistance, inflammation, pre-diabetes, Type 2 diabetes, MASH, hypertension, CKD, atherogenic dyslipidaemia, and heart failure. Management strategies involve lifestyle changes, pharmacotherapy, and metabolic surgery in severe cases, with emerging treatments focusing on genetic approaches. The staging system provides a structured approach to understanding and addressing the multi-faceted nature of SMD, which is crucial for improving health outcomes. Categorization of SMD abnormalities by presence and progression is aimed to improve awareness of a multi-system trait and encourage a tailored and global approach to treatment, ultimately aiming to reduce the burden of obesity-related comorbidities.

Advancing Diabetes Management and Glycemic Control While Exploring CagriSema's Impact on Obesity Management

Diabetes is a complex metabolic disorder affecting over 37 million people in the United States. Without proper management, diabetes can lead to a myriad of complications, including cardiovascular disease, kidney failure, and vision loss. Obesity is a major contributor to type 2 diabetes, but genetic and physiological factors make weight loss difficult, necessitating medication management for both conditions. Government-approved weight loss medications, including glucagon-like peptide-1 agonists and amylin analogs, have proven to be effective for both conditions. However, intensive glycemic control involving antidiabetic medications, while beneficial for reducing diabetic complications, can often precipitate hypoglycemic events, which are characterized by cardiac arrhythmias, coma, confusion, and even mortality. A new drug under investigation, CagriSema, combines cagrilintide, an amylin analog, with semaglutide, a glucagon-like peptide-1 agonist. This drug is being marketed as a safe and potentially superior medication to lower both Hemoglobin A1c and body weight. In this article, the pathophysiology, current guidelines, and management of diabetes will be reviewed, with an emphasis on the clinical evidence for tight glucose control and avoiding hypoglycemic events. Following this, an overview of recent trials on antidiabetic medications, including those involving CagriSema, will be presented, along with prospects for future trials in this promising area of research.

A pretrained transformer model for decoding individual glucose dynamics from continuous glucose monitoring data

Continuous glucose monitoring (CGM) technology has grown rapidly to track real-time blood glucose levels and trends with improved sensor accuracy. The ease of use and wide availability of CGM will facilitate safe and effective decision making for diabetes management. Here, we developed an attention-based deep learning model, CGMformer, pretrained on a well-controlled and diverse corpus of CGM data to represent individual's intrinsic metabolic state and enable clinical applications. During pretraining, CGMformer encodes glucose dynamics including glucose level, fluctuation, hyperglycemia, and hypoglycemia into latent space with self-supervised learning. It shows generalizability in imputing glucose value across five external datasets with different populations and metabolic states (MAE = 3.7 mg/dL). We then fine-tuned CGMformer towards a diverse panel of downstream tasks in the screening of diabetes and its complications using task-specific data, which demonstrated a consistently boosted predictive accuracy over direct fine-tuning on a single task (AUROC = 0.914 for type 2 diabetes (T2D) screening and 0.741 for complication screening). By learning an intrinsic representation of an individual's glucose dynamics, CGMformer classifies non-diabetic individuals into six clusters with elevated T2D risks, and identifies a specific cluster with lean body-shape but high risk of glucose metabolism disorders, which is overlooked by traditional glucose measurements. Furthermore, CGMformer achieves high accuracy in predicting an individual's postprandial glucose response with dietary modelling (Pearson correlation coefficient = 0.763) and helps personalized dietary recommendations. Overall, CGMformer pretrains a transformer neural network architecture to learn an intrinsic representation by borrowing information from a large amount of daily glucose profiles, and demonstrates predictive capabilities fine-tuned towards a broad range of downstream applications, holding promise for the early warning of T2D and recommendations for lifestyle modification in diabetes management.

Clinical Characteristics of Korean Patients with Youth-Onset Type 2 Diabetes Mellitus in Remission

Background

Improving β-cell function can lead to remission in some patients with type 2 diabetes mellitus (T2DM). However, research on pharmacotherapy-induced remission in youth-onset T2DM remains scarce. Our study aimed to identify the clinical characteristics of pediatric patients who experience remission.

Methods

We retrospectively reviewed 88 pediatric patients with T2DM followed for at least 1 year at Seoul National University Bundang Hospital between 2013 and 2023. Remission was defined as a glycosylated hemoglobin (HbA1c) level less than 6.5% for at least 3 months after ceasing glucose-lowering pharmacotherapy.

Results

Among 88 patients (60 males, 68.2%) diagnosed at an average age of 14.4±2.1 years, 19 patients (21.6%) achieved remission after a median duration of 1.4 years. The remission group had a larger proportion of males (89.5% vs. 62.3%, P=0.024) and a lower urinary albumin-to-creatinine ratio (ACR) at diagnosis (P=0.011). They also showed lower HbA1c levels at 1 year and more significant changes in HbA1c and body mass index (all P<0.05). Higher urinary ACR levels correlated with a longer duration to achieve remission (hazard ratio, 0.928; P=0.013). In three of the 19 remission patients (15.8%), recurrence occurred after a median of 1.5 years.

Conclusion

Among Korean youth with T2DM, 21.6% achieved remission after a median duration of 1.4 years. Those who experienced remission were predominantly male, had lower ACR at diagnosis, and had significant weight loss within the first year. Further investigation into the factors influencing remission and long-term outcomes is essential.

Impact of antidiabetic medication type on a new episode of depression: a retrospective cohort study in Texas, USA

OBJECTIVES

To examine the associations between antidiabetic medication type and a new episode of depression using 100% Texas Medicare database during 2009 and 2018.

DESIGN

A retrospective cohort study.

SETTING

A population-based study using the Texas Medicare data.

INTERVENTIONS

11 common antihyperglycaemic medication types, alone and in combinations: metformin-only, five non-metformin-containing regimens (dipeptidyl peptidase-4 inhibitor (DPP4i) only, sulfonylureas (SU) only, thiazolidinediones (TZD) only, SU/DPP4i and SU/TZD) and five metformin-containing combination treatments (metformin/DPP4i, metformin/SU, metformin/TZD, metformin/SU/DPP4i and metformin/SU/TZD).

PARTICIPANTS

This study included 59 057 type 2 diabetes (T2D) patients from a cohort of Texas Medicare beneficiaries who were aged ≥66 years, had consistent diabetes medication intake, were not diagnosed with depression or prescribed antidepressants during the 2-year look-back period and received regular care from Medicare providers.

MAIN OUTCOMES AND MEASURES

The main outcome was a new episode of depression, identified by a new depression diagnosis during the follow-up period.

RESULTS

A total of 59 057 T2D patients (mean (SD) age, 75.4 (6.4) years; 30 798 (52.1%) female) were followed up to 96 months. Of these, 22.5% patients had a new episode of depression at the 5-year follow-up. Compared with the metformin-only group, patients in the non-metformin-containing regimens had a higher risk of new episode depression (HR: 1.17, 95% CI 1.05 to 1.30 for DPP4i-only; HR: 1.06, 95% CI 1.01 to 1.12 for SU-only), but there was no significant difference among patients receiving metformin-containing combination therapy. Metformin/TZD and metformin/SU/DPP4i combination treatments had a lower risk of new episodes of depression than metformin-only (HR: 0.88, 95% CI 0.78 to 0.99 and HR: 0.83, 95% CI 0.71 to 0.98 separately). The same direction of association was observed in sensitivity analyses.

CONCLUSIONS

This retrospective cohort study found that T2D patients treated with metformin/TZD and metformin/SU/DPP4i had the lowest risk of new episodes of depression. These findings suggest that certain combinations of metformin with other antidiabetic medications may be associated with a reduced risk of new-onset depression. Therefore, it could be beneficial to incorporate depression risk evaluation into routine diabetes care and consider it in the decision-making process for diabetes medication types, especially when deprescribing metformin.

Pre-Prediabetes: Insulin Resistance Is Associated With Cardiometabolic Risk in Nonobese Patients (STOP DIABETES)

CONTEXT

Prior studies have demonstrated glycemic and cardiometabolic risk in the prediabetic state.

OBJECTIVE

This work aims to examine if insulin resistance (IR) is associated with markers of glycemic, cardiometabolic, and atherosclerotic risk in nonobese, nonprediabetic individuals compared to insulin-sensitive (IS) individuals matched for body mass index (BMI), sex, and age.

METHODS

Of 1860 patients from the STOP DIABETES study, 624 had normal fasting plasma glucose, BMI less than 30, and glycated hemoglobin A1c (HbA1c) less than 5.7%. All received an oral glucose tolerance test. Insulin sensitivity was quantitated using the Matsuda index: less than the 25th percentile equals IR (n = 151) and 25th percentile or greater equals IS (n = 473). Measures of dysglycemia and cardiometabolic risk were compared between IR individuals (n = 151) and a subset of IS individuals who were matched for BMI, sex, and age (n = 151). Carotid intima media thickness and carotid plaque were measured in 65 IR and 76 IS individuals.

RESULTS

Compared to matched IS patients, IR nonobese individuals demonstrated increased indicators of glycemic and cardiometabolic risk, including increased 60-minute plasma glucose and percentage of patients with 60-minute plasma glucose greater than 155 mg/dL; increased 120-minute plasma glucose; unrecognized impaired glucose tolerance and type 2 diabetes, decreased disposition index; increased systolic and diastolic blood pressure; elevated plasma triglycerides (TGs); reduced high-density lipoprotein (HDL) cholesterol; increased TGs/HDL ratio, and high-sensitivity C-reactive protein. The presence, size, and number of carotid plaques was greater in the IR group.

CONCLUSION

Approximately 1 in 4 nonobese patients in this population with normal fasting glucose and HbA1c were IR. In these nonobese participants, IR was associated with multiple indicators of dysglycemia and cardiometabolic risk.

Beta-cell preservation in T2DM using a pathophysiologic approach

Type 2 diabetes and obesity rates continue to rise. Type 2 diabetes affects 1-2 million new individuals annually. Despite a wide range of treatment options for type 2 diabetes, many people still fail to achieve therapeutic goals. Treating type 2 diabetes more proactively with a pathophysiologic approach can ensure higher rates of success and reduce complications. This article summarizes the progressive understanding of the pathophysiology of diabetes, draws a connection between illness and beta-cell health, and introduces the pathophysiologic approach to type 2 diabetes and its focus on beta-cell preservation. This article compiled clinical data, evidence-based medicine, and experimental results to create a comprehensive narrative review.

The association between the triglyceride-glucose index and vulnerable plaques in patients with type 2 diabetes mellitus: insights from coronary computed tomography angiography

BACKGROUND

The triglyceride‒glucose index (TyG index) has been verified to be a useful predictor of insulin resistance (IR), and is associated with the occurrence of acute coronary syndrome (ACS). However, the effect of the TyG index on vulnerable plaques (VP), which were identified when at least two high-risk features are present within the same lesion, in type 2 diabetes mellitus (T2DM) patients is not fully understood. This study aimed to explore the association between the TyG index and the presence of VP.

METHODS

We retrospectively enrolled 2056 T2DM patients who underwent coronary computed tomography angiography (CCTA) examinations at West China Hospital from February 2017 to February 2022. These patients were divided into four groups on the basis of the quartiles of the TyG index. The high-risk coronary plaque features, vulnerable plaques, plaque type, coronary artery stenosis, segment involvement score (SIS), segment stenosis score (SSS) and multivessel disease (MVD) based on CCTA data were evaluated and compared among the four groups.

RESULTS

Patients with a higher TyG index had more noncalcified and mixed plaques, high-risk plaque features, vulnerable plaques and fewer calcified plaques (P < 0.05 for all). The proportion of patients with high-risk plaque features, including low-attenuation noncalcified plaques, positive remodeling and "napkin ring" sign was associated with the TyG index (P for trend < 0.05 for all). Multivariate analysis revealed that the TyG index was significantly associated with vulnerable plaques in T2DM patients [OR = 1.23 (95% CI 1.00-1.51), P = 0.046]. Subgroup analysis revealed that the association between the TyG index and vulnerable plaques varied with age and the prevalence of cardiovascular (CVD) symptoms, even after controlling for confounding factors (P for interaction < 0.05 for both).

CONCLUSION

The TyG index was independently associated with vulnerable plaques of the coronary artery among patients with T2DM. The TyG index could be regarded as a marker to reduce the incidence of cardiovascular events in the targeted population of T2DM patients.

FGF1 as a New Promising Therapeutic Target in Type 2 Diabetes: Advances in Research and Clinical Trials

Type 2 diabetes mellitus (T2DM) represents a global health crisis, characterized by insulin resistance, β-cell dysfunction, and metabolic disturbances. Current treatments, such as insulin and metformin, often fail to address the dual challenges of β-cell preservation and insulin resistance, leading to suboptimal long-term outcomes. Fibroblast growth factor 1 (FGF1) has recently gained attention as a new promising therapeutic target due to its unique ability to regulate glucose homeostasis, enhance insulin sensitivity, and protect β-cells without inducing hypoglycemia. This review critically examines the mechanisms of FGF1 action, including its signaling pathways, interactions with metabolic regulators, and roles in key organs involved in glucose metabolism. Additionally, we summarize findings from preclinical and clinical studies and evaluate the challenges associated with its therapeutic application, including pharmacokinetic limitations, delivery strategies, and long-term safety concerns. By addressing these issues, FGF1 holds the potential to advance beyond symptom management to become a disease-modifying therapy for T2DM.

Perspectives of type 2 diabetes mellitus management in Algeria: a comprehensive expert review

Background

The health and economic impacts of type 2 diabetes mellitus (T2DM) remain substantial, notably in developing countries.

Objectives

To provide an in-depth assessment of the T2DM situation in Algeria to understand its multifaceted burden and identify priority areas of intervention.

Methods

A systematic literature search was conducted on all published articles about T2DM in Algeria over the past 30 years, including original research, reviews, and case series. The extracted data were thoroughly analyzed and synthesized by a committee of diabetes experts.

Results

Algerian epidemiological data point towards a constant rise of T2DM prevalence, roughly from 8.9% in 2003 to 14.4% in 2016-2017. The mean onset is around 41 years with women experiencing a greater burden at younger age. Low socioeconomic status, limited education, and lack of health insurance exacerbate T2DM risk and health inequities. Lifestyle and metabolic risk factors are prevalent. Despite advancements in glycemic control, prescribing practices lack standardization, with suboptimal use of antidiabetic drugs and absence of novel drugs in the market. Health and economic burdens are dominated by complications, highlighting inadequate primary and tertiary prevention strategies.

Conclusion

Notwithstanding the increasing burden of T2DM in Algeria, the healthcare strategies and therapeutic outcomes remain suboptimal. This underscores the necessity for a comprehensive strategy including enhanced prevention, access to novel treatments, standardized practices, along with a patient-centered approach.

Leptin and Insulin in COPD: Unveiling the Metabolic-Inflammatory Axis-A Narrative Review

Chronic obstructive pulmonary disease (COPD) is a progressive and debilitating condition characterized by airflow limitations and systemic inflammation. The interaction between the metabolic and inflammatory pathways plays a key role in disease progression, with leptin and insulin emerging as pivotal metabolic regulators. Leptin, an adipokine that regulates energy homeostasis, and insulin, the primary regulator of glucose metabolism, are both altered in COPD patients. This narrative review provides an in-depth examination of the roles of leptin and insulin in COPD pathogenesis, focusing on the molecular mechanisms through which these metabolic regulators interact with inflammatory pathways and how their dysregulation contributes to a spectrum of extrapulmonary manifestations. These disturbances not only exacerbate COPD symptoms but also increase the risk of comorbidities such as metabolic syndrome, diabetes, cardiovascular disease, or muscle wasting. By exploring the underlying mechanisms of leptin and insulin dysregulation in COPD, this review underscores the significance of the metabolic-inflammatory axis, suggesting that restoring metabolic balance through leptin and insulin modulation could offer novel therapeutic strategies for improving clinical outcomes.

Empagliflozin Reduces High Glucose-Induced Cardiomyopathy in hiPSC-Derived Cardiomyocytes : Glucose-induced Lipotoxicity in hiPSC-Derived Cardiomyocytes

Human-induced pluripotent stem cell (hiPSC) technology has been applied in pathogenesis studies, drug screening, tissue engineering, and stem cell therapy, and patient-specific hiPSC-derived cardiomyocytes (hiPSC-CMs) have shown promise in disease modeling, including diabetic cardiomyopathy. High glucose (HG) treatment induces lipotoxicity in hiPSC-CMs, as evidenced by changes in cell size, beating rate, calcium handling, and lipid accumulation. Empagliflozin, an SGLT2 inhibitor, effectively mitigates the hypertrophic changes, abnormal calcium handling, and contractility impairment induced by HG. Glucose concentration influences SGLT2 expression in cardiomyocytes, highlighting its potential role in diabetic cardiomyopathy. These findings support the potential utility of hiPSC-CMs in studying diabetic cardiomyopathy and the efficacy of empagliflozin in ameliorating HG-induced cardiomyocyte dysfunction. Such research may advance developments in precision medicine and therapeutic interventions for patients with diabetic cardiomyopathy.

Practical Approaches to Continuous Glucose Monitoring in Primary Care: A UK-Based Consensus Opinion

INTRODUCTION

Type 2 diabetes (T2D) imposes significant personal challenges and societal costs. Continuous glucose monitoring (CGM) is recognised as a state-of-the-art tool, but remains underutilised. Adoption of CGM in primary care should be informed by a broader understanding of the technology's capabilities and limitations.

METHODS

An expert panel was convened to review current literature and clinical experience to provide practical approaches to CGM for primary care practitioners and discuss the technology's value in the routine management of T2D. The goals were to review and reach consensus on the current state of CGM in non-specialist practice settings and on strategies for successfully initiating and maintaining people on CGM.

RESULTS

Initiation and maintenance of CGM therapy can be successfully conducted in primary care settings. CGM therapy should include proper patient selection, proper setting of expectations, and evidence-based adjustments to therapy. Most patients are likely to see quick, meaningful, and lasting improvements in their diabetes, along with a better understanding of their condition and greater motivation for successful management. Retrospective report interpretation is feasible and intuitive. Barriers to adoption and sustained use include cost, technological limitations, behavioural or psychological factors, and therapeutic inertia. Addressing these barriers is critical to enable better access to CGM. Continuous glucose monitoring can be leveraged by primary care teams to inform treatment decisions and also by patients to inform diabetes self-management.

CONCLUSION

CGM should be considered for all people with T2D. The recommendations provided here should simplify adoption and maintenance use of CGM in primary care and maximise the glycaemic and psychosocial benefits of the technology.

Exploring differential miRNA expression profiles in muscular and visceral adipose tissue of patients with severe obesity

BACKGROUND

This study aims to investigate the differential miRNA expression profile between the visceral white adipose tissue and the skeletal muscle of people with obesity undergoing bariatric surgery.

METHODS

Skeletal muscle and visceral adipose tissue samples of 10 controls and 38 people with obesity (50% also with type 2 diabetes) undergoing bariatric surgery were collected. miRNA expression profiles were analyzed using Next-Generation Sequencing and subsequently validated using RT-PCR.

RESULTS

Approximately 69% of miRNAs showed similar expression in both tissues, however, 55 miRNAs were preferentially expressed in visceral adipose tissue and 53 in skeletal muscle. miR-122b-5p was uniquely identified in skeletal muscle, while miR-1-3p and miR-206 were upregulated in skeletal muscle. Conversely, miR-224-5p and miR-335-3p exhibited upregulation in visceral adipose tissue. Notably, distinctions related to the presence of type 2 diabetes were observed solely in the expression of miR-1-3p and miR-206 in visceral adipose tissue.

CONCLUSIONS

This is the first study unveiling distinct miRNA expression profiles in paired samples of visceral adipose tissue and skeletal muscle in humans. The identification of obesity-specific miRNAs in these tissues opens up promising avenues for research into potential biomarkers for obesity diagnosis and treatment.

Sex-Specific Multimorbidity-Multibehaviour Patterns in Primary Care Populations

BACKGROUND

A conceptual shift in healthcare emphasises multimorbidity and multibehaviours as interconnected phenomena, highlighting dose-response associations and sex-specific differences. Data-driven approaches have been suggested for overcoming methodological challenges, of multimorbidity research. By using exploratory factor analysis, this study aimed to identify sex specific lifestyle associative multimorbidity patterns, providing valuable evidence to primary care providers and informing future multimorbidity guidelines.

METHODS

A retrospective observational study examined the electronic health records of three general practices in the UK between 2015 and 2018. The participants were aged 18+ with lifestyle multimorbidity, having engaged with multiple health risk behaviours. Stratified exploratory factor analysis with oblique rotation was used to identify sex specific lifestyle associative multimorbidity patterns.

RESULTS

The study included N = 7560 patients, with females comprising 53.9%. Eight independent lifestyle associative multimorbidity patterns were identified and distributed as follows. For females, three patterns emerged: cardiometabolic-neurovascular spectrum disorders (42.97% variance), respiratory conditions (8.08%), and sensory impairment (5.63%), with 25.4% assigned to these patterns. For males, five patterns were revealed: cardiometabolic-vascular spectrum disorders (34.10%), genitourinary (9.19%), respiratory-vision (8.20%), ocular (5.70%), and neurovascular-gastro-renal syndrome (4.54%), with 43%.

CONCLUSIONS

We revealed eight different sex-specific lifestyle-associated patterns, implying the need for tailored clinical approaches. The application of exploratory factor analysis yielded clinically valuable and scientifically rigorous multimorbidity patterns. Clinically, the findings advocate for a paradigm shift towards person-centred care, integrating multimorbidity and SNAP multibehaviours to enhance the complexity of inquiry and treatment of high-risk populations.

Transgenerational Effects of the Obesogen Tributyltin on Metabolic Health in Mice: Interactions With a Western Diet

Obesity is a global health crisis, with increasing evidence linking environmental factors such as exposure to endocrine-disrupting chemicals (EDCs) to its development. This study examines the transgenerational effects of exposure to the model obesogen, tributyltin (TBT), on obesity and metabolic health, specifically focusing on how these effects interact with a diet modeling the 50th percentile of US dietary consumption [the Total Western Diet (TWD)]. Pregnant F0 dams were exposed to TBT, and their offspring were subjected at adulthood to different diets, including a high-fat diet and TWD, across multiple subsequent generations (F1-F3). We found that TBT exposure predisposed male offspring to increased fat accumulation, insulin resistance, and metabolic dysfunction, effects that were exacerbated by the TWD. Notably, male offspring displayed elevated leptin levels, hepatic fibrosis, and inflammatory responses under TWD exposure, suggesting an additive or synergistic relationship between obesogen exposure and dietary fat intake. These transgenerational effects were largely absent in female offspring, underscoring sex-specific vulnerabilities to environmental and dietary factors. Our results demonstrated that the combination of prenatal TBT exposure and TWD amplifies metabolic disturbances across generations, highlighting the need to consider both environmental chemicals and dietary patterns in addressing the obesity pandemic. This study underscores the critical role of early-life EDC exposures and dietary factors in shaping long-term metabolic health and the potential for transgenerational programming of susceptibility to obesity and metabolic disorders.

The Unique Ethnicity-Specific Aspects of Burden, Pathogenesis and Management of Prediabetes: Insights from Africa

PURPOSEOF REVIEW

Prediabetes poses a significant risk of developing diabetes and it's complications. Africa faces specific challenges, hindering early recognition and management of prediabetes. We aimed to understand unique, ethnicity specific aspects of the burden, pathogenesis and management of prediabetes in Africa.

RECENT FINDINGS

The rate of progression from prediabetes to diabetes is higher in African, compared to European populations. Prediabetes in Africans is driven mainly by hyperinsulinemia and reduced hepatic clearance causing obesity and insulin resistance, rather than impaired insulin sensitivity. High risk, difficult to reach individuals in lower socioeconomic strata, benefited from community versus facility-based screening. Intensive lifestyle changes with low calorie or low fat-high fiber diet provide longer lasting effect versus drug monotherapy. Using structured community-based screening, early detection of prediabetes is achievable, requiring dedicated stakeholder engagement. Further research into the etiology and sequencing of pathogenetic anomalies and preventive strategies in African populations is needed.

A Genetics-guided Integrative Framework for Drug Repurposing: Identifying Anti-hypertensive Drug Telmisartan for Type 2 Diabetes

Drug development is a long and costly process, and repurposing existing drugs for use toward a different disease or condition may serve as a cost-effective alternative. As drug targets with genetic support have a doubled success rate, genetics-informed drug repurposing holds promise in translating genetic findings into therapeutics. In this study, we developed a Genetics Informed Network-based Drug Repurposing via in silico Perturbation (GIN-DRIP) framework and applied the framework to repurpose drugs for type-2 diabetes (T2D). In GIN-DRIP for T2D, it integrates multi-level omics data to translate T2D GWAS signals into a genetics-informed network that simultaneously encodes gene importance scores and a directional effect (up/down) of risk genes for T2D; it then bases on the GIN to perform signature matching with drug perturbation experiments to identify drugs that can counteract the effect of T2D risk alleles. With this approach, we identified 3 high-confidence FDA-approved candidate drugs for T2D, and validated telmisartan, an anti-hypertensive drug, in our EHR data with over 3 million patients. We found that telmisartan users were associated with a reduced incidence of T2D compared to users of other anti-hypertensive drugs and non-users, supporting the therapeutic potential of telmisartan for T2D. Our framework can be applied to other diseases for translating GWAS findings to aid drug repurposing for complex diseases.

Circadian phase inversion causes insulin resistance in a rat model of night work and jet lag

Shift workers have an increased risk to develop type 2 diabetes. We aimed to investigate the underlying mechanisms and the role of the timing of food intake by subjecting rats to an acute phase inversion of the light/dark (L/D) cycle. In the first experiment, with food available ad libitum, male Wistar rats were implanted with jugular vein catheters and intravenous glucose tolerance tests were performed at either ZT2 or ZT14. Three days after the 12 h phase shift, these glucose tolerance tests were repeated. In the second experiment, rats were housed in metabolic cages for the continuous measurement of multiple behavioral and metabolic parameters after the 12 h phase shift, food was available ad libitum or restricted to the light or dark period. The daily rhythm of glucose tolerance, and the peak and trough corticosterone levels, adapted within three days after exposure to the inverted L/D cycle. However, phase inversion caused insulin resistance at the onset of the active phase. Under ad libitum feeding conditions, the daily rhythms of locomotor activity and energy expenditure adapted faster to the inverted L/D cycle compared to the other behavioral rhythms measured. Food restriction to the dark period facilitated behavioral adaptation to the new circadian phase.

Association between the indicators of insulin resistance and periodontitis: a study using data from the National Health and Nutrition Examination Survey 2009-2014

BACKGROUND

The rising obesity rates are accompanied by an increasing prevalence of insulin resistance (IR) associated with obesity. To ascertain the best index for replacing IR, this study aimed to investigate the possible association between IR, which was assessed using the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), and the triglyceride-glucose (TyG) index and its derived indexes and periodontitis.

METHODS

The association between the indicators of IR and periodontitis was assessed via multivariate-adjusted logistic regression analyses using data from the National Health and Nutrition Examination Survey (NHANES) 2009-2014. In addition, subgroup analyses and receiver operating characteristic curve analyses were conducted to explore possible influencing factors.

RESULTS

Our study encompassed 1,588 participants, and 41.0% were diagnosed with periodontitis. Based on the multivariate logistic regression analysis, a higher TyG-waist-to-height ratio (WHtR) (odds ratio [OR] = 1.14, 95% confidence interval [CI]: 1.02-1.27, P = 0.0244) and HOMA-IR score (OR = 1.00, 95% CI: 1.00-1.00, P = 0.0028) were associated with an increased risk of periodontitis. Conversely, the TyG index, TyG-adjusted for body mass index, and TyG-adjusted for waist circumference (WC) were not associated with periodontitis. According to further subgroup analyses and interaction result analyses, sex affected the association between the TyG index, TyG-WC, and TyG-WHtR and periodontitis (P < 0.05 for interaction). Moreover, the influence of age regulated the association between periodontitis and both TyG and HOMA-IR score. In terms of diagnostic accuracy, the area under the receiver operating characteristic curve analysis revealed that HOMA-IR score and TyG-WHtR slightly outperformed the TyG index, TyG-body mass index, and TyG-WC. Thus, they can be robust markers for assessing IR-related periodontitis risk.

CONCLUSION

A consistent and positive association was found between HOMA-IR score and TyG-WHtR and the odds of periodontitis prevalence. Hence, HOMA-IR score and TyG-WHtR were significantly associated with periodontitis in this cross-sectional study. However, prospective studies are needed to determine whether higher TyG-waist-to-height ratio and HOMA-IR score can predict the occurrence of periodontitis.

Targeting Diabetic Atherosclerosis: The Role of GLP-1 Receptor Agonists, SGLT2 Inhibitors, and Nonsteroidal Mineralocorticoid Receptor Antagonists in Vascular Protection and Disease Modulation

Atherosclerosis is a closely related complication of diabetes mellitus (DM), driven by endothelial dysfunction, inflammation, and oxidative stress. The progression of atherosclerosis is accelerated by hyperglycemia, insulin resistance, and hyperlipidemia. Novel antidiabetic agents, SGLT2 inhibitors, and GLP-1 agonists improve glycemic control and offer cardiovascular protection, reducing the risk of major adverse cardiovascular events (MACEs) and heart failure hospitalization. These agents, along with nonsteroidal mineralocorticoid receptor antagonists (nsMRAs), promise to mitigate metabolic disorders and their impact on endothelial function, oxidative stress, and inflammation. This review explores the potential molecular mechanisms through which these drugs may prevent the development of atherosclerosis and cardiovascular disease (CVD), supported by a summary of preclinical and clinical evidence.

Multi-omics approaches for biomarker discovery and precision diagnosis of prediabetes

Recent advancements in multi-omics technologies have provided unprecedented opportunities to identify biomarkers associated with prediabetes, offering novel insights into its diagnosis and management. This review synthesizes the latest findings on prediabetes from multiple omics domains, including genomics, epigenomics, transcriptomics, proteomics, metabolomics, microbiomics, and radiomics. We explore how these technologies elucidate the molecular and cellular mechanisms underlying prediabetes and analyze potential biomarkers with predictive value in disease progression. Integrating multi-omics data helps address the limitations of traditional diagnostic methods, enabling early detection, personalized interventions, and improved patient outcomes. However, challenges such as data integration, standardization, and clinical validation and translation remain to be resolved. Future research leveraging artificial intelligence and machine learning is expected to further enhance the predictive power of multi-omics technologies, contributing to the precision diagnosis and tailored management of prediabetes.

Identification of Novel Genetic Variants and Food Intake Factors Associated with Type 2 Diabetes in South Korean Adults, Using an Illness-Death Model

Type 2 diabetes (T2D) is a prevalent chronic disease in the Korean population, influenced by lifestyle, dietary habits, and genetics. This study aimed to identify the effects of food intake and genetic factors on T2D progression in Korean adults using a multi-state illness-death model. We analyzed three transition models: normal glucose tolerance (NGT) to prediabetes (PD), NGT to T2D, and PD to T2D. We first identified dietary patterns significantly associated with each transition, using multivariate Cox proportional hazards models. Then, we assessed the impact of single-nucleotide polymorphisms (SNPs) on each transition, incorporating these dietary patterns as covariates. Our analysis revealed significant associations between the identified dietary patterns and the risk of PD and T2D incidence among individuals with NGT. We also identified novel genetic variants associated with disease progression: two SNPs (rs4607517 in Glucokinase [GCK] and rs758982 in Calcium/Calmodulin-Dependent Protein Kinase II Beta [CAMK2B]) in the NGT to PD model, and eight SNPs in the NGT to T2D model, including variants in the Zinc Finger Protein 106 (ZNF106), PTOV1 Extended AT-Hook Containing Adaptor Protein (PTOV1), Proprotein Convertase Subtilisin/Kexin Type 2 (PCSK2), Forkhead Box D2 (FOXD2), Solute Carrier Family 38 Member 7 (SLC38A7), and Neuronal Growth Regulator 1 (NEGR1) genes. Functional annotation analysis using ANNOVAR revealed that rs4607517 (GCK) and rs59595912 (PTOV1) exhibited high Combined Annotation-Dependent Depletion (CADD) and Deleterious Annotation of Genetic Variants using Neural Networks (DANN) scores, suggesting potential pathogenicity and providing a functional basis for their association with T2D progression. Integrating dietary and genetic factors with a multi-state model, this comprehensive approach offers valuable insights into T2D development and highlights potential targets for prevention and personalized interventions.

The association between triglyceride-glucose index and related parameters and risk of tuberculosis infection in American adults under different glucose metabolic states: a cross-sectional study

BACKGROUND

Tuberculosis (TB) and diabetes mellitus (DM) are known to influence each other, with insulin resistance playing a pivotal role. The relationship between the triglyceride-glucose (TyG) index and its derived indices with the incidence of TB infection across varying glucose metabolic statuses is not well defined.

METHODS

This cross-sectional study utilized data from the 2011-2012 National Health and Nutrition Examination Survey. Weighted multivariable regression analysis was employed to explore the correlation between TyG and associated parameters with the incidence of TB infection within different categories of glucose metabolism. Interaction analyses and restricted cubic splines were utilized to assess potential heterogeneity in these associations and to explore the link between TyG and its derivatives with the occurrence of TB infection.

RESULTS

The study included 4823 participants, of which 668 had TB infection. In individuals with normal glucose tolerance (NGT), the TyG index (OR 2.17, 95%CI 1.40-3.35), TyG-WC (OR 1.01, 95%CI 1.00-1.01), and TyG-BMI (OR 1.02, 95%CI 1.00-1.04) were correlated with TB infection (all P < 0.05). Among participants with impaired fasting glucose (IFG), TyG (OR 57.10, 95%CI 1.17-278.66), TyG-WC (OR 1.02, 95%CI 1.00-1.05), TyG-WHtR (OR 872.94, 95%CI 43.31-17592.72) were significant associated with TB infection (all P < 0.05). However, in those with impaired glucose tolerance (IGT) and DM, TyG and its related parameters did not show an association with TB infection (P > 0.05). The sensitive analysis, converting the TyG index from a continuous variable to a categorical variable (quartiles), revealed an association between the TyG index and an increase risk of TB infection in the NGT and IGT group (quartile 4: OR 2.45 (1.31-4.60) and 761.33 (10.54-54999.02), respectively). No significant association between the TyG index and TB infection was observed in DM and IFG groups.

CONCLUSIONS

In participants with NGT and IFG, the levels of the TyG index and its associated parameters were correlated with TB infection. A higher TyG index was independently linked to an increased likelihood of TB infection in individuals with NGT and IGT, but not in DM and IFG.

A comprehensive review of methodologies and application to use the real-world data and analytics platform TriNetX

Randomized controlled trials (RCTs) are the gold standard for evaluating the efficacy and safety of both pharmacological and non-pharmacological interventions. However, while they are designed to control confounders and ensure internal validity, their usually stringent inclusion and exclusion criteria often limit the generalizability of findings to broader patient populations. Moreover, RCTs are resource-intensive, frequently underpowered to detect rare adverse events, and sometimes narrowly focused due to their highly controlled environments. In contrast, real-world data (RWD), typically derived from electronic health records (EHRs) and claims databases, offers a valuable counterpart for answering research questions that may be impractical to address through RCTs. Recognizing this, the US Food and Drug Administration (FDA) has increasingly relied on real-world evidence (RWE) from RWD to support regulatory decisions and post-market surveillance. Platforms like TriNetX, that leverage large-scale RWD, facilitate collaborations between academia, industry, and healthcare organizations, and constitute an in-depth tool for retrieval and analysis of RWD. TriNetX's federated network architecture allows real-time, privacy-compliant data access, significantly enhancing the ability to conduct retrospective studies and refine clinical trial designs. With access to currently over 150 million EHRs, TriNetX has proven particularly effective in filling gaps left by RCTs, especially in the context of rare diseases, rare endpoints, and diverse patient populations. As the role of RWD in healthcare continues to expand, TriNetX stands out as a critical tool that complements traditional clinical trials, bridging the gap between controlled research environments and real-world practice. This review provides a comprehensive analysis of the methodologies and applications of the TriNetX platform, highlighting its potential contribution to advance patient care and outcomes.

Applications and prospects of biomaterials in diabetes management

Diabetes is a widespread metabolic disorder that presents considerable challenges in its management. Recent advancements in biomaterial research have shed light on innovative approaches for the treatment of diabetes. This review examines the role of biomaterials in diabetes diagnosis and treatment, as well as their application in managing diabetic wounds. By evaluating recent research developments alongside future obstacles, the review highlights the promising potential of biomaterials in diabetes care, underscoring their importance in enhancing patient outcomes and refining treatment methodologies.

Investigating the hypoglycaemic potential of processed apple and acarbose combination in vitro, ex vivo, and in vivo: the role of quercetin-3-glucoside in steering α-glucosidase inhibition

This study investigated the interaction between apple juice (AJ) and acarbose (A) in modulating glycaemic responses, with the aim of validating in vivo results previously observed in vitro. When administered to rats, AJ alone reduced the glycemic curve, but the combination of AJ with increasing doses of A resulted in higher glycemic responses, suggesting an antagonistic interaction in α-glucosidase inhibition. To explore this mechanism, quercetin-3-glucoside (Q-3-G), a major phenolic compound in AJ, was tested for α-glucosidase inhibition in vitro. Q-3-G and A together showed reduced inhibitory efficacy compared to either compound alone, consistent with in vivo findings. Ex vivo studies in Caco-2 cells further supported this antagonism. Sucrose hydrolysis experiments showed that low concentrations of Q-3-G increased residual sucrose when combined with moderate concentrations of A, but higher concentrations of Q-3-G favoured sucrose hydrolysis regardless of A levels. The results highlight the antagonistic interaction between Q-3-G and A in inhibiting α-glucosidase and emphasise the need to combine in vitro, ex vivo and in vivo studies to evaluate food-drug interactions. This comprehensive approach is essential before advocating the use of functional foods alongside pharmacological therapies.

Exploring cutting-edge approaches in diabetes care: from nanotechnology to personalized therapeutics

Diabetes mellitus (DM) is a persistent condition characterized by high levels of glucose in the blood due to irregularities in the secretion of insulin, its action, or both. The disease was believed to be incurable until insulin was extracted, refined, and produced for sale. In DM, insulin delivery devices and insulin analogs have improved glycemic management even further. Sulfonylureas, biguanides, alpha-glucosidase inhibitors, and thiazolidinediones are examples of newer-generation medications having high efficacy in decreasing hyperglycemia as a result of scientific and technological advancements. Incretin mimetics, dual glucose-dependent insulinotropic polypeptide, GLP-1 agonists, PPARs, dipeptidyl peptidase-4 inhibitors, anti-CD3 mAbs, glucokinase activators, and glimins as targets have all performed well in recent clinical studies. Considerable focus was placed on free FA receptor 1 agonist, protein tyrosine phosphatase-1B inhibitors, and Sparc-related modular calcium-binding protein 1 which are still being studied. Theranostics, stem cell therapy, gene therapy, siRNA, and nanotechnology are some of the new therapeutic techniques. Traditional Chinese medicinal plants will also be discussed. This study seeks to present a comprehensive analysis of the latest research advancements, the emerging trends in medication therapy, and the utilization of delivery systems in treating DM. The objective is to provide valuable insights into the application of different pharmaceuticals in the field of diabetes mellitus treatment. Also, the therapeutic approach for diabetic patients infected with COVID-19 will be highlighted. Recent clinical and experimental studies evidence the Egyptian experience. Finally, as per the knowledge of the state of the art, our conclusion and future perspective will be declared.

Feasibility of digital phenotyping based on continuous glucose monitoring to support personalized lifestyle medicine in type 2 diabetes

OBJECTIVES

Type 2 diabetes is a highly prevalent age-related chronic condition, with complex and heterogeneous pathogenesis. A 5-point oral glucose tolerance test can identify type 2 diabetes subtypes or "diabetypes" based on the degree of insulin resistance in muscle and/or liver, and beta-cell dysfunction. Due to its costly and invasive nature, the oral glucose tolerance test is not scalable. Presuming that differences in glucose and insulin dynamics manifest in continuous glucose monitoring profiles, we explore the potential of continuous glucose metrics to replace the oral glucose tolerance test for diabetyping.

STUDY DESIGN

In a prospective intervention study, 41 people with type 2 diabetes on lifestyle and/or metformin treatment wore a continuous glucose monitor during 3 control periods of 4 days. During each control period, participants underwent a 5-point oral glucose tolerance test after an overnight fast.

MAIN OUTCOME MEASURES

Continuous glucose monitoring data from the control periods, excluding the day of the oral glucose tolerance test, was retrospectively analyzed for associations with diabetypes, as well as Spearman correlations between bootstrapped continuous glucose features, including physiology-based and other time-series features, and oral glucose tolerance metrics.

RESULTS

Significant associations were observed between continuous glucose metrics (e.g., low and high blood glucose index, eA1c, and glucose excursions) and oral glucose tolerance metrics (e.g., 2-h glucose, disposition index, insulinogenic index). Furthermore, data-driven metrics (e.g., maximum shift, lumpiness) showed more selective correlations, indicating that data-driven metrics may contain additional information associated with oral glucose tolerance metrics.

CONCLUSIONS

These results indicate the potential of continuous glucose monitoring to replace the oral glucose tolerance test for diabetyping, driving proactive and personalized (lifestyle) treatment.

NETHERLANDS TRIAL REGISTER

NL7848.

Association between triglyceride-glucose related indices and all-cause and cardiovascular mortality among the population with cardiovascular-kidney-metabolic syndrome stage 0-3: a cohort study

BACKGROUND

Cardiovascular-Kidney-Metabolic (CKM) syndrome typically commences with the interaction of insulin resistance (IR), excessive or dysfunctional obesity, and the consequent systemic inflammatory response and oxidative stress. The relationship between the triglyceride-glucose (TyG) index and TyG-related indices that may simply assess IR and obesity, as well as the mortality risk in the CKM syndrome population, remains ambiguous.

METHODS

This study included 6,383 participants from the National Health and Nutrition Examination Survey (NHANES) 2009-2018. The TyG index, TyG-waist-to-height ratio (TyG-WHtR), TyG-waist circumference (TyG-WC), and TyG-body mass index (TyG-BMI) were developed. Cox proportional hazards models, smooth curve fitting, and two-stage Cox proportional hazards models were employed to examine the association of TyG and TyG-related indices with all-cause and cardiovascular mortality in the CKM syndrome population. Subgroup analyses and interaction tests were conducted to evaluate the risk within various demographics.

RESULTS

In survey-weighted multifactorial regression analyses, a significant positive association existed between TyG, TyG-related indices, and both all-cause mortality and cardiovascular mortality, except for the TyG index, which did not demonstrate a significant link with all-cause mortality. Of these indices, the TyG-WC index exhibited the strongest correlation with all-cause mortality, with a hazard ratio (HR) of 1.50 and a 95% confidence interval (CI) of 1.18-1.92, followed by the TyG-WHtR index (HR: 1.45, 95%CI 1.13-1.85). The TyG-WHtR index demonstrated the strongest correlation with cardiovascular mortality (HR: 1.85, 95% CI 1.19-2.86), followed by the TyG-WC index(HR: 1.83, 95%CI 1.21-2.78). An L-shaped association was identified between TyG-WHtR, TyG-BMI, and all-cause mortality in CKM syndrome during the examination of nonlinear relationships (both P for log-likelihood ratio < 0.05). The TyG-WHtR, TyG-WC, and TyG-BMI indices exhibited a more pronounced correlation with all-cause mortality in those with CKM syndrome stages 1 and 3 (P value < 0.05, P for interaction < 0.05).

CONCLUSION

Our study emphasizes the association between TyG and TyG-related indices and mortality in individuals with CKM syndrome stages 0-3. Individuals with CKM syndrome stages 1 and 3 should be more vigilant to abnormal alterations in TyG-related indices.

A Mathematical Model-Derived Disposition Index Without Insulin Validated in Youth With Obesity

CONTEXT

The gold-standard clamp measurements for insulin sensitivity (cSI), β-cell function (cBCF), and disposition index (cDI = cSI × cBCF) are not practical in large-scale studies.

OBJECTIVE

We sought to 1) validate a mathematical model-derived DI from oral glucose tolerance tests (OGTT) with insulin (mDI) and without (mDI-woI) against cDI and oral disposition index (oDI) and 2) evaluate the ability of the novel indices to detect prediabetes and type 2 diabetes (T2D).

METHODS

We carried out a secondary analysis of previously reported cross-sectional observational studies. The Insulin Sensitivity and Secretion mathematical model for glucose-insulin dynamics was applied to 5-point and 3-point OGTTs synchronized with hyperinsulinemic-euglycemic and hyperglycemic clamps from 130 youth with obesity (68 normal glucose tolerance [NGT], 33 impaired glucose tolerance [IGT], 29 T2D).

RESULTS

Model-derived DI correlated well with clamp DI (R = 0.76 [logged]). Between NGT and IGT, mDI and mDI-woI decreased more than oDI and cDI, (60% and 59% vs 29% and 27%), and by receiver operating characteristic analysis were superior at detecting IGT compared with oDI and cDI (area under the curve [AUC] 0.88-0.87 vs 0.68-0.65), as was mean glucose (AUC 0.87).

CONCLUSION

mDI-woI is better than oDI or the labor-intensive cDI for detecting dysglycemia in obese youth. Bypassing insulin measurements with mDI-woI from the OGTT provides a cost-effective approach for large-scale epidemiological studies of dysglycemia in youth.

A Research Roadmap to Address the Heterogeneity of Diabetes and Advance Precision Medicine

The current classification of diabetes had its genesis over 85 years ago, when individuals with diabetes were first subclassified into insulin sensitive and insulin insensitive states based on the response to an oral glucose tolerance test. About 35 years later, the contemporary classifications of type 1 and type 2 diabetes were coined. Today's evidence, however, suggests that multiple etiologic and pathogenic processes lead to both type 1 and type 2 diabetes, reflecting significant heterogeneity in factors associated with initiation, progression, and clinical presentation of each disorder of glucose homeostasis. Further, the current classification fails to recognize what is currently defined as "atypical" diabetes. Heterogeneity of diabetes continues through the life-course of an individual, with modification of prognosis risk (eg, diabetic complications) altered by genetics, life experience, comorbidities, and therapy. Understanding the sources of heterogeneity in diabetes will likely improve diagnosis, prevention, treatment, and prediction of complications in both the medical and public health settings. Such knowledge will help inform progress in the emerging era of precision diabetes medicine. This article presents NIDDK's Heterogeneity of Diabetes Initiative and a corresponding roadmap for future research in type 2 diabetes heterogeneity.

Models based on dietary nutrients predicting all-cause and cardiovascular mortality in people with diabetes

Dietary intervention plays a vital role in improving the prognosis of people with diabetes mellitus (DM). Currently, there is a lack of systematic analysis of the relation between dietary nutrients and long-term mortality risk in people with DM. The study aims to establish models predicting long-term mortality and explore dietary nutrients associated with reduced long-term events to guide daily dietary decisions in people with DM. The retrospective cohort study collected 5060 participants with DM from the National Health and Nutrition Examination Survey (NHANES) 1999-2018. The least absolute shrinkage and selection operator (LASSO) regression and random forest (RF) algorithm were applied to identify key mortality-related dietary factors, which were subsequently incorporated into risk prediction nomogram models. The receiver operating characteristic (ROC) curve, calibration plot and decision curve analysis (DCA) were utilized to evaluate the performance of the models. The association of key dietary nutrients with all-cause and cardiovascular mortality were visualized by restricted cubic spline (RCS) models both in the whole and subgroups by sex, age, drinking and smoking status. The overall median age of the cohort was 62.0 years (interquartile range (IQR) 52.0-70.0), 2564 (50.67%) being male. During a median follow-up period of 56.0 months, 997 (19.70%) all-cause deaths were recorded, with 219 (21.97%) of which being ascribed to cardiovascular disease. The nomogram models based on key dietary nutrients identified by LASSO and RF demonstrated a significant predicative value for all-cause and cardiovascular mortality. Dietary fiber and magnesium were the common predictive nutrients in the two nomogram models. The RCS curve revealed that dietary fiber and magnesium were negatively associated with long-term mortality in the whole and subgroups of people with DM after adjustment of potential confounders. The diet of people with DM is closely associated with mortality. The nomogram models based on dietary nutrients can predict long-term mortality of people with DM, and the higher intake of dietary fiber and magnesium was associated with reduced risks of both long-term all-cause and cardiovascular mortality.

The Twin Cycle Hypothesis of type 2 diabetes aetiology: From concept to national NHS programme

The development of magnetic resonance methods for quantifying intra-organ metabolites has permitted advances in the understanding of fasting and post-prandial carbohydrate and lipid handling in people with and without type 2 diabetes. Insulin resistance in the liver was shown to be related to excess intra-organ fat and was able to be returned to normal by weight loss. The practical effect of having muscle insulin sensitivity in the lower part of the wide normal range resulted in the obligatory shunting of carbohydrates via de novo lipogenesis into saturated fat. These observations provided the basis for the Twin Cycle Hypothesis of the aetiology of type 2 diabetes. Subsequent studies on people with type 2 diabetes confirmed the postulated pathophysiological abnormalities and demonstrated their reversibility by dietary weight loss of 10-15 kg. Overall, the fundamental understanding of the mechanisms causing type 2 diabetes has bridged physiological and clinical perspectives. Large population-based randomised controlled trials confirmed the practical clinical application of the method of achieving substantial weight loss, and an NHS programme is now in place offering potential remission to people within 6 years of diagnosis.

Phenolic acids from Anisopus mannii modulates phosphofructokinase 1 to improve glycemic control in patients with type 2 diabetes: A double-blind, randomized, clinical trial

Phenolic acid-rich fraction from Anisopus mannii (PhAM) contains abundance of ferulic acid, gallic acid, protocatechuic acid, and syringic acid. Among other glycolytic enzymes, in vitro, PhAM counteracted the binding of sodium orthovanadate to phosphofructokinase 1 (PFK-1), improving its activities. In a rat model of diet-induced diabetes, PhAM monotherapy reduced HbA1c by an average of 0.63 % and fasting plasma glucose by 25 mg/dl. This herb rescued β-cells from streptozotocin-mediated destruction, thereby improving glycemic control. Supported by the preclinical trial, eighty-five patients with type 2 diabetes (T2D) receiving first-line medications were enrolled in a double-blind, randomized, placebo-controlled trial with a 90 % power level. Patients were randomized into a placebo group or either of the following two treatment groups: oral administration of 12 mg or 20 mg/kg body weight of PhAM once every 48 h for 6 months. Both treatments were well tolerated. At the endpoint, more than 70 % of patients achieved a 0.5 - 2.0 decrease in HbA1c levels and a > 20 mg/dl decrease in fasting blood glucose, meeting the pre-specified primary outcome. 66 % of patients treated with 20 mg PhAM achieved the < 7 % HbA1c and HOMA-IR of > 1.0 goal. respectively. Our study shows that PhAM can supplement first-line medications to achieve target glycemic control within 6 months.

Pancreatic beta cell function and insulin resistance profiles in first-degree relatives of patients with prediabetes and type 2 diabetes

AIMS

To evaluate insulin secretion and insulin resistance profiles in individuals with family history of prediabetes and type 2 diabetes.

METHODS

This was a cross-sectional study to evaluate clinical and metabolic profiles between individuals with type 2 diabetes, prediabetes and their relatives. There were 911 subjects divided into five groups: (i) normoglycemic (NG), (ii) type 2 diabetes, (iii) prediabetes, (iv) first-degree relatives of patients with type 2 diabetes (famT2D), and (v) first-degree relatives of patients with prediabetes (famPD); anthropometrical, biochemical and nutritional evaluation, as well as insulin resistance and pancreatic beta cell function measurement was performed by oral glucose tolerance to compare between groups.

RESULTS

The most prevalent type 2 diabetes risk factors were dyslipidemia (81%), family history of type 2 diabetes (76%), central obesity (73%), male sex (63%), and sedentary lifestyle (60%), and most of them were progressively associated to prediabetes and type 2 diabetes groups. Insulin sensitivity was lower in famT2D groups in comparison to NG group (p < 0.0001). FamPD and famT2D had a 10% lower pancreatic beta cell function (DI) than the NG group (NG group 2.78 ± 1.0, famPD 2.5 ± 0.85, famT2D 2.4 ± 0.75, p˂0.001).

CONCLUSIONS

FamPD and famT2D patients had lower pancreatic beta cell function than NG patients, highlighting that defects in insulin secretion and insulin sensitivity appear long time before the development of hyperglycemia in patients genetically predisposed.

Associations of the triglyceride-glucose index and remnant cholesterol levels with the prevalence of Carotid Plaque in patients with type 2 diabetes: a retrospective study

BACKGROUND

The triglyceride-glucose (TyG) index has been identified as an alternative biomarker for insulin resistance (IR), while residual cholesterol (RC) is a simple, cost-effective, and easily detectable lipid metabolite. However, the associations of these two markers with carotid plaque presence remain unclear. Thus, this study aimed to explore their associations with carotid plaque presence.

METHODS

Participants were chosen from patients with T2DM admitted to The Second Affiliated Hospital of Anhui Medical University from October 2023 to April 2024, and they were separated into two groups (patients without carotid plaque and patients with carotid plaque) based on their carotid ultrasound results. By comparing the general information and biochemical indicators of the two groups, we employed multivariate logistic regression models and RCS regression models to investigate the associations of the TyG index and RC levels with carotid plaque presence, and made adjustments based on multiple confounding factors to identify the differences between subgroups.

RESULTS

This study comprised 278 patients with T2DM in total, including 165 males and 113 females. A multivariate logistic regression study indicated that, after adjusting statistically significant variables screened in LASSO regression, TyG index [OR (95% CI): 1.810 (1.077, 3.113)] and RC [OR (95% CI): 1.988 (1.034, 3.950)] remained the risk factors for carotid plaque presence. According to restricted cubic splines (RCS), RC levels increased linearly with carotid plaque presence (P - nonlinear > 0.05). Conversely, the TyG index and carotid plaque presence did not associate linearly (P - nonlinear < 0.05). Results of subgroup analyses showed no grouping variables exhibited association with TyG index or RC (p for interaction > 0.05).

CONCLUSIONS

In patients with T2DM, both TyG index and RC levels were strongly linked to carotid plaque presence, and could serve as independent risk factors for this presence. Monitoring the TyG index and RC levels can help gain a better understanding and knowledge of carotid plaque presence in patients with T2DM, offering guidance for the clinical prevention and treatment of cardiovascular and cerebrovascular diseases (CCVDs) in patients with T2DM.

Relationship between triglyceride glucose-body mass index baselines and variation with future cardiovascular diseases risk in the middle-aged and elderly individuals

Background

Cardiovascular diseases (CVDs) are gradually becoming the leading cause of morbidity and mortality among chronic non-communicable diseases. Previous studies have found that the TyG index is an effective alternative indicator for insulin resistance (IR) and is associated with cardiovascular events. Additionally, obesity directly or indirectly increases the risk of developing CVDs. Up to now, studies on the combined effects of these factors are insufficient, and the conclusions are not yet consistent. This study aims to analyze whether the baseline levels and fluctuations of triglyceride glucose-body mass index (TyG-BMI) are associated with the incidence of CVDs and their subtypes in a prospective cohort of middle-aged and elderly individuals.

Methods

The data for this study were obtained from the China Health and Retirement Longitudinal Study (CHARLS), which is an ongoing nationally representative prospective cohort study. After excluding participants with partially missing variables that could affect the study results, this study ultimately included 7,072 participants, with data records spanning from 2011 to 2020. The exposures were TyG-BMI and the change in TyG-BMI from 2011 to 2015. The TyG-BMI index was calculated as TyG index multiply BMI. The change of TyG-BMI was categorized using K-means clustering and baseline TyG-BMI was grouped based on quartiles. We used Cox proportional hazards models to evaluate the relationship between baseline quartiles of the TyG-BMI index and its variability with CVDs and their subtypes.

Results

Among the 7,072 participants (mean age of 59.1 ± 9.3 years), 3330 (47%) were male. During an average follow-up of 7.1 years, 1,774 (25.1%) participants developed new-onset cardiovascular diseases. After stratification by baseline TyG-BMI quartiles, higher TyG-BMI levels were associated with an increased risk of CVDs, The hazard ratio (HR) and 95% confidence interval (95% CI) for the highest quartile group were 1.69 (1.44-2.00). After adjusting for potential confounding factors, compared to participants with consistently low TyG-BMI levels, those with moderate TyG-BMI levels and a slowly increasing trend had an HR of 1.27 (95% CI 1.10-1.47), while those with the highest TyG-BMI levels and a slowly decreasing trend had an HR of 1.52 (95% CI 1.26-1.83).

Conclusion

Material changes in the TyG-BMI are independently associated with the risk of CVDs in middle-aged and elderly individuals. Detecting long-term changes in the TyG-BMI may aid in the early identification of high-risk individuals and help prevent the occurrence of various cardiovascular diseases.

Islet NO-Synthases, extracellular NO and glucose-stimulated insulin secretion: Possible impact of neuronal NO-Synthase on the pentose phosphate pathway

The impact of islet neuronal nitric oxide synthase (nNOS) on glucose-stimulated insulin secretion (GSIS) is less understood. We investigated this issue by performing simultaneous measurements of the activity of nNOS versus inducible NOS (iNOS) in GSIS using isolated murine islets. Additionally, the significance of extracellular NO on GSIS was studied. Islets incubated at basal glucose showed modest nNOS but no iNOS activity. Glucose-induced concentration-response studies revealed an increase in both NOS activities in relation to secreted insulin. Culturing at high glucose increased both nNOS and iNOS activities inducing a marked decrease in GSIS in a following short-term incubation at high glucose. Culturing at half-maximal glucose showed strong iNOS expression revealed by fluorescence microscopy also in human islets. Experiments with nNOS-inhibitors revealed that GSIS was inversely related to nNOS activity, the effect of iNOS activity being negligible. The increased GSIS after blockade of nNOS was reversed by the intracellular NO-donor hydroxylamine. The enhancing effect on GSIS by nNOS inhibition was independent of membrane depolarization and most likely exerted in the pentose phosphate pathway (PPP). GSIS was markedly reduced, 50%, by glucose-6-phosphate dehydrogenase (G-6-PD) inhibition both in the absence and presence of nNOS inhibition. NO gas stimulated GSIS at low and inhibited at high NO concentrations. The stimulatory action was dependent on membrane thiol groups. In comparison, carbon monoxide (CO) exclusively potentiated GSIS. CO rather than NO stimulated islet cyclic GMP during GSIS. It is suggested that increased nNOS activity restrains GSIS, and that the alternative pathway along the PPP initially might involve as much as 50% of total GSIS. In the PPP, the acute insulin response is downregulated by a negative feedback effect executed by a marked upregulation of nNOS activity elicited from secreted insulin exciting insulin receptors at exocytotic sites of an nNOS-associated population of secretory granules.

Impact of Exercise Manual Program on Biochemical Markers in Sedentary Prediabetic Patients: A Randomized Controlled Trial

Background and Objectives: Prediabetes is a medical disease characterized by elevated blood sugar levels that exceed normal levels but do not meet the criteria for a diagnosis of diabetes mellitus. This study aimed to assess the impact of structured exercise manual interventions on the biochemical markers of sedentary prediabetic patients over sixteen weeks. Materials and Methods: A sixteen-weeks randomized controlled trial was conducted to assess the impact of an exercise-based manual program on biochemical markers, such as HbA1c, insulin sensitivity measures, and lipid profiles, in sedentary individuals with prediabetes. The Riphah Rehabilitation Center in Lahore, Pakistan, was the site of the trial. In this investigation, 126 individuals with prediabetes were randomly assigned to three groups: control, unsupervised, and supervised. The RCT was completed by 36 participants in each group after a 16-weeks intervention in the supervised and unsupervised groups, as well as a follow-up in the control group. An activity-based exercise manual that included dietary guidelines, educational materials, and an exercise routine was followed by both the supervised and unsupervised groups. The exercise interventions included both aerobic and resistance components. Results: The results indicated that the supervised group exhibited a substantial increase in insulin sensitivity, lipid profiles, and glycemic control when contrasted with the unsupervised and control groups. Significant improvements were observed in key biochemical parameters, including fasting blood levels (supervised as compared to unsupervised and control, respectively, the mean difference was 12.82 mg/dL vs. 11.36 mg/dL vs. 0.09 mg/dL p > 0.001), HbA1c (supervised as compared to unsupervised and control groups, respectively, the mean difference was 0.67% vs. 0.69% vs. 0.13% p < 0.001), and lipid profile (triglycerides (mean difference 0.25 mmol/L, 0.08 mmol/L, 0.11 mmol/L p < 0.001); LDL (mean difference 19.31 mg/dL, 10.51 mg/dL, 2.49 mg/dL p < 0.001); HDL (mean difference -12.68 mg/dL, -8.03 mg/dL, -1.48 mg/dL p < 0.001)). In comparison to the unsupervised and control groups, the insulin sensitivity parameters also demonstrated a modest improvement in the supervised group. The supervised group exhibited the greatest benefits from exercise among the groups that received exercise interventions. Conclusions: The present investigation demonstrated the significance of including structured physical activity into the regular routine of individuals with prediabetes, to decelerate the advancement of prediabetes to type 2 diabetes mellitus (T2DM). The current study emphasizes the essential role of structured exercise routines in the control of prediabetes and suggests that monitoring enhances the adherence and effectiveness of lifestyle interventions.

Association between insulin resistance indices and outcomes in patients with heart failure with preserved ejection fraction

BACKGROUND

Insulin resistance (IR) plays a pivotal role in the interplay between metabolic disorders and heart failure with preserved ejection fraction (HFpEF). Various non-insulin-based indices emerge as reliable surrogate markers for assessing IR, including the triglyceride-glucose (TyG) index, the TyG index with body mass index (TyG-BMI), atherogenic index of plasma (AIP), and the metabolic score for insulin resistance (METS-IR). However, the ability of different IR indices to predict outcome in HFpEF patients has not been extensively explored.

METHODS

Patients having HFpEF were recruited from January 2012 and December 2023. The outcome was defined as major adverse cardiovascular event (MACE), encompassing all-cause mortality and rehospitalization for heart failure. The potential linear relationship was visualized by the restricted cubic spline (RCS) curve. Both univariable and multivariable Cox proportional hazards models were employed to examine the association between the IR indexes and MACE. Furthermore, to assess the incremental prognostic value of the TyG index, we conducted comprehensive analyses using area under the curve (AUC), the continuous net reclassification index (cNRI), and the integrated discrimination index (IDI).

RESULTS

A total of 8693 patients met the inclusion criteria and were included in the final analysis. The mean age of the patients was 70.59 ± 10.6 years, with 5045 (58.04%) being male. The Kaplan-Meier survival analysis revealed that higher degree of the four IR indexes was associated with higher risk of MACE (all log-rank P < 0.05). When treated as a continuous variable, the TyG index showed a significant association with MACE (HR 2.1, 95% CI 1.98-2.23, P < 0.001 in model 1; HR 1.81, 95% CI 1.73-1.9, P < 0.001 in model 2; HR 1.68, 95% CI 1.6-1.76, P < 0.001 in model 3). When categorized into quartiles, the highest quartile of the TyG index (Q4) was significantly associated with MACE (HR 2.48, 95% CI 2.24-2.76, P < 0.001 in model 3). Similar significant associations were found between TyG-BMI, AIP, METS-IR, and MACE. The TyG index was found to enhance the risk stratification capability of the MAGGIC score (AUC from 0.601 to 0.666). When compared to other IR indicators, the TyG index exhibited superior discrimination and reclassification abilities in predicting MACE. Additionally, the TyG-BMI index revealed a U-shaped correlation with MACE, indicating that both an elevated and a lower TyG-BMI index were associated with an increased risk.

CONCLUSION

All four IR indices are independently associated with MACE in patients with HFpEF. Notably, these IR indices significantly enhance the predictive accuracy of the MAGGIC score, a widely used risk assessment tool in HFpEF. Among these indices, the TyG index demonstrated the highest discriminatory and reclassification abilities, providing the greatest incremental value in predicting MACE and exhibiting significant superiority compared to the other indices. These findings highlight the importance of assessing IR indices, particularly the TyG index, in the risk assessment and management strategies for HFpEF patients. However, it should be noted that our findings need to be validated in diverse populations to ensure their applicability and generalizability.

Adipocentric Strategy for the Treatment of Type 2 Diabetes Mellitus

The global prevalence of obesity and type 2 diabetes mellitus (T2D) has risen in parallel over recent decades. Most individuals diagnosed with T2D exhibit adiposopathy-related diabetes (ARD), a condition characterized by hyperglycemia accompanied by three core features: increased ectopic and visceral fat deposition, dysregulated adipokine secretion favoring a pro-inflammatory state, and insulin resistance. Despite advancements in precision medicine, international guidelines for T2D continue to prioritize individualized therapeutic approaches focused on glycemic control and complications, and many healthcare providers predominantly maintain a glucocentric strategy. This review advocates for an adipocentric treatment paradigm for most individuals with T2D, emphasizing the importance of prioritizing weight loss and visceral fat reduction as key drivers of therapeutic intensification. By combining lifestyle modifications with pharmacological agents that promote weight loss-including SGLT-2 inhibitors, GLP-1 receptor agonists, or dual GLP-1/GIP receptor agonists-and, when appropriate, metabolic surgery, this approach offers the potential for disease remission in patients with shorter disease duration. For others, it enables superior metabolic control compared to traditional glucose-centered strategies while simultaneously delivering cardiovascular and renal benefits. In conclusion, an adipocentric treatment framework for ARD, which represents the majority of T2D cases, effectively integrates glucocentric and cardio-nephrocentric goals. This approach constitutes the optimal strategy for ARD due to its efficacy in achieving disease remission, improving metabolic control, addressing obesity-related comorbidities, and reducing cardiovascular and renal morbidity and mortality.

Pro-Arg, The Potential Anti-Diabetes Peptide, Screened from Almond by In-Silico Analysis

Insulin resistance was considered to be the most important clinical phenotype of type 2 diabetes (T2DM). Almond is a widely-consumed nut and long-term intake was beneficial to alleviating insulin resistance in patients with T2DM. Hence, screening of anti-diabetic peptides from almond proteins was feasible based on the effectiveness of peptides in the treatment of T2DM. Pro-Arg (PR), a potential anti-diabetic peptide screened from almonds proteins using in-silico technology and cell experiment, upregulated the phosphorylation levels of IRS1, PI3K, AKT, and translocation of GLUT4, and showed potential to target AKT1 in molecular simulation, suggesting PR mediated the activation of IRS1/PI3K/AKT/GLUT4 signaling pathway by targeting AKT1 to alleviate insulin resistance. Consequently, PR was the potential anti-diabetes peptide from almond proteins and showed the potential application as a candidate drug for alleviating T2DM.