Physical Function in Middle-aged and Older Adults With Type 1 Diabetes: Long-term Follow-up of the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study

Muscle regeneration and muscle stem cells in metabolic disease

Skeletal muscle has a high regenerative capacity due to its resident adult muscle stem cells (MuSCs), which can repair damaged tissue by forming myofibres de novo. Stem cell dependent regeneration is critical for maintaining skeletal muscle health, and different conditions can draw heavily on MuSC support to preserve muscle function, including metabolic diseases such as diabetes. The global incidence and burden of diabetes is increasing, and skeletal muscle is critical for maintaining systemic metabolic homeostasis and improving outcomes for diabetic patients. Thus, poor muscle health in diabetes, termed diabetic myopathy, is an important complication that must be addressed. The health of MuSCs is also affected by diabetes, responsible for the poor muscle regenerative capacity and contributing to the functional decline in diabetic patients. Here, we review the impact of diabetes and metabolic disease on MuSCs and skeletal muscle, including potential mechanisms for impaired muscle regeneration and MuSC dysfunction, and how these deficits could be addressed.

Older Adults Benefit From Virtual Support for Continuous Glucose Monitor Use But Require Longer Visits

BACKGROUND

Older adults may be less comfortable with continuous glucose monitoring (CGM) technology or require additional education to support use. The Virtual Diabetes Specialty Clinic study provided the opportunity to understand glycemic outcomes and support needed for older versus younger adults living with diabetes and using CGM.

METHODS

Prospective, virtual study of adults with type 1 diabetes (T1D, N = 160) or type 2 diabetes (T2D, N = 74) using basal-bolus insulin injections or insulin pump therapy. Remote CGM diabetes education (3 scheduled visits over 1 month) was provided by Certified Diabetes Care and Education Specialists with additional visits as needed. CGM-measured glycemic metrics, HbA1c and visit duration were evaluated by age (<40, 40-64 and ≥65 years).

RESULTS

Median CGM use was ≥95% in all age groups. From baseline to 6 months, time 70 to 180 mg/dL improved from 45% ± 22 to 57% ± 16%; 50 ± 25 to 65 ± 18%; and 60 ± 28 to 69% ± 18% in the <40, 40-64, and ≥65-year groups, respectively (<40 vs 40-64 years P = 0.006). Corresponding values for HbA1c were 8.0% ± 1.6 to 7.3% ± 1.0%; 7.9 ± 1.6 to 7.0 ± 1.0%; and 7.4 ± 1.4 to 7.1% ± 0.9% (all P > 0.05). Visit duration was 41 min longer for ages ≥65 versus <40 years (P = 0.001).

CONCLUSIONS

Adults with diabetes experience glycemic benefit after remote CGM use training, but training time for those >65 years is longer compared with younger adults. Addressing individual training-related needs, including needs that may vary by age, should be considered.

Adolescents and type 1 diabetes: A grounded theory on adolescents' experiences of adaptation to type 1 diabetes

PURPOSE

Type 1 diabetes influences adolescents' health status and therapeutic management. Adaptation for adolescents with type 1 diabetes is considered a significant issue for this cohort group and is based on many factors, including availability of resources, and family and community support. Thus, this study aimed to explore Palestinian adolescents' experiences of adaptation to type 1 diabetes in the West Bank.

DESIGN AND METHODS

A qualitative grounded theory approach was adopted. The purposive sample consisted of fourteen adolescents aged from 12 to 18 years and diagnosed with type 1 diabetes. The data were collected using semi-structured and face-to-face individual interviews during the period from March to June 2023. A constant comparative method was used to analyze data.

FINDINGS

The core category had emerged with categories and subcategories. There were three categories and ten subcategories including difficulties in the management of type 1 diabetes, for example, "insulin injections, dietary management, and control of HbA1c levels", burdens of type1 diabetes, for example, "burden regarding follow-up treatment, the burden of interaction and communication, emotional burden, and economic burden", and fears and worries of unexpected future life, for example, "worries about disease complications, worries regarding social relationships, and worries about marriage and parenthood".

CONCLUSION

Adolescents diagnosed with type 1 diabetes suffer from difficult experiences influencing their adaptation to this disease.

PRACTICE IMPLICATIONS

Counseling programs concerning self-care management for those adolescents need to be developed in addition to support programs. Health education programs are needed to develop their adaptation and coping skills to these experiences.

Impact of Overnight Glucose on Next-Day Functioning in Adults With Type 1 Diabetes: An Exploratory Intensive Longitudinal Study

OBJECTIVE

While there is evidence that functioning, or ability to perform daily life activities, can be adversely influenced by type 1 diabetes, the impact of acute fluctuations in glucose levels on functioning is poorly understood.

RESEARCH DESIGN AND METHODS

Using dynamic structural equation modeling, we examined whether overnight glucose (coefficient of variation[CV], percent time <70 mg/dL, percent time >250 mg/dL) predicted seven next-day functioning outcomes (mobile cognitive tasks, accelerometry-derived physical activity, self-reported activity participation) in adults with type 1 diabetes. We examined mediation, moderation, and whether short-term relationships were predictive of global patient-reported outcomes.

RESULTS

Overall next-day functioning was significantly predicted from overnight CV (P = 0.017) and percent time >250 mg/dL (P = 0.037). Pairwise tests indicate that higher CV is associated with poorer sustained attention (P = 0.028) and lower engagement in demanding activities (P = 0.028), time <70 mg/dL is associated with poorer sustained attention (P = 0.007), and time >250 mg/dL is associated with more sedentary time (P = 0.024). The impact of CV on sustained attention is partially mediated by sleep fragmentation. Individual differences in the effect of overnight time <70 mg/dL on sustained attention predict global illness intrusiveness (P = 0.016) and diabetes-related quality of life (P = 0.036).

CONCLUSIONS

Overnight glucose predicts problems with objective and self-reported next-day functioning and can adversely impact global patient-reported outcomes. These findings across diverse outcomes highlight the wide-ranging effects of glucose fluctuations on functioning in adults with type 1 diabetes.

The evolving therapeutic landscape of diabetic retinopathy

INTRODUCTION

Diabetic retinopathy (DR) is a leading cause of blindness worldwide. Recent decades have seen rapid progress in the management of diabetic eye disease, evolving from pituitary ablation to photocoagulation and intravitreal pharmacotherapy. The advent of effective intravitreal drugs inhibiting vascular endothelial growth factor (VEGF) marked a new era in DR therapy. Sustained innovation has since produced several promising biologics targeting angiogenesis, inflammation, oxidative stress, and neurodegeneration.

AREAS COVERED

This review surveys traditional, contemporary, and emerging therapeutics for DR, with an emphasis on anti-VEGF therapies, receptor tyrosine kinase inhibitors, angiopoietin-Tie2 pathway inhibitors, integrin pathway inhibitors, gene therapy 'biofactory' approaches, and novel systemic therapies. Some of these investigational therapies are being delivered intravitreally via sustained release technologies for extended durability. Other investigational agents are being delivered non-invasively via topical and systemic routes. These strategies hold promise for early and long-lasting treatment of DR.

EXPERT OPINION

The evolving therapeutic landscape of DR is rapidly expanding our toolkit for the effective and durable treatment of blinding eye disease. However, further research is required to validate the efficacy of novel therapeutics and characterize real world outcomes.

Precision Medicine in Type 1 Diabetes

Type 1 diabetes is a complex, chronic disease in which the insulin-producing beta cells in the pancreas are sufficiently altered or impaired to result in requirement of exogenous insulin for survival. The development of type 1 diabetes is thought to be an autoimmune process, in which an environmental (unknown) trigger initiates a T cell-mediated immune response in genetically susceptible individuals. The presence of islet autoantibodies in the blood are signs of type 1 diabetes development, and risk of progressing to clinical type 1 diabetes is correlated with the presence of multiple islet autoantibodies. Currently, a "staging" model of type 1 diabetes proposes discrete components consisting of normal blood glucose but at least two islet autoantibodies (Stage 1), abnormal blood glucose with at least two islet autoantibodies (Stage 2), and clinical diagnosis (Stage 3). While these stages may, in fact, not be discrete and vary by individual, the format suggests important applications of precision medicine to diagnosis, prevention, prognosis, treatment and monitoring. In this paper, applications of precision medicine in type 1 diabetes are discussed, with both opportunities and barriers to global implementation highlighted. Several groups have implemented components of precision medicine, yet the integration of the necessary steps to achieve both short- and long-term solutions will need to involve researchers, patients, families, and healthcare providers to fully impact and reduce the burden of type 1 diabetes.

Study Selection Bias and Racial or Ethnic Disparities in Estimated Age at Onset of Cardiometabolic Disease Among Midlife Women in the US

Importance

Racial disparities in cardiometabolic health are consistently observed in cohort studies. However, most studies neither evaluate differences in age at onset nor account for systematic exclusion stemming from "weathering" (accelerated health declines for minoritized groups due to structural social and economic marginalization).

Objective

To evaluate racial or ethnic disparities in age at onset of 4 cardiometabolic outcomes (hypertension, isolated systolic hypertension [ISH], insulin resistance [IR], and diabetes), accounting for multiple forms of potential selection bias.

Design, Setting, and Participants

This cohort study used data from the Study of Women's Health Across the Nation longitudinal cohort (1995-2016) and a cross-sectional screening sample (1995-1997). Data were analyzed from July 2019 to October 2021. Participants were eligible for the cohort if they were aged 42 to 52 years, had not received hormone therapy in the past 3 months, were not pregnant, had an intact uterus and at least 1 ovary, and were premenopausal or early perimenopausal (most recent menses ≤3 months).

Exposures

Self-reported racial or ethnic group (Black, Chinese, Hispanic, Japanese, or White).

Main Outcomes and Measures

The main outcomes were hypertension (systolic blood pressure [BP] ≥140 mm Hg and diastolic BP ≥90 mm Hg or use of antihypertensive medication), ISH (systolic BP ≥140 mm Hg and diastolic BP <90 mm Hg or use of antihypertensive medication), IR (homeostasis model assessment for IR value >5.9 or insulin use), and diabetes (fasting serum glucose level ≥126 mg/dL [to convert to mmol/L, multiply by 0.0555], use of insulin or oral antidiabetic medication, or physician diagnosis). Selection into the cohort was addressed via inverse probability weighting and interval-censored survival models and selection out via multiple imputation. Accelerated failure time models were used to examine racial or ethnic differences in age at disease onset and estimate the median age at onset.

Results

A total of 3302 women were included in the study, with a median age of 46.2 years (range, 42-52 years) at baseline. In the sample, 42.6% had a bachelor's degree or higher and 36.3% self-rated their health as "very good" at baseline; 23.9% had hypertension, 43.7% had ISH, 13.5% had IR, and 4.6% had diabetes at baseline. Hypertension occurred a median of 5.0 years (95% CI, 5.4-5.5 years) earlier and metabolic outcomes (diabetes and IR) a median of 11.3 years (95% CI, 9.7-12.9 years) earlier for Black and Hispanic women vs White women; ISH occurred a median of 7.7 years (95% CI, 7.3-8.1 years) earlier for Black women vs White women. Adjustment for selection was associated with a mean 20-year decrease in estimated median age at onset, with greater decreases among Black and Hispanic women.

Conclusions and Relevance

In this multiracial cohort of midlife women, failure to account for selection biases, especially at study onset, was associated with falsely high estimates of age at cardiometabolic onset, with greater misestimation among Black and Hispanic women. The results suggest that hypertension and metabolic interventions, particularly for Black and Hispanic women, should be targeted to women aged as young as 30 years for hypertension and 40 years for metabolic interventions. Considering the timing of disease and fully addressing inherent selection biases in research are critical to understanding aging and disease risk, especially for racial and ethnic minoritized populations.