Management of Type 2 Diabetes Mellitus in Elderly Patients with Frailty and/or Sarcopenia

Evaluation of the Effectiveness of In-Hospital Exercise Rehabilitation in Middle-Aged and Elderly Patients with Type 2 Diabetes Mellitus Combined with Sarcopenia Effect of Lifestyle Management on Disease Status in Patients with Type 2 Diabetes Mellitus

OBJECTIVE

The aim of this study was to explore the effects of in-hospital exercise rehabilitation on glucose and lipid metabolism and healthy physical fitness in middle-aged and elderly patients with type 2 diabetes mellitus (T2DM) combined with sarcopenia, and to provide a reference for the effective implementation of exercise rehabilitation for middle-aged and elderly patients with T2DM combined with sarcopenia in healthcare institutions.

METHODS

This study retrospectively included 122 patients with T2DM combined with sarcopenia treated at the General Hospital of Ningxia Medical University from August 2017 to August 2020 and randomly divided into a control group and an experimental group. The control group was given conventional treatment and the experimental group was given exercise rehabilitation in the hospital for 12 weeks to compare the indexes related to glucose and lipid metabolism and healthy fitness in the two groups.

RESULTS

After the intervention, the experimental group showed significant decreases in fasting blood glucose (FBG), glycated hemoglobin (HbA1c), insulin resistance index (HOMA-IR), triglycerides (TG), total cholesterol (TC), low-density cholesterol (LDL-C) and body fat percentage (p < 0.05), while high-density cholesterol (HDL-C), grip strength, lower limb extension, lower limb flexion, peak oxygen uptake were significantly higher (p < 0.05) and were more significant at 12 weeks compared to the 6-week intervention (p < 0.05). However, there were no significant changes in any of the glucose metabolism indicators in the control group before and after the intervention. A two-way repeated measures ANOVA showed that at control baseline levels, HbA1c decreased significantly in the experimental group after both 6 and 12 weeks of intervention compared to the control group (p < 0.05). After 6 weeks of intervention, the experimental group showed a significant decrease in body fat percentage and a significant increase in grip strength. After 12 weeks of intervention, the experimental group showed an increase in glycemic control from 33.3% to 73.3%, a significant decrease in body fat percentage and a significant increase in grip strength, lower limb extension and lower limb flexion strength and peak oxygen uptake.

CONCLUSION

In-hospital exercise rehabilitation can effectively improve the glycemic and lipid profiles of patients with T2DM combined with sarcopenia and enhance their health fitness, with good clinical rehabilitation effects.

Role of muscle ultrasound in frailty assessment in older adults with type 2 diabetes mellitus

BACKGROUND

Frailty is a geriatric syndrome that is characterized by increased vulnerability to intrinsic and extrinsic stressors due to decreased biologic reserves. Muscle ultrasound (US) is a valid and reliable method for assessing muscle quantity in older adults. The study aims to examine the relationship between frailty definitions and US-derived muscle parameters.

METHODS

We conducted a cross-sectional study with type 2 diabetes mellitus outpatients in a tertiary hospital, and all participants underwent a comprehensive geriatric assessment. For frailty assessment, the Fried Frailty Phenotype (FFP), the Clinical Frailty Scale (CFS), and the Edmonton Frailty Scale (EFS) were performed. Muscle US measurements included Gastrocnemius Medialis (GM) muscle thickness, GM fascicle length, GM pennation angle, Rectus Femoris (RF) muscle thickness, Rectus Femoris cross-sectional area (RFCSA), Rectus Abdominis (RA) muscle thickness, External Oblique (EO) muscle thickness, Internal Oblique (IO) muscle thickness, and Transverse Abdominis (TA) muscle thickness.

RESULTS

In all, 373 participants were included in the study. The median age of participants was 72.7 ± 5.9 years, and 64.6% of them were female. According to the FFP, 18.2% of the participants were living with frailty, 56% of them were pre-frail; 57.4% of them were living with frailty according to the CFS; 25.2% of them were living with frailty, and 20.6% of them were pre-frail according to the EFS. The FFP, CFS, and EFS scores were related to muscle thickness of GM, RF, and RA, fascicle length of GM, and pennation angle of GM and RFCSA. Particularly, GM pennation angle, RF muscle thickness, and RFCSA were associated with an increased risk of frailty. Besides muscle thickness of GM, RF, and RA, fascicle length of GM, pennation angle of GM, and RFCSA were significant for predicting the presence of frailty.

CONCLUSIONS

US-derived regional muscle measurements are associated with frailty definitions (in both physical, cumulative deficit, and multidimensional models) in a diabetic geriatric population.

Impaired skeletal muscle regeneration in diabetes: From cellular and molecular mechanisms to novel treatments

Diabetes represents a major public health concern with a considerable impact on human life and healthcare expenditures. It is now well established that diabetes is characterized by a severe skeletal muscle pathology that limits functional capacity and quality of life. Increasing evidence indicates that diabetes is also one of the most prevalent disorders characterized by impaired skeletal muscle regeneration, yet underlying mechanisms and therapeutic treatments remain poorly established. In this review, we describe the cellular and molecular alterations currently known to occur during skeletal muscle regeneration in people with diabetes and animal models of diabetes, including its associated comorbidities, e.g., obesity, hyperinsulinemia, and insulin resistance. We describe the role of myogenic and non-myogenic cell types on muscle regeneration in conditions with or without diabetes. Therapies for skeletal muscle regeneration and gaps in our knowledge are also discussed, while proposing future directions for the field.

Associations between thyroid hormones and appendicular skeletal muscle index, and hand grip strength in people with diabetes: The KAMOGAWA-A study

AIM

To assess the effects of thyroid hormones on appendicular skeletal muscle index (SMI) and hand grip strength (HGS) in people with diabetes.

METHODS

This cross-sectional cohort included 1,135 participants with diabetes admitted to 3 hospitals in Japan. Multiple regression analysis was performed to determine the associations among thyroid hormone levels, SMI, and HGS.

RESULTS

Of the 1,135 participants, 480 were female. Their median (interquartile range) age, body mass index, durations of diabetes, and glycated haemoglobin levels were 68 years, 24.3 kg/m2, 10 years, and 7.6 %, respectively. The median (interquartile range) SMI (kg/m2) and hand grip strength of the cohort were 7.1 kg/m2 and 28.2 kg, respectively. Positive correlations between FT3 and the FT3/FT4 ratio with SMI and HGS was observed after adjusting for covariates in males. A negative correlation was found between the FT3/FT4 ratio and sarcopenia as a result of low SMI and low HGS in the male participants but not in females (p for interaction = 0.02).

CONCLUSIONS

FT3/FT4 ratios may impact skeletal muscles in people with diabetes-particularly in males. Assessments of FT3/FT4 ratios may represent key indicators of muscle mass and strength in males.

De-escalating treatment indications for patients who achieve metabolic goals

INTRODUCTION

Robust evidence exists regarding initiation, intensification or modification of treatments. Recommendations to de-escalate therapy are lacking, specifically in diabetes. A successful treatment de-intensification reduces overtreatment, polypharmacy, and risk of adverse effects.

OBJECTIVE

To encompass current recommendations for deprescribing common drugs and create a consensus among health professionals.

METHODS

We reviewed four databases for deprescribing approaches published between 2010 and 2022. Articles were divided into different groups of drugs (for uric-acid, hypoglycemic, lipid-lowering, and psychotropic drugs).

RESULTS

Hypoglycemic agents: strategies were limited to newer agents and insulin regimens for elderly individuals. Reducing insulin was associated with 1.1% reduction of A1c over time. SGLT2i and GLP-1RAs dose reduction depends on adverse events. Lipid-lowering agents: studies show that patients with very low cholesterol have fewer cardiovascular events without associated increased risk. Antihypertensive agents: Younger patients, lower systolic blood pressure, and few comorbidities are ideal characteristics for discontinuation. Uric acid therapy: we found no recommendation for dose de-escalation. Poor treatment adherence is associated with episodes of gout and deforming arthritis in the long term.

CONCLUSION

Deprescribing hypoglycemic, statins, antihypertensives, and urate-lowering agents may be feasible in selected patients, but periodic surveillance is important. More evidence is necessary to support this decision entirely.

Pathophysiological interactions between sarcopenia and type 2 diabetes: A two-way street influencing diagnosis and therapeutic options

This review will try to elucidate the interconnected pathophysiology of sarcopenia and type 2 diabetes (T2D) and will try to identify a common pathway to explain their development. To this end, the PubMed and Scopus databases were searched for articles published about the underlying pathophysiology, diagnosis and treatment of both sarcopenia and T2D. The medical subject heading (MeSH) terms 'sarcopenia' AND 'diabetes mellitus' AND ('physiopathology' OR 'diagnosis' OR 'therapeutics' OR 'aetiology' OR 'causality') were used. After screening, 32 papers were included. It was evident that sarcopenia and T2D share multiple pathophysiological mechanisms. Common changes in muscle architecture consist of a shift in myocyte composition, increased myosteatosis and a decreased capacity for muscle regeneration. Further, both diseases are linked to an imbalance in myokine and sex hormone production. Chronic low-grade inflammation and increased levels of oxidative stress are also known pathophysiological contributors. In the future, research efforts should be directed towards discovering common checkpoints in the development of T2D and sarcopenia as possible shared therapeutic targets for both diseases. Current treatment for T2D with biguanides, incretins and insulin may already convey a protective effect on the development of sarcopenia. Furthermore, attention should be given to early diagnosis of sarcopenia within the population of people with T2D, given the sizeable physical and medical burden it encompasses. A combination of simple diagnostic techniques could be used at regular diabetes check-ups to identify sarcopenia at an early stage and start lifestyle modifications and treatment as soon as possible.

Prolonged hospitalization and 1-year mortality are associated with sarcopenia and malnutrition in older patients with type 2 diabetes: A prospective cohort study

AIM

To assess the relationship of the presence of sarcopenia and malnutrition with unfavorable clinical outcomes: prolonged length of hospital stay (LOS), readmission, and one-year mortality in older patients with type 2 diabetes (T2D).

METHODS

Were included 319 patients with ≥ 60 years of age with T2D hospitalized at a university hospital in Southern Brazil. Sarcopenia was diagnosed according to handgrip strength (HGS), calf circumference (CC), and the timed up and go (TUG) walking test, and malnutrition according to the subjective global assessment (SGA) and the mini nutritional assessment long form (MNA-LF). Multivariate analyses, adjusted for confounders, were performed to assess the association of sarcopenia and malnutrition with clinical outcomes. One-year survival was compared using Kaplan-Meier analysis.

RESULTS

The association between sarcopenia and malnutrition increased by 2.42 times (95 %CI 1.35-4.36) the probability of LOS ≥ 14 days and by 2.01 times (95 %CI 1.09-3.72) the risk of one-year mortality. Older patients with malnutrition and sarcopenia have a higher risk of one-year mortality (log-rank p < 0.05) compared with well-nourished patients without sarcopenia.

CONCLUSION

In older patients with type 2 diabetes, those with sarcopenia, and malnutrition have higher odds of prolonged hospitalization and risk of mortality within one year after hospital discharge.

Walking pace and microvascular complications among individuals with type 2 diabetes: A cohort study from the UK Biobank

INTRODUCTION

Walking pace is associated with various health-related outcomes. The aim of this study was to investigate the association between self-reported walking pace and the incidences of diabetic microvascular complications among participants with type 2 diabetes (T2D).

METHODS

Self-reported walking pace was classified as brisk, average, or slow. The outcomes were the incidences of diabetic retinopathy, diabetic neuropathy, and diabetic nephropathy. COX proportional hazards models adjusted for sociodemographic, lifestyle, and health-related factors were used to estimate hazard ratios (HRs) and 95% CIs.

RESULTS

A total of 14 518 participants with T2D in the UK Biobank (mean age 59.7 ± 7.0 years, 5028 [34.6%] women) were included. During a median follow-up of 12.5 (interquartile range: 11.6-13.4) years, 2980 participants developed diabetic microvascular complications. After adjusting for confounding factors, and compared with brisk walkers, slow walkers had a multivariable-adjusted HR of 1.98 (95% CI 1.58, 2.47) for composite diabetic microvascular complications, 1.54 (95% CI 1.11, 2.14) for diabetic retinopathy, 3.26 (95% CI 2.08, 5.11) for diabetic neuropathy, and 2.32 (95% CI 1.91, 2.82) for diabetic nephropathy. Average walking pace was associated with a higher risk for diabetic nephropathy (HR 1.51, 95 CI% 1.27-1.79) compared with brisk walking. Additionally, ≥1 diabetic microvascular complication occurred in 447 (14.7%) of participants with brisk walking pace, 1702 (19.5%) with average walking pace, and 831 (30.4%) with slow walking pace. Time from study recruitment to first diagnosis was shorter in participants who reported a slow walking pace, compared with brisk or average walkers. Among participants who had diabetic nephropathy as their first diagnosis, slow walking pace was associated with subsequent risk of a second diabetic microvascular complication (HR 3.88, 95 CI% 2.27-6.60).

CONCLUSIONS

Self-reported slow walking pace is associated with a higher risk of diabetic microvascular complications among participants with T2D in this population-based cohort study.

Management of Glucose-Lowering Therapy in Older Adults with Type 2 Diabetes: Challenges and Opportunities

The population of older adults (≥65 years) with type 2 diabetes mellitus (T2DM) is diverse, encompassing individuals with varying functional capabilities, living arrangements, concomitant medical conditions, and life expectancies. Hence, their categorization into different patient profiles (ie, good health, intermediate health, poor health) may aid in clinical decision-making when establishing glycemic goals and pharmacological treatment strategies. Further granularity in assessing each patient profile through interdisciplinary collaboration may also add precision to therapeutic and monitoring decisions. In this review, we discuss with a multidisciplinary approach how to deliver the best benefit from advanced diabetes therapies and technologies to older adults with T2DM according to each patient profile. There remain however several areas that deserve further research in older adults with T2DM, including the efficacy and safety of continuous glucose monitoring and automated insulin delivery systems, the switch to once-weekly insulin, the effectiveness of multidisciplinary care models, and the use of supported telemedicine and remote blood glucose monitoring in the oldest-old (≥85 years) who particularly require the assistance of others.

Relationship between sodium-glucose cotransporter-2 inhibitors and muscle atrophy in patients with type 2 diabetes mellitus: a systematic review and meta-analysis

Aim

This study aims to assess the association between sodium-glucose cotransporter type-2 inhibitor (SGLT-2i) treatment and muscle atrophy in patients with type 2 diabetes mellitus (T2DM).

Methods

We searched six databases from 1 January 2012 to 1 May 2023, without language restrictions. The primary outcome was muscle. Secondary outcomes were weight loss, weakness, malaise, or fatigue. Subgroup analyses were performed according to different definitions of muscle, treatment duration, and measurement methods. The quality of the studies was assessed using the Cochrane tool. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool.

Results

Nineteen randomized controlled trials (RCTs) involving 1,482 participants were included. Compared with the control group, a meta-analysis showed that T2DM participants in the group treated with SGLT-2i demonstrated statistically significant reductions in lean body mass of 0.66 (95% confidence interval (CI), -1.05 to -0.27; p = 0.0009) and skeletal muscle mass of 0.35 (95% CI, -0.66 to -0.04; p = 0.03). No deaths or serious adverse events were reported. The quality of evidence in the included trials was low.

Conclusions

SGLT-2i may lead to a reduction in muscle strength in the treatment of T2DM compared to the control group. However, there is still a lack of high-quality evidence to evaluate muscle atrophy caused by SGLT-2i.

Systematic review registration

https://inplasy.com/inplasy-2022-12-0061/, identifier 2022120061.

Insulin resistance drives cognitive impairment in hypertensive pre-diabetic frail elders: the CENTENNIAL study

AIMS

Pre-diabetes is a condition that confers an increased cardiovascular risk. Frailty is very common in hypertensive patients, and insulin resistance has been linked to frailty in older adults with diabetes. On these grounds, our aim was to evaluate the association between insulin resistance and cognitive impairment in hypertensive and pre-diabetic and frail older adults.

METHODS AND RESULTS

We studied consecutive pre-diabetic and hypertensive elders with frailty presenting at the Avellino local health authority of the Italian Ministry of Health (ASL AV) from March 2021 to March 2022. All of them fulfilled the following inclusion criteria: a previous diagnosis of hypertension with no clinical or laboratory evidence of secondary causes, a confirmed diagnosis of pre-diabetes, age >65 years, Montreal Cognitive Assessment (MoCA) Score <26, and frailty. We enrolled 178 frail patients, of which 141 successfully completed the study. We observed a strong inverse correlation (r = -0.807; P < 0.001) between MoCA Score and Homeostatic Model Assessment for Insulin Resistance (HOMA-IR). The results were confirmed by a linear regression analysis using MoCA Score as dependent variable, after adjusting for several potential confounders.

CONCLUSION

Taken together, our data highlight for the first time the association between insulin resistance and global cognitive function in frail elders with hypertension and pre-diabetes.

The outcome of frailty in older people with diabetes as a function of glycaemic control and hypoglycaemic therapy: a review

INTRODUCTION

Frailty is an emerging and newly recognized complication of diabetes in older people. However, frailty is not thoroughly investigated in diabetes outcome studies.

AREAS COVERED

This manuscript reviews the effect of glycemic control and hypoglycemic therapy on the incidence of frailty in older people with diabetes.

EXPERT OPINION

Current studies show that both low glycemia and high glycemia are associated with frailty. However, most of the studies, especially low glycemia studies, are cross-sectional or retrospective, suggesting association, rather than causation, of frailty. In addition, frail patients in the low glycemia studies are characterized by lower body weight or lower body mass index (BMI), contrary to those in the high glycemia studies, who are either overweight or obese. This may suggest that frailty has a heterogeneous metabolic spectrum, starting with an anorexic malnourished (AM) phenotype at one end, which is associated with low glycemia and a sarcopenic obese (SO) phenotype on the other end, which is associated with high glycemia. The current little evidence suggests that poor glycemic control increases the risk of frailty, but there is a paucity of evidence to suggest that tight glycemic control would reduce the risk of incident frailty. Metformin is the only well-studied hypoglycemic agent, so far, to have a protective effect against frailty independent of glycemic control in the non-frail older people with diabetes. However, once frailty is developed, the choice of the best hypoglycemic agent for these patients will be affected by the metabolic phenotype of frailty. For example, sodium glucose transporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) are appropriate in the SO phenotype due to their weight losing properties, while insulin therapy may be considered early in the AM phenotype due to its anabolic and weight gaining benefits. Future studies are still required to further investigate the metabolic effects of frailty on older people with diabetes, determine the most appropriate HbA1c target, and explore the most suitable hypoglycemic agent in each metabolic phenotype of frailty.

Diabetes mellitus, malnutrition, and sarcopenia: The bond is not explained by bioelectrical impedance analysis in older adults

As people age, their risk of diabetes mellitus (DM) and sarcopenia increases due to the decline in muscle mass and strength. Bioelectrical impedance analysis (BIA) is a method used to detect changes in body composition. The primary aim of the study was to determine the distribution of BIA variables among a group of non-DM people and two groups of patients with controlled and uncontrolled DM. The secondary aim was to establish the independent association between BIA-derived data, lipidic assets, and the prevalence of metabolic syndromes with DM. This study included a total of 235 participants who were categorized into three groups based on the presence of diabetes mellitus (DM) and their glycated hemoglobin (HbA1c) levels: non-DM, controlled DM (HbA1c≤7.0%), and uncontrolled DM (HbA1c>7.0%). Waist circumference (p=0.005), bone (p<0.001), muscular (p<0.001), and appendicular skeletal mass (p<0.001) were lower in the non-DM group, while sarcopenic risk (p<0.001), total cholesterol (p<0.001), and LDL (p<0.001), were higher. Grip strength (p<0.001), visceral fat (p=0.01), and phase angle (p=0.04) were significantly lower in non-DM than uncontrolled DM patients, as well as the number of drugs taken (p=0.014). A multivariate analysis highlighted that LDL (coefficient -0.006, p=0.01) was negatively associated, while bone mass (coefficient 0.498, p=0.0042) was positively associated with DM uncontrol. Our study shows that BIA may not be the ideal tool for distinguishing between elderly individuals with and without DM, as it can be affected by numerous covariates, including potential differences in glucometabolic and cardiovascular control.

The predictive values of admission characteristics for 28-day all-cause mortality in septic patients with diabetes mellitus: a study from the MIMIC database

Background

Septic patients with diabetes mellitus (DM) are more venerable to subsequent complications and the resultant increase in associated mortality. Therefore, it is important to make tailored clinical decisions for this subpopulation at admission.

Method

Data from large-scale real-world databases named the Medical Information Mart for Intensive Care Database (MIMIC) were reviewed. The least absolute selection and shrinkage operator (LASSO) was performed with 10 times cross-validation methods to select the optimal prognostic factors. Multivariate COX regression analysis was conducted to identify the independent prognostic factors and nomogram construction. The nomogram was internally validated via the bootstrapping method and externally validated by the MIMIC III database with receiver operating characteristic (ROC), calibration curves, decision curve analysis (DCA), and Kaplan-Meier curves for robustness check.

Results

A total of 3,291 septic patients with DM were included in this study, 2,227 in the MIMIC IV database and 1,064 in the MIMIC III database, respectively. In the training cohort, the 28-day all-cause mortality rate is 23.9% septic patients with DM. The multivariate Cox regression analysis reveals age (hazard ratio (HR)=1.023, 95%CI: 1.016-1.031, p<0.001), respiratory failure (HR=1.872, 95%CI: 1.554-2.254, p<0.001), Sequential Organ Failure Assessment score (HR=1.056, 95%CI: 1.018-1.094, p=0.004); base excess (HR=0.980, 95%CI: 0.967-0.992, p=0.002), anion gap (HR=1.100, 95%CI: 1.080-1.120, p<0.001), albumin (HR=0.679, 95%CI: 0.574-0.802, p<0.001), international normalized ratio (HR=1.087, 95%CI: 1.027-1.150, p=0.004), red cell distribution width (HR=1.056, 95%CI: 1.021-1.092, p=0.001), temperature (HR=0.857, 95%CI: 0.789-0.932, p<0.001), and glycosylated hemoglobin (HR=1.358, 95%CI: 1.320-1.401, p<0.001) at admission are independent prognostic factors for 28-day all-cause mortality of septic patients with DM. The established nomogram shows satisfied accuracy and clinical utility with AUCs of 0.870 in the internal validation and 0.830 in the external validation cohort as well as 0.820 in the septic shock subpopulation, which is superior to the predictive value of the single SOFA score.

Conclusion

Our results suggest that admission characteristics show an optimal prediction value for short-term mortality in septic patients with DM. The established model can support intensive care unit physicians in making better initial clinical decisions for this subpopulation.

Low Muscle Mass Is Associated with Poorer Glycemic Control and Higher Oxidative Stress in Older Patients with Type 2 Diabetes

Body composition changes that occur during aging, such as loss of lean mass, are unfavorable at metabolic level and they can explain, in part, the appearance of certain age-associated diseases such as type 2 diabetes (T2D). Separately, T2D is associated with an increase in oxidative stress (OS) which negatively affects skeletal muscle. Our aim was to study the differences in clinical and nutritional parameters, disease control, and OS in a cohort of older patients with T2D classified according to the amount of lean mass they had. We included 100 adults older than 65 years with T2D. We found that women with low fat-free mass and muscle mass have worse T2D metabolic control. Moreover, the patients with a low percentile of muscle mass present a high value of OS. The study shows that the presence of low lean mass (LM) in the geriatric population diagnosed with T2D is associated with poorer glycemic control and greater OS.

Possible sarcopenia and risk of new-onset type 2 diabetes mellitus in older adults in China: a 7-year longitudinal cohort study

BACKGROUND

Previous studies have shown that type 2 diabetes mellitus (T2DM) can cause sarcopenia; however, these conditions may have a bidirectional association. This study aimed to explore the longitudinal association between possible sarcopenia and new-onset T2DM.

METHODS

We conducted a population-based cohort study using nationally representative data from the China Health and Retirement Longitudinal Study (CHARLS). This study included participants aged ≥ 60 years who were free of diabetes during the baseline survey of CHARLS (2011 to 2012) and were followed up until 2018. Possible sarcopenia status was defined according to the Asian Working Group for Sarcopenia 2019 criteria. Cox proportional hazards regression models were used to evaluate the effect of possible sarcopenia on new-onset T2DM.

RESULTS

In total, 3,707 individuals were enrolled in this study, with a median age of 66 years; the prevalence of possible sarcopenia was 45.1%. During the 7-year follow-up, 575 cases (15.5%) of incident diabetes were identified. Participants with possible sarcopenia were more likely to have new-onset T2DM than those without possible sarcopenia (hazard ratio: 1.27, 95% confidence interval: 1.07-1.50; p = 0.006). In subgroup analysis, we found a significant association between possible sarcopenia and T2DM in individuals aged < 75 years or with a BMI < 24 kg/m². However, this association was not significant in individuals aged ≥ 75 years or with a BMI ≥ 24 kg/m².

CONCLUSIONS

Possible sarcopenia is associated with an increased risk of new-onset T2DM in older adults, especially in individuals who are not overweight and aged 75 years or younger.

Role of Muscle Ultrasound for the Study of Frailty in Elderly Patients with Diabetes: A Pilot Study

BACKGROUND

Sarcopenia and diabetes contribute to the development of frailty. Therefore, accessible methods, such as muscle ultrasounds (MUSs), to screen for sarcopenia should be implemented in clinical practice.

METHODS

We conducted a cross-sectional pilot study including 47 patients with diabetes (mean age: 77.72 ± 5.08 years, mean weight: 75.8 kg ± 15.89 kg, and body mass index: 31.19 ± 6.65 kg/m²) categorized as frail by the FRAIL Scale or Clinical Frailty Scale and confirmed by Fried's Frailty Phenotype or Rockwood's 36-item Frailty Index. We used the SARC-F questionnaire to identify sarcopenia. The Short Physical Performance Battery (SPPB) and the Timed Up and Go (TUG) tests were used to assess physical performance and the risk of falls, respectively. In addition, other variables were measured: fat-free mass (FFM) and Sarcopenia Risk Index (SRI) with the bioimpedance analysis (BIA); thigh muscle thickness (TMT) of the quadriceps with MUS; and hand-grip strength with dynamometry.

RESULTS

We observed correlations between the SARC-F and FFM (R = -0.4; p < 0.002) and hand-grip strength (R = -0.5; p < 0.0002), as well as between the TMT and FFM of the right leg (R = 0.4; p < 0.02) and the SRI (R = 0.6; p < 0.0001). We could predict sarcopenia using a logistic regression model with a ROC curve (AUC = 0.78) including FFM, handgrip strength, and TMT. The optimal cut-off point for maximum efficiency was 1.58 cm for TMT (sensitivity = 71.4% and specificity = 51.5%). However, we did not observe differences in the TMT among groups of greater/less frailty based on the SARC-F, SPPB, and TUG (p > 0.05).

CONCLUSIONS

MUSs, which correlated with the BIA (R = 0.4; p < 0.02), complemented the diagnosis, identifying regional sarcopenia of the quadriceps in frail patients with diabetes and improving the ROC curve to AUC = 0.78. In addition, a TMT cut-off point for the diagnosis of sarcopenia of 1.58 cm was obtained. Larger studies to validate the MUS technique as a screening strategy are warranted.

A Comprehensive Review on Bio-Based Materials for Chronic Diabetic Wounds

Globally, millions of people suffer from poor wound healing, which is associated with higher mortality rates and higher healthcare costs. There are several factors that can complicate the healing process of wounds, including inadequate conditions for cell migration, proliferation, and angiogenesis, microbial infections, and prolonged inflammatory responses. Current therapeutic methods have not yet been able to resolve several primary problems; therefore, their effectiveness is limited. As a result of their remarkable properties, bio-based materials have been demonstrated to have a significant impact on wound healing in recent years. In the wound microenvironment, bio-based materials can stimulate numerous cellular and molecular processes that may enhance healing by inhibiting the growth of pathogens, preventing inflammation, and stimulating angiogenesis, potentially converting a non-healing environment to an appropriately healing one. The aim of this present review article is to provide an overview of the mechanisms underlying wound healing and its pathophysiology. The development of bio-based nanomaterials for chronic diabetic wounds as well as novel methodologies for stimulating wound healing mechanisms are also discussed.

Frailty and risk of microvascular complications in patients with type 2 diabetes: a population-based cohort study

BACKGROUND

Cross-sectional studies found that frailty was associated with prevalent diabetic microvascular complications (DMC). Longitudinal evidence in this regard is inconclusive and insufficient. We aimed to prospectively evaluate the association of pre-frailty and frailty with DMC in patients with type 2 diabetes (T2D).

METHODS

We included 18,062 adults (mean age 59.4 ± 7.2 years, 37.4% female) with T2D at baseline in the UK Biobank. Frailty was defined using the frailty phenotype according to five components (weight loss, exhaustion, low physical activity, slow gait speed, and low grip strength). DMC, defined as diabetic nephropathy, diabetic neuropathy, or diabetic retinopathy, was identified using hospital inpatient records and death registries. Cox proportional hazard regression models considering competing risks were used to evaluate the associations of frailty phenotype with overall DMC events and subtypes.

RESULTS

Among all participants, 6101 (33.8%) were classified as non-frail, 10,073 (55.8%) were classified as pre-frail, and 1888 (10.4%) were classified as frail. During a median follow-up of 12.0 years, 3678 DMC cases were documented, including 2213 diabetic nephropathy, 1520 diabetic retinopathy, and 673 diabetic neuropathy events. In the multivariable-adjusted model, compared with participants with non-frail, both pre-frailty and frailty were significantly associated with increased risk of overall DMC (HR 1.10, 95% CI: [1.02, 1.18] for pre-frailty and HR 1.52 [95% CI: 1.36, 1.69] for frailty). Similar results were observed in the subtypes of DMC. For each one-point increase in frailty phenotype score, the risk of overall DMC, diabetic nephropathy, diabetic retinopathy, and diabetic neuropathy event increased by 13%, 16%, 10%, and 20%, respectively.

CONCLUSIONS

Both pre-frailty and frailty were associated with an increased risk of DMC in patients with T2D. These findings have important implications for integrating early assessment and surveillance of frailty in diabetes and may favor the identification of at-risk patients.

Frailty is associated with the progression of prediabetes to diabetes and elevated risks of cardiovascular disease and all-cause mortality in individuals with prediabetes and diabetes: Evidence from two prospective cohorts

AIMS

To investigate the impacts of frailty on the progression of prediabetes to diabetes, cardiovascular disease (CVD) and all-cause mortality in individuals with prediabetes and diabetes.

METHODS

7,933 subjects with prediabetes and diabetes were included from the China Health and Retirement Longitudinal Study (CHARLS) and English Longitudinal Study of Ageing (ELSA). Frailty status was assessed by frailty index and classified as robust, pre-frail, and frail. Logistic regression was used to calculate risks of progression to diabetes. Cox regression was used to calculate risks of CVD and all-cause mortality.

RESULTS

In prediabetes, frail subjects had significantly increased risks of progression to diabetes (CHARLS, OR = 1.55, 95 %CI: 1.09-2.20; ELSA, OR = 1.86, 95 %CI: 1.02-3.37) compared with robust subjects. Frail subjects with prediabetes also presented significantly increased risks of CVD (CHARLS: HR = 1.90, 95 %CI: 1.45-2.48; ELSA: HR = 1.94, 95 %CI: 1.31-2.88) and all-cause mortality (CHARLS: HR = 2.45, 95 %CI: 1.79-3.36; ELSA: HR = 2.13, 95 %CI: 1.46-3.10) than robust subjects with prediabetes. In diabetes, frailty still increased risks of CVD (CHARLS, HR = 2.72, 95 %CI: 1.97-3.77; ELSA, HR = 2.41, 95 %CI: 1.43-4.06) and all-cause mortality (CHARLS, HR = 2.28, 95 %CI: 1.56-3.33; ELSA, HR = 2.28, 95 %CI: 1.47-3.53).

CONCLUSIONS

Frailty is associated with the progression of prediabetes to diabetes and elevated risks of CVD and all-cause mortality in individuals with prediabetes and diabetes.