Response to Comment on Laiteerapong et al. The Legacy Effect in Type 2 Diabetes: Impact of Early Glycemic Control on Future Complications (The Diabetes & Aging Study). Diabetes Care 2019;42:416-426

Malus toringoides (Rehd.) Hughes Ameliorates Nonalcoholic Fatty Liver Disease with Diabetes via Downregulation of SREBP-1c and the NF-κB Pathway In Vivo and In Vitro

Diabetic patients are more prone to developing nonalcoholic fatty liver disease (NAFLD) compared with healthy people. As a plant homologous to both medicine and food, Malus toringoides (Rehd.) Hughes has been used as an intervention for both NAFLD and diabetes. However, the effect and mechanism of M. toringoides on NAFLD on type 2 diabetes mellitus (T2DM) is unclear. The current investigation was designed to evaluate the ameliorative effects and mechanism of M. toringoides ethanol extract (CBTM-E375) on T2DM, and to identify the compounds in these extracts. The effects of CBTM-E375 on T2DM were verified using a high-fat diet-/streptozotocin-induced diabetic rat and free fatty acid (0.5 mM)-induced human hepatocellular carcinoma cell (HepG2) models. The components of CBTM-E375 were identified by high performance liquid chromatography-mass spectrometry/mass spectrometry. Our results demonstrate that CBTM-E375 ameliorated lipid accumulation (total cholesterol, triglyceride), oxidative stress (superoxide dismutase, catalase, malondialdehyde, glutathione peroxidase), and inflammation (tumor necrosis factor-α [TNF-α], interleukin [IL]-1β, IL-6, C-reactive protein [CRP]) in vivo and in vitro, these effects were associated with a CBTM-E375-mediated downregulation of SREBP-1c (sterol regulatory element binding protein 1c) and the NF-κB (nuclear factor κB) signaling pathway. A total of 20 chemical compounds were identified in CBTM-E375, including phlorizin, isoquercitrin, chlorogenic acid, quercetin, naringenin, and trigonelline, which have been reported to have positive effects on diabetes or on NAFLD.

[Insulin therapy is a personalized approach to glycemic management in diabetes]

Type 2 diabetes is characterized by chronic hyperglycemia and varying degrees of insulin resistance and insulinopenia. Achieving targeted glycemic control in diabetic patients is important to reduce the risk of late complications, and many patients with type 2 diabetes ultimately require insulin therapy to maintain adequate glycemic control. Timely administration of insulin can prevent the progression of diabetes, reduce the development of complications, and have fewer side effects. Basal insulin is the preferred option in most cases when glycemic control is not achieved. However, there is considerable therapeutic inertia in clinical practice, both with respect to initiation of insulin therapy and titration of the basal insulin dose. The longer duration of action, reduced glucose variability and a lower risk of hypoglycemia seen with the latest generation of basal insulin analogs compared to the previous generation simplify titration and may increase patient compliance.