Prevalence and predictors of diabetes distress and depression in people with type 1 diabetes

Background

People living with diabetes often encounter psychosocial challenges, including diabetes distress and depression. Despite this, little research has focused on the co-occurrence of these conditions. This study aimed to explore the prevalence of depressive symptoms and diabetes distress in people with type 1 diabetes in Kuwait and to identify clinical and demographic factors associated with these conditions.

Methods

A total of 832 people with type 1 diabetes (females: 54.1%, mean age: 29 ± 8.5 years), were invited to participate in Dose Adjustment for Normal Eating (DAFNE) course. Diabetes distress was measured using the Problem Areas in Diabetes (PAID) scale and depressive symptoms were measured using the Patient Health Questionnaire-9 (PHQ-9). Depressive symptoms were defined as PHQ-9 scores ≥10. Data on biomedical outcomes, lifestyle factors, and sociodemographic information were collected.

Results

The prevalence rates of diabetes distress and depressive symptoms were 27.8% and 38.3%, respectively. Notably, 19.6% of people experienced both conditions. In the regression analysis, PAID scale and PHQ-9 scores were significantly associated, patients with higher score on depressive symptoms scale were more likely to suffer diabetes distress (B= 2.65, p < 0.001). Female sex (odds ratio [OR]= 2.2, 95% CI= 1.5, 3.2), higher hemoglobin A1c levels (OR= 1.6, 95% CI= 1.0, 2.5), obesity (OR= 1.7, 95% CI= 1.1, 2.8), inactivity (OR= 2.4, 95% CI= 1.6, 3.6), microvascular complications (OR= 2.8, 95% CI= 1.5, 5.4), and lipohypertrophy (OR= 1.7, 95% CI= 1.1, 2.5) were associated with greater odds for the co-occurrence of diabetes distress and depressive symptoms (p< 0.05 for all).

Conclusion

The majority of people with type 1 diabetes in Kuwait experience both diabetes distress and depressive symptoms. The strong correlation between diabetes distress and depressive symptoms suggests mutual predictability. The co-occurrence of both symptoms is associated with many sociodemographic and clinical factors.

The emergence of obesity in type 1 diabetes

Obesity, a chronic low-grade inflammatory disease represented by multifactorial metabolic dysfunctions, is a significant global health threat for adults and children. The once-held belief that type 1 diabetes is a disease of people who are lean no longer holds. The mounting epidemiological data now establishes the connection between type 1 diabetes and the subsequent development of obesity, or vice versa. Beyond the consequences of the influx of an obesogenic environment, type 1 diabetes-specific biopsychosocial burden further exacerbates obesity. In the course of obesity management discussions, recurring challenges surfaced. The interplay between weight gain and escalating insulin dependence creates a vicious cycle from which patients struggle to break free. In the absence of weight management guidelines and regulatory approval for this population, healthcare professionals must navigate the delicate balance between benefits and risks. The gravity of this circumstance highlights the importance of bringing these topics to the forefront. In this Review, we discuss the changing trends and the biopsychosocial aspects of the intersection between type 1 diabetes and obesity. We highlight the evidence supporting the therapeutic means (i.e., exercise therapy, nutritional therapy, adjunct pharmacotherapy, and bariatric surgery) and directions for establishing a more robust and safer evidence-based approach.

Obesity Treatments to Improve Type 1 Diabetes (OTID): a randomized controlled trial of the combination of glucagon-like peptide 1 analogues and sodium-glucose cotransporter 2 inhibitors-protocol for Obesity Treatments to Improve Type 1 Diabetes (the OTID trial)

BACKGROUND

The guidelines of the American Diabetes Association and European Association for the Study of Diabetes suggest that patients with obesity type 2 diabetics and chronic kidney disease need either glucagon-like peptide 1 receptor analogues or sodium-glucose cotransporter-2 inhibitors. If neither achieve metabolic control, then the recommendation is to combine both drugs. The evidence base for combining glucagon-like peptide 1 receptor analogues and sodium-glucose cotransporter-2 inhibitors is not well researched, and hence, the impact of the guidelines is limited. The aim of this randomized controlled trial is to test the impact of the combination of glucagon-like peptide 1 receptor analogues/sodium-glucose cotransporter-2 inhibitors on body weight and kidney damage, in patients with type 1 diabetes and chronic kidney disease. In addition, we will explore the associated changes in the metabolic pathways with each of the treatments used in this randomized controlled trial.

METHODS

In this 6-month randomized control trial, 60 participants aged between 21 and 65 years, with a body mass index above 25 kg/m2, and type 1 diabetics with chronic kidney disease will be randomized to receive 1 of 5 possible treatments: (1) standard care (control), (2) glucagon-like peptide 1 receptor analogues alone, (3) sodium-glucose cotransporter-2 inhibitors alone, (4) combination of glucagon-like peptide 1 receptor analogues and sodium-glucose cotransporter-2 inhibitors and (5) combination of glucagonlike peptide 1 receptor analogues and sodium-glucose cotransporter-2 inhibitors with intensive lifestyle advice. The primary objective will be the percentage change in total body weight from baseline at 6 months. The secondary objectives are to compare the change in glycaemia; blood pressure; dyslipidaemia; albuminuria; proportion of participants reaching weight loss of ≥ 5%, ≥ 10% and ≥ 15%; and change in BMI (kg/m2) from baseline and change in waist circumference (cm). All the experiments will be conducted at the Dasman Diabetes Institute after approval from the local research and ethics committee.

DISCUSSION

The present randomized controlled trial aims to investigate the impact of the combination of glucagon-like peptide 1 receptor analogues and sodium-glucose cotransporter-2 inhibitors on body weight and kidney damage in patients with type 1 diabetes mellitus and chronic kidney disease, as well as exploring the associated changes in the metabolic pathways with each of the treatments used. This study addresses the current gap in the evidence base regarding the combination of these two drugs, which is particularly relevant given the American Diabetes Association and European Association for the Study of Diabetes guidelines recommending their combined use for patients with obesity, type 2 diabetes, and chronic kidney disease who do not achieve metabolic control with either drug alone.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05390307 Trial registration date - 25th May 2022.

Increased Levels of Circulating IGFBP4 and ANGPTL8 with a Prospective Role in Diabetic Nephropathy

Diabetic nephropathy (DN) is a complicated condition related to type 2 diabetes mellitus (T2D). ANGPTL8 is a hepatic protein highlighted as a risk factor for DN in patients with T2D; additionally, recent evidence from DN studies supports the involvement of growth hormone/IGF/IGF-binding protein axis constituents. The potential link between ANGPTL8 and IGFBPs in DN has not been explored before. Here, we assessed changes in the circulating ANGPTL8 levels in patients with DN and its association with IGFBP-1, -3, and -4. Our data revealed a significant rise in circulating ANGPTL8 in people with DN, 4443.35 ± 396 ng/mL compared to 2059.73 ± 216 ng/mL in people with T2D (p < 0.001). Similarly, levels of IGFBP-3 and -4 were significantly higher in people with DN compared to the T2D group. Interestingly, the rise in ANGPTL8 levels correlated positively with IGFBP-4 levels in T2DM patients with DN (p < 0.001) and this significant correlation disappeared in T2DM patients without DN. It also correlated positively with serum creatinine and negatively with the estimated glomerular filtration rate (eGFR, All < 0.05). The area under the curve (AUC) on receiver operating characteristic (ROC) analysis of the combination of ANGPTL8 and IGFBP4 was 0.76 (0.69-0.84), p < 0.001, and the specificity was 85.9%. In conclusion, our results showed a significant increase in ANGPTL8 in patients with DN that correlated exclusively with IGFBP-4, implicating a potential role of both proteins in the pathophysiology of DN. Our findings highlight the significance of these biomarkers, suggesting them as promising diagnostic molecules for the detection of diabetic nephropathy.

Plasma insulin is required for the increase in plasma angiopoietin-like protein 8 in response to nutrient ingestion

BACKGROUND

Plasma levels of angiopoietin-like protein 8 (ANGPTL8) are regulated by feeding and they increase following glucose ingestion. Because both plasma glucose and insulin increase following food ingestion, we aimed to determine whether the increase in plasma insulin and glucose or both are responsible for the increase in ANGPTL8 levels.

METHODS

ANGPTL8 levels were measured in 30 subjects, 14 with impaired fasting glucose (IFG), and 16 with normal fasting glucose (NFG); the subjects received 75g glucose oral Glucose tolerance test (OGTT), multistep euglycaemic hyperinsulinemic clamp and hyperglycaemic clamp with pancreatic clamp.

RESULTS

Subjects with IFG had significantly higher ANGPTL8 than NGT subjects during the fasting state (p < 0.05). During the OGTT, plasma ANGPTL8 concentration increased by 62% above the fasting level (p < 0.0001), and the increase above fasting in ANGPTL8 levels was similar in NFG and IFG individuals. During the multistep insulin clamp, there was a dose-dependent increase in plasma ANGPTL8 concentration. During the 2-step hyperglycaemic clamp, the rise in plasma glucose concentration failed to cause any change in the plasma ANGPTL8 concentration from baseline.

CONCLUSIONS

In response to nutrient ingestion, ANGPTL8 level increased due to increased plasma insulin concentration, not to the rise in plasma glucose. The incremental increase above baseline in plasma ANGLPTL8 during OGTT was comparable between people with normal glucose tolerance and IFG.

Glucagon-like peptide-1 agonists combined with sodium-glucose cotransporter-2 inhibitors reduce weight in type 1 diabetes

OBJECTIVE

This study evaluated whether adding sodium-glucose cotransporter-2 inhibitors (SGLT2i) and/or glucagon-like peptide-1 receptor agonists (GLP1-RA) to insulin reduced weight and glycemia in people with type 1 diabetes.

METHODS

This retrospective analysis of electronic health records evaluated 296 people with type 1 diabetes over 12 months after medications were first prescribed. Four groups were defined: control n = 80, SGLT2i n = 94, GLP1-RA n = 82, and combination of drugs (Combo) n = 40. We measured changes at 1 year in weight and glycated hemoglobin (HbA1c).

RESULTS

The control group did not have changes in weight or glycemic control. The mean (SD) percentage weight loss after 12 months was 4.4% (6.0%), 8.2%  (8.5%), and 9.0% (8.4%) in the SGLT2i, GLP1-RA, and Combo groups, respectively (p < 0.001). The Combo group lost the most weight (p < 0.001). The HbA1c reduction was 0.4%  (0.7%), 0.3% (0.7%), and 0.6% (0.8%) in the SGLT2i, GLP1-RA, and Combo groups, respectively (p < 0.001). The Combo group had the biggest improvements in glycemic control and total and low-density lipoprotein cholesterol compared with baseline (all p < 0.01). Severe adverse events were similar between all the groups, with no increased risk of diabetic ketoacidosis.

CONCLUSIONS

The SGLT2i and GLP1-RA agents on their own improved body weight and glycemia, but combining the medications resulted in more weight loss. Treatment intensification appears to result in benefits with no difference in severe adverse events.

A randomised crossover trial: Exploring the dose-response effect of carbohydrate restriction on glycaemia in people with well-controlled type 2 diabetes

BACKGROUND

Trials investigating the role of carbohydrate restriction in the management of glycaemia in type 2 diabetes (T2D) have been confounded by multiple factors, including degree of calorie restriction and dietary protein content, as well as by no clear definition of a low-carbohydrate diet. The present study aimed to provide insight into the relationship between carbohydrate restriction and glycaemia by testing the effect of varying doses of carbohydrate on continuous glucose concentrations within a range of intakes defined as low-carbohydrate at the same time as controlling for confounding factors.

METHODS

This was a randomised crossover trial in participants with T2D (HbA1c: 6.6 ± 0.6%, 49 ± 0.9 mmol mol^-1 ) testing five different 6-day eucaloric dietary treatments with varying carbohydrate content (10%, 15%, 20%, 25%, and 30% kcal). Diets exchanged %kcal from carbohydrate with fat, keeping protein constant at 15% kcal. Daily self-weighing was employed to ensure weight stability throughout each treatment arm. Between dietary treatments, participants underwent a washout period of at least 7 days and were advised to maintain their habitual diet. Glycaemic control was assessed using a continuous glucose monitoring device.

RESULTS

Twelve participants completed the study. There were no differences in 24-h and post-prandial sensor glucose concentrations between the 30 and 10%kcal doses (7.4 ± 1.1 mmol L^-1 vs. 7.6 ± 1.3 mmol L^-1 [p = 0.28] and 8.1 ± 1.5 mmol L^-1 vs. 8.5 ± 1.4 mmol L^-1 [p = 0.28], respectively). In our exploratory analyses, we did not find any dose-response relationship between carbohydrate intake and glycaemia. A small amount of weight loss occurred in each treatment arm (range: 0.4-1.1 kg over the 6 days) but adjusting for these differences did not influence the primary or secondary outcomes.

CONCLUSIONS

Modest changes in dietary carbohydrate content in the absence of weight loss at the same time as keeping dietary protein intake constant do not appear to influence glucose concentrations in people with well-controlled T2D.

SUMMARY

This study randomised people with T2D to receive five different doses of carbohydrate from 10% to 30% of calories in random order to see what effect it had on their blood glucose.

Metabolic and Vascular Risk Factor Variability Over 25 Years Relates to Midlife Brain Volume and Cognition

BACKGROUND

Metabolic and vascular risk factors (MVRF) are associated with neurodegeneration and poor cognition. There is a need to better understand the impact of these risk factors on brain health in the decades that precede cognitive impairment. Longitudinal assessments can provide new insight regarding changes in MVRFs that are related to brain imaging features.

OBJECTIVE

To investigate whether longitudinal changes in MVRF spanning up to 25 years would be associated with midlife brain volume and cognition.

METHODS

Participants were from the CARDIA study (N = 467, age at year 25 = 50.6±3.4, female/male = 232/235, black/white = 161/306). Three models were developed, each designed to capture change over time; however, we were primarily interested in the average real variability (ARV) as a means of quantifying MVRF variability across all available assessments.

RESULTS

Multivariate partial least squares that used ARV metrics identified two significant latent variables (partial correlations ranged between 0.1 and 0.26, p < 0.01) that related MVRF ARV and regional brain volumes. Both latent variables reflected associations between brain volume and MVRF ARV in obesity, cholesterol, blood pressure, and glucose. Subsequent bivariate correlations revealed associations among MVRF factors, aggregate brain volume and cognition.

CONCLUSION

This study demonstrates that MVRF variability over time is associated with midlife brain volume in regions that are relevant to later-life cognitive decline.

Association Between Depression, Diabetes Self-Care Activity and Glycemic Control in an Arab Population with Type 2 Diabetes

PURPOSE

Poor self-care behavior and depression are associated with worse glycemic control, but the relationship between these variables is poorly reported. The present study aimed to describe self-care behaviors and explore the association between depression, self-care and glycemic control in people with type 2 diabetes in an Arab population.

PATIENTS AND METHODS

This study recruited 446 patients with type-2 diabetes from an outpatient clinic in Kuwait and completed assessments of diabetes self-care using the Summary of Diabetes Self-Care Activities (SDSCA) questionnaire and depression using the Patients Health Questionnaire-9 (PHQ-9) scales. Multiple linear regression models were used to determine the associations between depression, self-care behaviors and glycemic control.

RESULTS

Self-care behaviors were highest for medication taking (92.9%), an average for foot care (61.4%), blood glucose testing (60%) and healthy diet (55.7%), and lowest for exercise (27.1%). Depression, poor self-care activities and poor HbA1c levels were inter-correlated in univariate analysis (p< 0.03). In regression analysis, following healthful eating (B= -0.27, p< 0.001), general eating plan (B= -0.21, p= 0.01), more space carbohydrates evenly throughout the day (B= - 0.17, p= 0.03) and exercise at least 30 minutes (B= -0.17, p= 0.02) behaviors were associated with better HbA1c levels. However, depression was associated with poor scores of following a general eating plan (B= -0.20, p= 0.03), space carbohydrates evenly throughout the day (B= -0.21, p= 0.05), and exercising at least 30 minutes (B= -0.24, p= 0.03) behaviors. Depression scores were also associated with poor HbA1c levels (B= 0.32, p= 0.03). However, this association no longer persists after mutual adjustment with following a healthy diet (B= 0.14, p= 0.38) and exercise (B = 0.26, p = 0.08) behaviors.

CONCLUSION

Self-care activity was less than fifty percent in people with type 2 diabetes and higher activity was associated with better glycemic control. However, depression adversely affects self-care behaviors. To maintain and achieve glycemic control, diabetes educators might motivate people with type 2 diabetes to enhance their self-care activities, particularly those with depression symptoms and poor compliance with self-care activities.

Are we ready for the next pandemic? Lessons learned from healthcare professionals' perspectives during the COVID-19 pandemic

Background

The mental health and wellbeing of people watching the Corona Virus Disease 2019 (COVID-19) pandemic unfold has been discussed widely, with many experiencing feelings of anxiety and depression. The state of mental health of medical staff on the frontlines providing care should be examined; medical staff are overworked to meet the demands of providing care to the rise in cases and deterioration in capacity to meet demands, and this has put them under great psychological pressure. This may lead to an increase in medical errors, affect quality of care, and reduce staff retention rates. Understanding the impact the pandemic has had on healthcare professionals is needed to provide recommendations to prepare for future crises.

Objectives

To be able to meet the needs of the medical workforce on the frontlines and inform psychological support interventions and strategies for future pandemics, we aim to identify and explore the psychological impact of COVID-19 in Kuwait on healthcare professionals in close contact with patients.

Methods

Using semi-structured interviews, we conducted interviews between February and July 2021 with 20 healthcare professionals across Ministry of Health hospitals who were part of COVID teams. Interviews were transcribed verbatim, and analysis was conducted using principles of thematic framework analysis.

Results

Three themes emerged to help prepare future healthcare frontline workers on an individual, organizational, and national level: enhance self-resilience, a better-equipped workforce and healthcare environment, and mitigate stigma and increase public awareness.

Conclusion

The results have assisted in highlighting areas of improvement to support the healthcare workforce in the current environment, as well as better prepare them for future pandemics. The findings have also provided insight to recommend targeted interventions. These should improve the psychological wellbeing and help in supporting healthcare professionals to reduce burnout, continue effective care of patients, and enhance resilience.

Effect of COVID-19 vaccine on blood glucose metrics in Arabic people with type 1 diabetes

INTRODUCTION

People with diabetes are at a higher risk for coronavirus disease-19 (COVID-19) and hence are prioritized for vaccination. The aim of the current study was to investigate the effects of COVID-19 vaccination on blood glucose control in Arabic people with type 1 diabetes (T1D). Secondary aim was to compare the responses between the two vaccines approved for use in Kuwait.

METHOD

This retrospective study compared ambulatory glucose metrics, using a continuous glucose monitoring device, measured for 14 days before, and 7 days and 14 days after, the first and second dose of the COVID-19 vaccine in Arabic people with Type 1 diabetes (T1D). We also explored possible links with vaccine type and other clinical characteristics. Glucose metrics calculated were time in range (TIR, 3.9-10 mmol/L), time above range (TAR, 10.1- 13.9 mmol/L or >13.9 mmol/L), time below range (TBR, 3- 3.9 mmol/L or <3 mmol/L) and glucose variability (CV).

RESULTS

We enrolled 223 participants in the study. Over the 7 days period after the first vaccination dose there was a decrease in TIR (mean difference (SD) -1.9% ± 14.8%; p = 0.05) and increase in TAR >10 mmol/L (2.2% ± 15.9%; p = 0.04), with no effects on TBR. These effects were not seen after the second dose or 14 days after either dose. There was a decrease in CV over the 7 days period after the first (-1.2% ± 7.4%; p = 0.02) and second vaccine doses (-1.1% ± 6.9%; p = 0.03), with no effects noted 14 days after either dose. In subgroup analysis similar effects on TIR and TAR were also seen in those who had received the viral vector-based vaccine, but not the mRNA-based vaccine, although the decrease in CV was seen in those who had received the mRNA based vaccine but not the viral vector-based vaccine.

CONCLUSION

We found a temporary impairment in glucose control in the first 7 days, particularly among individuals receiving viral vector vaccines. The group receiving mRNA vaccine was likely to experience an increase in glucose levels above the target range. However, the temporary change in metrics appears to return to pre-vaccination levels after one-week post-vaccination. The effects on glycemic parameters were more neutral after the second dose.

Fatal COVID-19 is Associated with Reduced HLA-DR, CD123 or CD11c Expression on Circulating Dendritic Cells

Purpose

Severe coronavirus disease 2019 (COVID-19) is linked to insufficient control of viral replication and excessive inflammation driven by an unbalanced immune response. Plasmacytoid dendritic cells (pDCs) are specialized in the rapid production of interferons in response to viral infections, and can also prime and activate T-cells. Conventional DCs (cDCs) are critical for the elimination of viral infections owing to their specialized ability to prime and activate T cells. We assessed the frequency and phenotype of pDCs and cDCs in survivors and non-survivors of COVID-19.

Patients and methods

Patients with COVID-19 were enrolled, and 22 were included in this study. Peripheral whole blood was obtained during the 2^nd week of illness, stained with antibodies specific for lineage markers, human leukocyte antigen-DR isotype (HLA-DR), CD11c, and CD123, and analyzed by flow cytometry. Patients were followed-up during hospital admission and grouped into survivors (n=17) and non-survivors (n=5) of COVID-19.

Results

The ratio of pDCs to pre-cDCs was significantly lower (P=0.0005) in non-survivors compared to survivors. The frequency of pDCs was significantly higher than cDC2-like cells (P=0.0002) and pre-cDCs (P<0.0001) in survivors but not in non-survivors. HLA-DR expression level on pDCs and cDC2-like cells was lower in non-survivors compared to survivors (P=0.02 and P=0.058, respectively), and HLA-DR was inversely correlated with disease severity rating (pDCs: r= –0.47, P=0.027; cDC2-like cells: r= –0.45, P=0.037). CD123 expression level on pDCs was significantly lower (P=0.038) in non-survivors compared to survivors, and CD123 was inversely correlated with disease severity rating (r=–0.5, P=0.016). CD11c expression level on cDC2-like cells was significantly lower (P=0.03) in non-survivors compared to survivors, and CD11c was inversely correlated with disease severity rating (r=–0.47, P=0.025).

Conclusion

A lower frequency of pDCs compared to other circulating DCs, and lower expression levels of HLA-DR, CD123 or CD11c on DCs is associated with fatal COVID-19.

Increased Adipose Tissue Expression of IL-23 Associates with Inflammatory Markers in People with High LDL Cholesterol

Chronic low-grade inflammation induced by obesity is a central risk factor for the development of metabolic syndrome. High low-density lipoprotein cholesterol (LDL-c) induces inflammation, which is a common denominator in metabolic syndrome. IL-23 plays a significant role in the pathogenesis of meta-inflammatory diseases; however, its relationship with LDL-c remains elusive. In this cross-sectional study, we determined whether the adipose tissue IL-23 expression was associated with other inflammatory mediators in people with increased plasma LDL-c concentrations. Subcutaneous adipose tissue biopsies were collected from 60 people, sub-divided into two groups based on their plasma LDL-c concentrations (<2.9 and ≥2.9 mmol/L). Adipose expression of IL-23 and inflammatory markers were determined using real-time qRT-PCR; plasma concentrations of total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-c) and LDL-c were determined using the standard method; and adiponectin levels were measured by enzyme-linked immunosorbent assay (ELISA). Adipose IL-23 transcripts were found to be increased in people with high LDL-c, compared to low LDL-c group (H-LDL-c: 1.63 ± 0.10–Fold; L-LDL-c: 1.27 ± 0.09–Fold; p < 0.01); IL-23 correlated positively with LDL-c (r = 0.471, p < 0.0001). Immunochemistry analysis showed that AT IL-23 protein expression was also elevated in the people with H-LDL-c. IL-23 expression in the high LDL-c group was associated with multiple adipose inflammatory biomarkers (p ≤ 0.05), including macrophage markers (CD11c, CD68, CD86, CD127), TLRs (TLR8, TLR10), IRF3, pro-inflammatory cytokines (TNF-α, IL-12, IL-18), and chemokines (CXCL8, CCL3, CCL5, CCL15, CCL20). Notably, in this cohort, IL-23 expression correlated inversely with plasma adiponectin. In conclusion, adipose IL-23 may be an inflammatory biomarker for disease progression in people with high LDL-c.

Palmitate Potentiates Lipopolysaccharide-Induced IL-6 Production via Coordinated Acetylation of H3K9/H3K18, p300, and RNA Polymerase II

IL-6 is elevated in obese individuals and participates in the metabolic dysfunction associated with that condition. However, the mechanisms that promote IL-6 expression in obesity are incompletely understood. Because elevated levels of palmitate and LPS have been reported in obesity, we investigated whether these agents interact to potentiate IL-6 production. In this study, we report that LPS induces higher levels of IL-6 in human monocytes in the presence of palmitate. Notably, the priming effect of palmitate is associated with enhanced p300 binding and transcription factor recruitment to Il6 promoter regions. Gene silencing of p300 blocks this action of palmitate. RNA polymerase II recruitment was also enhanced at the Il6 promoter in palmitate/LPS-exposed cells. Acetylation levels of H3K9 and H3K18 were increased in monocytes treated with palmitate. Moreover, LPS stimulation of palmitate-treated cells led to increased levels of the transcriptionally permissive acetylation marks H3K9/H3K18 in the Il6 promoter compared with LPS alone. The effect of palmitate on LPS-induced IL-6 production was suppressed by the inhibition of histone acetyltransferases. Conversely, histone deacetylase inhibitors trichostatin A or sodium butyrate can substitute for palmitate in IL-6 production. Esterification of palmitate with CoA was involved, whereas β-oxidation and ceramide biosynthesis were not required, for the induction of IL-6 and H3K9/H3K18 acetylation. Monocytes of obese individuals showed significantly higher H3K9/H3K18 acetylation and Il6 expression. Overall, our findings support a model in which increased levels of palmitate in obesity create a setting for LPS to potentiate IL-6 production via chromatin remodeling, enabling palmitate to contribute to metabolic inflammation.

Salivary Biomarkers as Predictors of Obesity and Intermediate Hyperglycemia in Adolescents

Introduction

Childhood obesity presents a major risk for metabolic diseases in adulthood. Noninvasive methods are needed for predicting the course of obesity in children and its complications. Using blood for longitudinal analyses of biomarkers to predict disease in children is not a convenient method. Saliva presents a noninvasive platform to detect inflammatory changes in biomarkers as possible predictive measures of future pathological events.

Objectives

The aim of this study was to evaluate the relationship between specific salivary biomarkers, obesity, and intermediate hyperglycemia in children. We also investigated the longitudinal association between the salivary biomarkers and change in Body Mass Index-for-age percentile scores (BMIz).

Methods

Data on 353 adolescents were collected from the individuals recruited for seven years in an ongoing Kuwait Healthy Life Study cohort. BMIz was measured at 10, 12, and 17 years of age. Interleukin (IL)-6, IL-8, IL-10, Leptin, C-Reactive Protein (CRP), Insulin, Vascular Endothelial Growth Factor (VEGF), and Monocyte Chemoattractant Protein-1 (MCP-1) were measured in saliva and serum. Additionally, fasting blood plasma glucose levels were recorded. Multilevel longitudinal regression modeling, mediation analyses, and logistic regression were used to determine the predictive value of salivary biomarkers in obesity and hyperglycemia.

Results

Longitudinal analyses showed that with each one-unit increase of salivary CRP and insulin, there was a 3.5 kg/m² and 3.2 kg/m² increase in BMIz, respectively. Comparable to serum CRP and insulin, higher salivary CRP and insulin OR 4.94 [95%CI: 1.66,14., OR 2.64 [95%CI: 1.09, 6.38], respectively) were predictive of hyperglycemia and obesity (OR 4.53 [95%CI: 2.40,8.50], OR 3.29 [95%CI: 1.82,5.97], respectively). Insulin was a strong mediator in the relationship between obesity and hyperglycemia.

Conclusion

Our findings demonstrated that salivary CRP and insulin were associated with hyperglycemia, obesity, and possibly diabetes in adolescents. Salivary biomarkers are a noninvasive approach with significant value for disease risk assessment and prevention.

Association between Frequency of Toothbrushing and Metabolic Syndrome among Adolescents: A 5-Year Follow-Up Study

This study longitudinally examines the relationship between the frequency of toothbrushing and the development of selected components of metabolic syndrome (MetS), along with the potential role of salivary biomarkers in this relationship. In 2014, 6317 12-year-old children underwent health examinations (T1), of which, 348 children participated in the second stage of data collection in 2019 (T2). The association between the change in the metabolic status during the 5-year follow-up examination (between T1 and T2) and frequency of toothbrushing was assessed using multinomial logistic regression analyses. At T2, healthy adolescents had significantly higher odds of toothbrushing twice or more daily compared with adolescents with components of MetS (OR = 1.99, 95% CI 1.15–3.45). Adolescents who were healthy at T1 but developed components of MetS at T2, had significantly higher frequencies of dining-out compared with adolescents with components of MetS at both T1 and T2 (OR = 0.09, 95% CI 0.02 to 0.49). Adolescents who were ‘healthy’ at both T1 and T2 had significantly (p < 0.05) lower levels of C-reactive protein (T2), insulin (T1 and T2), interleukin-6 (T1) and adiponectin (T1) compared with adolescents who had components of MetS. Toothbrushing and frequency of dining-out were associated with the presence of MetS components.

Technical report: an online international weight control registry to inform precision approaches to healthy weight management

BACKGROUND

Personalizing approaches to prevention and treatment of obesity will be a crucial aspect of precision health initiatives. However, in considering individual susceptibility to obesity, much remains to be learned about how to support healthy weight management in different population subgroups, environments and geographical locations.

SUBJECTS/METHODS

The International Weight Control Registry (IWCR) has been launched to facilitate a deeper and broader understanding of the spectrum of factors contributing to success and challenges in weight loss and weight loss maintenance in individuals and across population groups. The IWCR registry aims to recruit, enroll and follow a diverse cohort of adults with varying rates of success in weight management. Data collection methods include questionnaires of demographic variables, weight history, and behavioral, cultural, economic, psychological, and environmental domains. A subset of participants will provide objective measures of physical activity, weight, and body composition along with detailed reports of dietary intake. Lastly, participants will be able to provide qualitative information in an unstructured format on additional topics they feel are relevant, and environmental data will be obtained from public sources based on participant zip code.

CONCLUSIONS

The IWCR will be a resource for researchers to inform improvements in interventions for weight loss and weight loss maintenance in different countries, and to examine environmental and policy-level factors that affect weight management in different population groups. This large scale, multi-level approach aims to inform efforts to reduce the prevalence of obesity worldwide and its associated comorbidities and economic impacts.

TRIAL REGISTRATION

NCT04907396 (clinicaltrials.gov) sponsor SB Roberts; Tufts University IRB #13075.

Effectiveness of virtual mindfulness-based interventions on perceived anxiety and depression of physicians during the COVID-19 pandemic: A pre-post experimental study

BACKGROUND

The outbreak of coronavirus disease 2019 (COVID-19) created unprecedented stress on physicians. Mindfulness is a type of meditation that focuses on being fully present, aware of senses, and emotions in the present moment without analyzing or judging them, and it may help reduce psychological distress in physicians. This study aimed to examine the effectiveness of virtual mindfulness-based intervention (MBI) on physicians' perceived anxiety and depression and different facets of mindfulness.

METHODS

During the COVID-19 pandemic, an online survey was administered to physicians to assess depression, anxiety, and awareness using the 9-item Patient Health Questionnaire (PHQ-9), 7-item General Anxiety Disorder (GAD-7), and Five-Facets Mindfulness Questionnaire (FFMQ), respectively. Physicians that received the virtual MBI sessions also completed post-questionnaires at a 3-week follow-up time point.

RESULTS

A total of 125 physicians responded to the online survey, with 56 completing the MBI. The prevalence of moderate to severe anxiety and depression was 45.0 and 46.7%, respectively. Mindfulness scores were negatively associated with depression (r = -0.38, P < 0.001) and anxiety (r = -0.36, p < 0.001). Mindfulness scores for the 56 physicians who received virtual MBI sessions were significantly improved (mean difference ± SD, 17.7 ± 16.1, p = 0.001). Significant reductions were also evidenced in anxiety (4.4 ± 4.2) and depression (4.5 ± 5.1) scores (p's < 0.001). There was also an improvement in mindfulness facets of observing (5.1 ± 4.7), describing (2.3 ± 4.3), acting with awareness (2.7 ± 5.3), non-judging of inner experience (3.6 ± 6.1), and non-reactivity to inner experience (3.9 ± 4.0) (p's < 0.001). A facet of mindfulness, acting with awareness was most efficiently associated with improved anxiety (B = -0.3, p = 0.02) and depression (B = -0.4, p = 0.01).

CONCLUSION

This study has demonstrated that virtual MBI improved physicians' psychological wellbeing and mindfulness during the crisis. Regular mindfulness practice may help physicians to tolerate and handle unpleasant circumstances, such as future epidemics or pandemics.

IL-1β and TNFα Cooperativity in Regulating IL-6 Expression in Adipocytes Depends on CREB Binding and H3K14 Acetylation

IL-6 was found to be overexpressed in the adipose tissue of obese individuals, which may cause insulin resistance. However, the regulation of IL-6 in adipocytes in obesity setting remains to be explored. Since IL-1β and TNFα are increased in obese adipose tissue and promote inflammation, we investigated whether cooperation between IL-1β and TNFα influences the production of IL-6. Our data show that IL-1β and TNFα cooperatively enhance IL-6 expression in 3T3L-1 adipocytes. Similar results were seen in human adipocytes isolated from subcutaneous and visceral fat. Although adipocytes isolated from lean and obese adipose tissues showed similar responses for production of IL-6 when incubated with IL-1β/TNFα, secretion of IL-6 was higher in adipocytes from obese tissue. TNFα treatment enhanced CREB binding at CRE locus, which was further enhanced with IL-1β, and was associated with elevated histone acetylation at CRE locus. On the other hand, IL-1β treatments mediated C/EBPβ binding to NF-IL-6 consensus, but not sufficiently to mediate significant histone acetylation. Interestingly, treatment with both stimulatory factors amplifies CREB binding and H3K14 acetylation. Furthermore, histone acetylation inhibition by anacardic acid or curcumin reduces IL-6 production. Notably, inhibition of histone deacetylase (HDAC) activity by trichostatin A (TSA) resulted in the further elevation of IL-6 expression in response to combined treatment of adipocytes with IL-1β and TNFα. In conclusion, our results show that there is an additive interaction between IL-1β and TNFα that depends on CREB binding and H3K14 acetylation, and leads to the elevation of IL-6 expression in adipocytes, providing interesting pathophysiological connection among IL-1β, TNFα, and IL-6 in settings such as obesity.

Risk of mortality among inpatients with COVID-19 and type 2 diabetes: National data from Kuwait

Introduction

To investigate type 2 diabetes as a risk factor for COVID‐19 death following hospital admission in Kuwait.

Methods

A retrospective cohort study using data from a central hospital that cared for all hospitalized COVID‐19 patients in Kuwait. We investigated the association between type 2 diabetes, with COVID‐19 mortality using multiply imputed logistic regression and calculated the population attributable fraction.

Results

A total of 5333 patients were admitted with COVID‐19, of whom 244 died (4.6%). Diabetes prevalence was 24.8%, but 53.7% of those who died had diabetes. After adjusting for age, sex, ethnicity and other comorbidities, diabetes was associated with death (OR 1.70 [95% CI 1.23, 2.34]) and admission to the intensive care unit more than 3 days after initial admission (OR 1.78 [95% CI 1.17, 2.70]). Assuming causality, the population attributable fraction for type 2 diabetes in COVID‐19 death was 19.6% (95% CI 10.8, 35.6).

Conclusion

Type 2 diabetes is a strong risk factor for COVID‐19 death in the Middle East. Given the high prevalence of type 2 diabetes in the Middle East, as well as many Western countries, the public health implications are considerable.

Changing how we risk-categorise in Ramadan: Does the IDF-DAR scoring system achieve the requirements for people with diabetes internationally?

The IDF-DAR guidance was most recently updated this year. The most notable change is the moving to a scoring system from a tabulated risk categorization to determine and classify the risk of harm from fasting derived from an online survey. This change may be appealing and is welcomed. However, such a system and the methodology underpinning it is not without limitations. This commentary highlights some of these limitations and the associated limited safe options available to individuals with diabetes desiring to fast during Ramadan. Overlooked clinical considerations that deserve formal recognition include the role of technology (aspects relating to glucose monitoring and/or insulin delivery) and previous experience of safe Ramadan fasting. Further, duration of fast (which can almost double in temperate regions from winter to summer) needs greater emphasis. We also advocate separate scoring systems for people with type 1 diabetes and complex type 2 diabetes. The guidance acknowledges fasting is an individual's decision, however the general message needs to be more person-centred and currently only presents a binary approach to fasting - all or nothing choices. We propose and discuss addition options including, trial fasting of voluntary fasts, starting the fast and terminating due to health and/or safety, intermittent fasting and winter fasting.

Prevalence of Cardiovascular and Renal Co-morbidities in Patients with Type 2 Diabetes in the Gulf, a Cross-sectional Observational Study

INTRODUCTION

Understanding comorbid conditions with type 2 diabetes mellitus (T2DM) is critical for clinical decision-making regarding the choice of pharmacotherapy. This study aimed at describing the prevalence and co-prevalence of comorbidities, including chronic kidney disease (CKD) and cardiovascular disease (CVD) (coronary artery disease (CAD), cerebrovascular disease, peripheral arterial disease (PAD) and congestive heart failure (CHF)) among patients with T2DM.

METHODS

A cross-sectional multi-center observational study on 300 patients with T2DM. Data were collected from patients' records during the enrollment visit.

RESULTS

Overall, 38%, 10% and 2% of the patients had one, two and three comorbidities, respectively, with the number of comorbidities significantly increasing with age. The most prevalent comorbidities were CVD (17.3%), CAD (15%) and CKD (44.3%), mostly stages 2 and 3. However, the prevalence of  CHF (0.7%),  PAD (2.3%) and cerebrovascular diseases (1.3%) was low. The highest percentage of anti-hyperglycemic agents used was metformin (81%), dipeptidyl peptidase-4 inhibitors (46%), sodium-glucose co-transporter 2 inhibitors (37%), insulin (36%) and sulfonylurea (34%). The choice of the anti-hyperglycemic class did not change across age groups and gender.

CONCLUSION

Half of the patients had T2DM only. The most prevalent comorbidity found was CKD, mainly stage 2. The comorbidity burden tended to increase significantly in older age groups.

Cellular and Humoral Immune Responses in Covid-19 and Immunotherapeutic Approaches

Coronavirus disease 2019 (Covid-19), caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can range in severity from asymptomatic to severe/critical disease. SARS-CoV-2 uses angiotensin-converting enzyme 2 to infect cells leading to a strong inflammatory response, which is most profound in patients who progress to severe Covid-19. Recent studies have begun to unravel some of the differences in the innate and adaptive immune response to SARS-CoV-2 in patients with different degrees of disease severity. These studies have attributed the severe form of Covid-19 to a dysfunctional innate immune response, such as a delayed and/or deficient type I interferon response, coupled with an exaggerated and/or a dysfunctional adaptive immunity. Differences in T-cell (including CD4+ T-cells, CD8+ T-cells, T follicular helper cells, γδ-T-cells, and regulatory T-cells) and B-cell (transitional cells, double-negative 2 cells, antibody-secreting cells) responses have been identified in patients with severe disease compared to mild cases. Moreover, differences in the kinetic/titer of neutralizing antibody responses have been described in severe disease, which may be confounded by antibody-dependent enhancement. Importantly, the presence of preexisting autoantibodies against type I interferon has been described as a major cause of severe/critical disease. Additionally, priorVaccine and multiple vaccine exposure, trained innate immunity, cross-reactive immunity, and serological immune imprinting may all contribute towards disease severity and outcome. Several therapeutic and preventative approaches have been under intense investigations; these include vaccines (three of which have passed Phase 3 clinical trials), therapeutic antibodies, and immunosuppressants.

Chia seed (Salvia hispanica L.) supplementation to the diet of adults with type 2 diabetes improved systolic blood pressure: A randomized controlled trial

BACKGROUND

Functional food ingredients, such as dietary fiber, long-chain polyunsaturated fatty acids, and high-quality protein, have been shown to help control blood glucose concentration and lower high blood pressure (BP), as well as improving other cardiovascular disease risk factors. However, little research has assessed the impacts of consuming chia seeds, which are rich in these nutrients, on metabolic and physiological outcomes, and results are conflicting.

AIM

The study aimed to investigate the possible effects of chia seeds on fasting blood glucose, insulin, glycated hemoglobin, BP, lipid profile, body weight, and the inflammatory marker - high-sensitivity C-reactive protein - in people with type 2 diabetes (T2DM).

METHODS

Adults with T2DM (n = 42) were randomly assigned equally to the chia seed group, which consumed 40 g/day chia seeds for 12 weeks, or a control group, which did not consume any supplement. Blood samples were collected at baseline and after a 12-week intervention period to assess the study outcomes, such as glycemic control, BP, cardiovascular risk parameters including lipid profile, inflammatory marker, and body weight.

RESULTS

Adjusted for gender and baseline values, the chia seed group had systolic BP (SBP) significantly reduced compared to control [t (1) = 2.867, p = 0.007, η ² _p = 0.174]. No differences were observed in any other parameter tested in the chia seed or control group.

CONCLUSIONS

People with T2DM and hypertension, maintaining usual dietary consumption, physical activity pattern, and medications, had significantly reduced SBP compared to the control group when having consumed 40 g/d of chia seeds for 12 weeks.

Skeletal Muscle and Metabolic Health: How Do We Increase Muscle Mass and Function in People with Type 2 Diabetes?

BACKGROUND

Whilst skeletal muscles' primary role is allowing movement, it has important metabolic roles, including in glycemic control. Indeed, evidence indicates that low muscle mass and function are associated with an increased risk of type 2 diabetes, highlighting its importance in the development of metabolic disease.

METHODS

In this mini-review, we detail the evidence highlighting the importance of muscle in type 2 diabetes and the efficacy of resistance exercise in improving glycemic control alongside our approach to increase uptake of such exercise in people with type 2 diabetes. This summary is based in the authors' knowledge of the filed supplemented by a Pubmed search using the terms "muscle," "glycemic control," "HbA1c," "type 2 diabetes," and "resistance exercise."

RESULTS

The main strategy to increases muscle mass is to perform resistance exercise and, although the quality of evidence is low, such exercise appears effective in reducing Glycated Haemoglobin (HbA1c) in people with type 2 diabetes. However, to increase participation we need to improve our understanding of barriers and facilitators to such exercise. Current data indicate that barriers are similar to those reported for aerobic exercise, with additional resistance exercise specific barriers of looking to muscular, increase risk of cardiovascular event, having access to specialized equipment and knowledge of how to use it.

CONCLUSIONS

The development of simple resistance exercises that can be performed anywhere, that use little or no equipment and are effective in reducing HbA1c will be, in our opinion, key to increasing the number of people with type 2 diabetes performing resistance exercise.

Combination therapy with pioglitazone/exenatide improves beta-cell function and produces superior glycaemic control compared with basal/bolus insulin in poorly controlled type 2 diabetes: A 3-year follow-up of the Qatar study

AIM

To examine the long-term efficacy of thiazolidinedione plus a glucagon-like peptide-1 receptor agonist versus basal-bolus insulin on glycaemic control and beta-cell function in patients with poorly controlled type 2 diabetes (T2D) on metformin plus sulphonylurea.

MATERIALS AND METHODS

Three hundred and thirty-one patients with poorly controlled T2D were recruited over 3 years and were followed for an additional year. Subjects received a 75 g oral glucose tolerance test (OGTT) at baseline and at study end. After completing the baseline OGTT, subjects were randomized to receive either pioglitazone plus weekly exenatide (combination therapy) or basal/bolus insulin (insulin therapy) to maintain an HbA1c of less than 7.0%. The primary outcome of the study was the difference in HbA1c at study end between the two treatment groups.

RESULTS

Both therapies caused a robust decrease in HbA1c. However, combination therapy caused a greater decrement (-1.1%, P < .0001) than insulin therapy, and more subjects in the combination therapy group (86%) achieved the American Diabetes Association goal of glycaemic control (HbA1c < 7.0%) than those in the insulin therapy group (44%) (P < .0001). Both therapies improved insulin secretion. However, the improvement in insulin secretion with combination therapy was 2.5-fold greater (P < .001) than with insulin therapy (50%). Insulin therapy caused more weight gain and hypoglycaemia.

CONCLUSION

Both combination therapy and insulin therapy effectively reduced HbA1c in poorly controlled T2D on multiple oral agents. However, combination therapy produced a greater improvement in insulin secretion and decrease in HbA1c with a lower risk of hypoglycaemia.

Clinical characteristics of coronavirus disease 2019 (COVID-19) patients in Kuwait

This is a retrospective single-center study of 417 consecutive patients with coronavirus disease 2019 (COVID-19) admitted to Jaber Al-Ahmad Hospital in Kuwait between February 24, 2020 and May 24, 2020. In total, 39.3% of patients were asymptomatic, 41% were symptomatic with mild/moderate symptoms, 19.7% were admitted to the intensive care unit (ICU). Most common symptoms in cohort patients were fever (34.3%) and dry cough (32.6%) while shortness in breath was reported in (75.6%) of ICU admissions. Reported complications requiring ICU admission included Sepsis (68.3%), acute respiratory distress syndrome (95.1%) and heart failure (63.4%). ICU patients were more likely to have comorbidities, in comparison to non-ICU patients, including diabetes (35.4% vs 20.3%) and hypertension (40.2% vs 26.9%). Mortality rate of cohort was 14.4% and mean age of death was 54.20 years (± 11.09) and 90% of death cases were males. Chest high-resolution computed tomography for ICU cases reveled multifocal large patchy areas of ground glass opacification mixed with dense consolidation. Cases admitted to ICU showed abnormal levels of markers associated with infection, inflammation, abnormal blood clotting, heart problems and kidney problems. Mean hospital stay for asymptomatic cases was 20.69 days ±8.57 and for mild/moderate cases was 21.4 days ±8.28. Mean stay in ICU to outcome for survivors was 11.95 days ±8.96 and for death cases 13.15 days ±10.02. In this single-center case series of 417 hospitalized COVID-19 patients in Kuwait 39.3% were asymptomatic cases, 41% showed mild/moderate symptoms and 18.7% were admitted to ICU with a mortality rate of 14.4%.

Secondary Impact of Social Media via Text Message Screening for Type 2 Diabetes Risk in Kuwait: Survey Study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is an international problem of alarming epidemic proportions. T2DM can develop due to multiple factors, and it usually begins with prediabetes. Fortunately, this disease can be prevented by following a healthy lifestyle. However, many health care systems fail to properly educate the public on disease prevention and to offer support in embracing behavioral interventions to prevent diabetes. SMS messaging has been combined with cost-effective ways to reach out to the population at risk for medical comorbidities. To our knowledge, the use of nationwide SMS messaging in the Middle East as a screening tool to identify individuals who might be at risk of developing T2DM has not been reported in the literature.

OBJECTIVE

The primary aim of this study was to assess the feasibility of conducting a series of SMS messaging campaigns directed at random smartphone users in Kuwait for the detection and prevention of T2DM. It was predicted that 1% of those receiving the text message would find it relevant and participate in the study. The secondary aim of this study was to assess the incidence of participation of those who were forwarded the initial text message by family members and friends.

METHODS

In this study, 5 separate text message screening campaigns were launched inviting recipients to answer 6 questions to determine the risk of developing T2DM. If subjects agreed to participate, a link to the prediabetes screening test devised by the Centers for Disease Control and Prevention was automatically transmitted to their mobile devices. Those identified as high risk were invited to participate in a diabetes prevention program.

RESULTS

A total of 180,000 SMSs were sent to approximately 6% of the adult population in Kuwait. Of these, 0.14% (260/180,000) of the individuals who received the SMS agreed to participate, of whom 58.8% (153/260) completed the screening. Surprisingly, additional surveys were completed by 367 individuals who were invited via circulated SMS messages forwarded by family members and friends. Altogether, 23.3% (121/520) qualified and agreed to participate in a diabetes prevention program. The majority of those who chose to participate in the prevention program were overweight, aged 45-65 years, and reported being less physically active than those who chose not to participate (χ²₂=42.1, P<.001).

CONCLUSIONS

Although health care screening via text messaging was found to have limited effectiveness by itself, it exhibited increased reach through shared second-party social media messaging. Despite the fact a subpopulation at possible risk of developing T2DM could be reached via text messaging, most responders were informed about the screening campaign by family and friends. Future research should be designed to tap into the benefits of social media use in health risk campaigns.

Mediation effect of C-reactive protein in the relationship between abdominal obesity and intermediate hyperglycemia in Kuwaiti adolescents

Aim: This study aimed to investigate the mediating effect of C-reactive protein (CRP) on obesity and hyperglycemia. Materials & methods: Fasting blood glucose, high-sensitivity CRP (hs-CRP) levels and waist circumference (WC) were measured on 353 participants. Multilevel regression modeling and mediation analyses were used to investigate the link between abdominal obesity, hs-CRP and hyperglycemia. Results: Elevation in hs-CRP was predictive of hyperglycemia in nonobese individuals (OR = 1.3, p = 0.03). With every 1-mg/l increase in hs-CRP, there was a 1-cm increase in WC (B = 0.87, p = 0.001). hs-CRP was a full mediator in the relationship between WC and hyperglycemia. Conclusion: hs-CRP predicts hyperglycemia development in nonobese individuals and the effect of increased WC on hyperglycemia was fully mediated by hs-CRP.

Elevated adipose tissue associated IL-2 expression in obesity correlates with metabolic inflammation and insulin resistance

Adipose tissue (AT) associated cytokines are involved in the development of chronic low-grade inflammation in obese individuals. IL-2, a pleiotropic cytokine, contributes to immune alterations during inflammation. However, the interaction between AT-IL-2 and other inflammatory biomolecules in obesity remains elusive. We investigated whether AT-IL-2 expression was associated with markers of inflammation and insulin resistance in overweight/obese individuals. Subcutaneous fat tissues were collected from 56 individuals (lean/overweight/obese) for RNA extraction. IL-2 and inflammatory mediators were quantified by qRT-PCR and immunohistochemistry. CRP was measured by ELISA. AT-IL-2 expression was higher in obese compared with lean individuals (P < 0.021) and correlated with BMI. IL-2 correlated with interleukins IL-8 and IL-12A (r = 0.333–0.481; p = 0.0001–0.029); as well as with chemokines and their receptors including CCL5, CCL19, CCR2 and CCR5 (r = 0.538–0.677; p < 0.0001). Moreover, IL-2 correlated with toll-like receptors (TLR2, TLR8, TLR10), interferon regulatory factor 5 (IRF5) and cluster of differentiation CD11c (r = 0.282–0.357; p < 0.039). Notably, IL-2 was associated positively with fasting blood glucose (FBG), HbA1c, TGL and CRP (r ≥ 0.423;P ≤ 0.007). In multiple regression analysis, IL-2 is an independent predictor of IL-8, IL-12A, TLR10, TGL and HbA1c. Overall, our data demonstrate that increased expression of the AT-IL-2, in obesity, may represent a novel biomarker for progression of metabolic inflammation and insulin-resistance.

A Wearable Technology Delivering a Web-Based Diabetes Prevention Program to People at High Risk of Type 2 Diabetes: Randomized Controlled Trial

BACKGROUND

Intensive lifestyle interventions are effective in reducing the risk of type 2 diabetes, but the implementation of learnings from landmark studies is expensive and time consuming. The availability of digital lifestyle interventions is increasing, but evidence of their effectiveness is limited.

OBJECTIVE

This randomized controlled trial (RCT) aimed to test the feasibility of a web-based diabetes prevention program (DPP) with step-dependent feedback messages versus a standard web-based DPP in people with prediabetes.

METHODS

We employed a two-arm, parallel, single-blind RCT for people at high risk of developing diabetes. Patients with a hemoglobin A_1c (HbA_1c) level of 39-47 mmol/mol were recruited from 21 general practices in London. The intervention integrated a smartphone app delivering a web-based DPP course with SMS texts incorporating motivational interviewing techniques and step-dependent feedback messages delivered via a wearable device over 12 months. The control group received the wearable technology and access to the web-based DDP but not the SMS texts. As this was a feasibility study, the primary aim was to estimate potential sample size at different stages of the study, including the size of the target study population and the proportion of participants who consented, were randomized, and completed follow-up. We also measured the main outcomes for a full-scale RCT, namely, change in weight and physical activity at 6- and 12-month follow-ups, and secondary outcomes, including changes in the HbA_1c level, blood pressure, waist circumference, waist-to-hip ratio, and lipid levels.

RESULTS

We enrolled 200 participants: 98 were randomized to the intervention and 102 were randomized to the control group. The follow-up rate was higher in the control group (87/102, 85.3%) than in the intervention group (69/98, 70%) at 12 months. There was no treatment effect on weight at 6 months (mean difference 0.15; 95% CI -0.93 to 1.23) or 12 months (mean difference 0.07 kg; 95% CI -1.29 to 1.44) or for physical activity levels at 6 months (mean difference -382.90 steps; 95% CI -860.65 to 94.85) or 12 months (mean difference 92.64 steps; 95% CI -380.92 to 566.20). We did not observe a treatment effect on the secondary outcomes measured at the 6-month or 12-month follow-up. For the intervention group, the mean weight was 92.33 (SD 15.67) kg at baseline, 91.34 (SD 16.04) kg at 6 months, and 89.41 (SD 14.93) kg at 12 months. For the control group, the mean weight was 92.59 (SD 17.43) kg at baseline, 91.71 (SD 16.48) kg at 6 months, and 91.10 (SD 15.82) kg at 12 months. In the intervention group, the mean physical activity was 7308.40 (SD 4911.93) steps at baseline, 5008.76 (SD 2733.22) steps at 6 months, and 4814.66 (SD 3419.65) steps at 12 months. In the control group, the mean physical activity was 7599.28 (SD 3881.04) steps at baseline, 6148.83 (SD 3433.77) steps at 6 months, and 5006.30 (SD 3681.1) steps at 12 months.

CONCLUSIONS

This study demonstrates that it is feasible to successfully recruit and retain patients in an RCT of a web-based DPP.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02919397; http://clinicaltrials.gov/ct2/show/NCT02919397.

Photo-Assisted Dietary Method Improves Estimates of Dietary Intake Among People with Sleeve Gastrectomy

INTRODUCTION

Bariatric operations are effective obesity treatments because of the significant reductions in food intake after surgery, but weight regain remains a problem in a small group of patients after surgery. Estimating food intake is difficult due to dieting status, weight, gender, and challenges with estimating portion size. We aimed to evaluate the use of digital food photography in comparison to conventional methods among patients after sleeve gastrectomy.

METHODS

Participants used a mobile device (mHealth) to photo-document their dietary intake of all food and beverages consumed before and after eating. They also completed a 24 h food recall interview with a dietician.

RESULTS

Data from 383 eating occasions were analyzed. Food intake using 24 h recall was reported as 972.5 ± 77 kcal and estimates from photographs were 802.9 ± 63.4 kcal, with a difference of 169.6 ± 451.4 kcal (95% confidence interval (CI) of 41.4 to 297.9 kcal, p = 0.005). There was no difference for protein intake, but carbohydrate intake reported during the 24 h recall was 541.2 ± 298 kcal and estimates from photographs were 395.2 ± 219.6 kcal, with a difference of 145.8 ± 256.3 kcal (95% CI of 73.2 to 218.8 kcal, p = 0.0001).

CONCLUSION

After sleeve gastrectomy, patients reported eating more total calories and calories from carbohydrates compared to estimations using photographs. The implication for patients are that tools such as mHealth might be useful to optimize food intake and calories after sleeve gastrectomy, especially for those patients that may struggle with weight regain after surgery.

Fructose tolerance test in obese people with and without type 2 diabetes

BACKGROUND

Fructose is distinct among common sugars in its ability to raise serum uric acid, and some studies suggest fructose-induced uric acid production may have a role in the ability of this sugar to induce metabolic syndrome. A fructose tolerance test has been previously developed to evaluate the relative ability of fructose to raise uric acid in individuals. However, the effect of fructose to raise uric acid in people with diabetes has not been studied.

METHODS

People with type 2 diabetes (n = 143) and without diabetes controls (n = 132) with similar body mass index (BMI) underwent an oral fructose tolerance test. As a comparison, participants also had their uric acid levels measured after an oral glucose tolerance test on a different day.

RESULTS

Serum uric acid was lower in people with type 2 diabetes compared to controls with a similar BMI, especially those with poor glucose control (glycosylated hemoglobin [HbA1c] ≥ 8%). Fructose administration raised serum uric acid in both groups, with a lower absolute rise in people with diabetes. People with diabetes with a blunted rise in serum uric acid had higher baseline serum uric acid concentrations and a higher BMI. People without diabetes with a higher BMI also showed a blunted serum uric acid response. Oral glucose administration lowered serum uric acid in both participants, with a greater fall in those with diabetes.

CONCLUSION

Both the presence of diabetes and obesity blunt the serum uric acid response to fructose ingestion. These data demonstrate altered fructose-dependent urate metabolism in type 2 diabetes.

Late bedtime and dental caries incidence in Kuwaiti children: A longitudinal multilevel analysis

OBJECTIVE

Inadequate sleep contributes to several adverse systemic health outcomes due to hormonal and metabolic disorders. The purpose of this study was to determine the effect of bedtime on the development of dental caries and the relationship with salivary ghrelin and leptin in a prospective cohort study of Kuwaiti children.

METHODS

Data were collected from 5456 10-year-old children in 2012 and repeated in 2014. We selected children from 138 middle schools representing the six governorates of Kuwait. We derived data from oral examinations, self-reported sleep interviews, body and weight measurements, and chemical analysis of whole saliva samples. Leptin and ghrelin were determined by salivary assay in a subset of 744. Two separate analyses were performed. a) Using the entire longitudinal data set (n = 5456), multilevel random intercept analysis was conducted to assess the relationship between reported bedtime and dental caries. b) Using data from a subset of the original sample (n = 744), multiple linear regression analysis was conducted to determine the relationship between dental caries and salivary ghrelin and leptin. The outcome variable was the development of dental caries in children. The independent explanatory variables and confounders were bedtime, sleep duration, salivary ghrelin and leptin; confounders assessed were gingivitis, sex, age and governorate (school location).

RESULTS

With every additional hour past 8 pm for bedtime, there was a 20% increase in dental caries incidence over two years (B = 0.2, P = .01), adjusting for age, gender, gingivitis and governorate. There was a significant difference in the magnitude of dental caries between the six governorates of Kuwait. Lower levels of salivary leptin and higher levels of salivary ghrelin were associated with increased dental caries, and sleep duration was an effect modifier that negatively affected the relationship between leptin and dental caries (B = -0.09, P < .05) and positively affects the relationship between ghrelin and dental caries (B = 0.07, P < .05). Additionally, there was a significant clustering effect within schools in this cohort.

CONCLUSION

In a cohort study of Kuwaiti children, late bedtime was associated with increased dental caries incidence. Additionally, dental caries experience increased with higher levels of salivary ghrelin and lower levels of salivary leptin, and sleep duration mediates the relationship between these two biomarkers and dental caries.

Correlation Profile of Suppression of Tumorigenicity 2 and/or Interleukin-33 with Biomarkers in the Adipose Tissue of Individuals with Different Metabolic States

PURPOSE

The suppression of tumorigenicity 2 (ST2) has two main splice variants including a membrane bound (ST2) form, which activates the myeloid differentiation primary response 88 (MyD88)/nuclear factor-kappa B (NF-κB) signaling pathway, and a secreted soluble form (sST2), which acts as a decoy receptor for ST2 ligand, interleukin (IL)-33. The IL-33/ST2 axis is protective against obesity, insulin resistance, and type 2 diabetes (T2D). In humans, adipose tissue IL-33 displays distinct correlation profiles with glycated hemoglobin, ST2, and other immunometabolic mediators, depending on the glycemic health of the individuals. We determined whether adipose tissue ST2 displays distinct correlation profiles with immunometabolic mediators and whether ST2 and/or IL-33 are correlated with intracellular signaling molecules.

PATIENTS AND METHODS

A total of 91 adults with normal glycemia, prediabetes, and T2D were included. After measuring their anthropometric and biochemical parameters, subcutaneous adipose tissues were isolated and mRNA expression of biomarkers was measured.

RESULTS

In individuals with normal glycemia, adipose tissue ST2 was directly correlated with chemokine (C-C motif) ligand (CCL)-2, CCL5, IL-12, fibrinogen-like protein 2 (FGL2) and interferon regulatory factor (IRF)-4, but inversely correlated with cytochrome C oxidase subunit 7A1. IL-33 and ST2 were directly correlated with tumor necrosis factor receptor-associated factor 6 (TRAF6), NF-κB, and nuclear factor of activated T-cells 5 (NFAT5). In individuals with prediabetes, ST2 was inversely correlated with IL-5, whereas IL-33 but not ST2 was directly correlated with MyD88 and NF-κB. In individuals with T2D, ST2 was directly correlated with CCL2, IL-1β, and IRF5. IL-33 and ST2 were directly correlated with MyD88, TRAF6, and NF-κB.

CONCLUSION

Adipose tissue ST2 and IL-33 show different correlation profiles with various immunometabolic biomarkers depending on the metabolic state of the individuals. Therefore, targeting the IL-33/ST2 axis might form the basis for novel therapies to combat metabolic disorders.

The Epidemiology of Depression and Diabetes Distress in Type 2 Diabetes in Kuwait

This study is aimed at describing the prevalence of and risk factors for depression and diabetes distress in people with type 2 diabetes and whether depression and distress are independently associated with worse biomedical outcomes. The study was of cross-sectional design. The setting was the Dasman Diabetes Institute, Kuwait. The Patient Health Questionnaire-9 (PHQ-9) was used to measure the prevalence of depression, defined as a score ≥ 10 (depression caseness). The Problem Areas in Diabetes (PAID) was used to measure diabetes-related distress. Data on biomedical outcomes, lifestyle factors, and sociodemographic information were collected. The prevalence of depression and diabetes distress caseness was 29% and 14%, respectively. Depression caseness patients were more likely to be female (60%; p = 0.001), have Kuwaiti nationality (68%, p = 0.121), were on insulin (67%, p = 0.001), have higher body mass index (p = 0.047), were less physically active (78%; p = 0.034), have a higher PAID score (p < 0.001), and have hypertension (74%, p = 0.047). After adjustment of sociodemographics (age, gender, and marital status) and body mass index, the prevalence of depression was associated with higher HbA1c (B = 0.04, 95% confidence interval 0.01 to 0.60), while diabetes distress had a weak association with HbA1c (B = 0.13, 95% confidence interval 0.04 to 0.22). In conclusion, people with type 2 diabetes in Kuwait have a high prevalence of depression but lower diabetes distress and this was associated with worse glycaemic control.

Adipose tissue gene expression of CXCL10 and CXCL11 modulates inflammatory markers in obesity: implications for metabolic inflammation and insulin resistance

BACKGROUND

The CXCL subfamily of chemokines (CXCL9, CXCL10, and CXCL11; angiostatic chemokines) plays a key role in many inflammatory diseases. However, the expression of CXCLs in adipose tissue (AT) during obesity and association of these CXCLs with inflammatory markers and insulin resistance are poorly understood. Therefore, this study aimed to investigate the effects of CXCL gene expression on subcutaneous AT inflammatory markers and insulin resistance.

METHODS

Subcutaneous-fat biopsies were collected from 59 nondiabetic (lean/overweight/obese) individuals for RNA isolation. Expression levels of AT CXCL and inflammatory markers were determined by quantitative reverse transcriptase polymerase chain reaction (RT-qPCR). Biomedical parameters in the plasma were measured by enzyme-linked immunosorbent assay (ELISA). Insulin resistance was estimated using homeostatic model assessment (HOMA-IR).

RESULTS

AT CXCL expression was higher in obese compared with lean individuals (p < 0.05) and positively correlated with body mass index (BMI; r ⩾ 0.269, p < 0.05). Expression of CXCL9, CXCL10, and CXCL11 correlated significantly with various pro-inflammatory markers, including family members of interleukins, chemokines, and their prospective receptors (r ⩾ 0.339, p ⩽ 0.009), but not anti-inflammatory markers. CXCL11 expression correlated specifically with the expression of CCL5, CCL18, TLR3, TLR4, TLR8, IRF5, and NF-κB (r ⩾ 0.279, p ⩽ 0.039). Notably, CXCL11 was correlated with C-reactive protein (CRP), fasting blood glucose (FBG), and HOMA-IR. In multiple regression analysis, CXCL11 was identified as an independent predictor of CCL19, CCL5, IL-6, and TLR3.

CONCLUSION

These data suggest that the CXCL family members, specifically CXCL10 and CXCL11, are potential biomarkers for the onset of AT inflammation during obesity.

Atherogenic Index of Plasma (AIP) a Tool to Assess Changes in Cardiovascular Disease Risk Post Laparoscopic Sleeve Gastrectomy

Predictive indices like the atherogenic index of plasma (AIP) have been developed to estimate the risk of cardiovascular disease (CVD). Metabolic surgery is the most effective treatment for a rapid improvement of morbid obesity and its comorbidities such as type 2 diabetes (T2D) and CVD. A decreased reoccurrence of CVD after metabolic surgery has been reported by several studies. However, studies utilizing predictive indices for CVD risk in CVD-free morbid-obese patients who undertook laparoscopic sleeve gastrectomy (LSG) are lacking. Here, we use AIP as a tool to evaluate the improvement in CVD risk post-LSG in morbid-obese people who had no history of CVD. Method. We compared baseline, 6- and 12-month post-LSG score of AIP, vascular age, circulating biochemical markers related to CVD in two groups of BMI and age-matched morbid-obese participants with and without T2D. Results. At baseline, people with T2D had significantly higher AIP both, with morbid obesity (0.23 ± 0.06, p < 0.001) and normal weight (0.022 ± 0.05, p < 0.001) compared to their BMI-matched without T2D group. People with morbid obesity had low AIP (-0.083 ± 0.06). Vascular age was significantly higher in people with morbid obesity and T2D (65.8 ± 3.7year, p < 0.0001) compared to morbid obesity (37.9 ± 2.6 year). After one year, AIP was significantly reduced compared to baseline score in people with morbid obesity with/without T2D, respectively (-0.135 ± 0.07, p = 0.003; and -0.36 ± 0.04, p = 0.0002). Conclusion. Our data illuminates AIP as a reliable predictive index for CVD risk in morbid-obese people who had no history of CVD. Moreover, AIP accurately distinguishes between morbid obesity with T2D and morbid obesity and showed a rapid and significant reduction in CVD risk after LSG in people who had no history of CVD. This is a ClinicalTrials.gov registered trial (Reference NCT03038373).

Fasting in Ramadan with type 1 diabetes: A dose adjustment for normal eating workshop in Kuwait

This pre-Ramadan workshop was aimed at educating and counselling people with type 1 diabetes, who graduated from the Dose Adjustment for Normal Eating (DAFNE) Kuwait programme, on safe fasting practices as well as determining their views on the challenges associated with fasting. The workshop also served as a pilot for a Ramadan-specific module to inform its implementation in all DAFNE programmes with the goal of meeting the needs of Muslim DAFNE graduates wishing to fast safely. A 2-day workshop (5 hours each) was conducted at DAFNE Kuwait 3 days before the start of Ramadan 2018 and all DAFNE graduates were invited to attend. The workshop consisted of group discussions about fasting-related challenges, followed by three interactive lectures and hands-on experience with popular Ramadan dishes. A qualitative approach was employed to determine the experiences of the participants with fasting by conducting three focus group discussions. The discussions were recorded via handwritten notes and analysed thematically. Seventy-two people with type 1 diabetes attended and 47 participated in the group discussions. Participants discussed their past experiences with fasting and the associated challenges, and shared practices adopted over the years. In addition, they confirmed the positive impact of DAFNE on their fasting experiences. The workshop provided a platform for people with type 1 diabetes to share their experiences with fasting and learn how to fast safely. Furthermore, it provided preliminary information that can be further explored to inform recommendations for safer fasting practices and the implementation of a specific fasting curriculum for people with type 1 diabetes.

A prospective study of the effect of fasting during the month of Ramadan on depression and diabetes distress in people with type 2 diabetes

AIMS

Depression in diabetes has been associated with hyperglycemia and an increase risk for metabolic disorder complications. Ramadan is a period of self-discipline, self control, and spirituality, which has shown benefits in physical, mental, and social well being. The aim of this study is to examine the association between fasting during the month of Ramadan and depression.

METHODS

Data from 463 participants were collected at three time points. A paired t-test was used to examine the difference between PHQ-9 score and difference of PAID score before and after Ramadan to measure depression. A multivariable regression with adjusting for potential confounders was used to study the association between fasting and depression.

RESULTS

The difference in PHQ-9 score before and after Ramadan was -3.5 points (95% Confidence Interval (CI) -4.05 to -2.95). The difference in PAID score before and after the Ramadan was -5.02 points (95% CI -6.38 to -3.69). For every one year increase in diabetes diagnosis PHQ-9 score decreased by 0.09 (95% CI -0.17 to 0.003) after Ramadan. Female participants had 1.17 more points (95% CI -0.23 to 0.02) decrease in PHQ-9 score compared to male participants.

CONCLUSION

Improving depression in people with diabetes is crucial in controlling blood glucose and metabolic disorder complications in people with diabetes. People with diabetes who experience depression may improve their depression by increasing self discipline, self control, and manage disease.

Experiences of people with type 1 diabetes fasting Ramadan following structured education: A qualitative study

BACKGROUND AND AIMS

Although people with type 1 diabetes are exempt from fasting the month of Ramadan due to the risk to their health, many wish to fast nonetheless. Little is known about the impact of structured education on the fasting experiences of people with type 1 diabetes. This study aimed to explore how the Dose Adjustment for Normal Eating (DAFNE) course affected people with type 1 diabetes' fasting experiences to provide insight into the benefits of structured education for people wishing to fast while managing their diabetes.

METHODS

Semi-structured interviews were conducted with 40 DAFNE graduates who fasted Ramadan. The purposive sample was selected from the DAFNE registry at Dasman Diabetes Institute in Kuwait. The interviews were transcribed verbatim and analysed thematically in an iterative process. Topics discussed included fasting experiences prior to attending the DAFNE course, fasting experiences this year, and how DAFNE affected their fasting.

RESULTS

Five themes emerged; (1) Reduction in fluctuations and complications, (2) Improvement in confidence and self-reliance, (3) Tailored support for dose and pump programming adjustments, (4) Positive effect on wellbeing, and (5) Encouraging informed-decision making about fasting.

CONCLUSIONS

The findings have provided insight into the impact of DAFNE structured education on the fasting experiences of people with type 1 diabetes and has shown how overall, DAFNE had enhanced the quality of fasting. In addition, by assisting them in fulfilling their fasting wishes, DAFNE has had a positive effect on their wellbeing.

Acute effects of air pollution on mortality: A 17-year analysis in Kuwait

BACKGROUND

The health burden from exposure to air pollution has been studied in many parts of the world. However, there is limited research on the health effects of air quality in arid areas where sand dust is the primary particulate pollution source.

OBJECTIVE

Study the risk of mortality from exposure to poor air quality days in Kuwait.

METHODS

We conducted a time-series analysis using daily visibility as a measure of particulate pollution and non-accidental total mortality from January 2000 through December 2016. A generalized additive Poisson model was used adjusting for time trends, day of week, and temperature. Low visibility (yes/no), defined as visibility lower than the 25th percentile, was used as an indicator of poor air quality days. Dust storm events were also examined. Finally, we examined these associations after stratifying by gender, age group, and nationality (Kuwaitis/non-Kuwaitis).

RESULTS

There were 73,748 deaths from natural causes in Kuwait during the study period. The rate ratio comparing the mortality rate on low visibility days to high visibility days was 1.01 (95% CI: 0.99-1.03). Similar estimates were observed for dust storms (1.02, 95% CI: 1.00-1.04). Higher and statistically significant estimates were observed among non-Kuwaiti men and non-Kuwaiti adolescents and adults.

CONCLUSION

We observed a higher risk of mortality during days with poor air quality in Kuwait from 2000 through 2016.

Intermittent Fasting Could Be Safely Achieved in People With Type 1 Diabetes Undergoing Structured Education and Advanced Glucose Monitoring

Background: Fasting during Ramadan is a form of intermittent fasting in which a person abstains from oral intake between the hours of sunrise and sunset. The fasting month of Ramadan is observed by Muslims worldwide. People with type 1 diabetes (T1DM) who choose to fast during Ramadan are at a particularly high risk of acute diabetes complications including hypoglycemia and significant hyperglycemia. We hypothesized that people with uncomplicated T1DM would be able to fast safely during Ramadan following structured education and with daily advanced glucose monitoring. Methods: People with stable and uncomplicated T1DM treated with multiple daily injections (MDIs) or continuous subcutaneous insulin infusion (CSII) who chose to fast during Ramadan were recruited for the study. Participants attended Dose Adjustment for Normal Eating (DAFNE) structured education training, and basal insulin was reduced in a controlled fashion. Participants were assigned a sensor-augmented insulin pump or FreeStyle Libre for advanced glucose monitoring. The primary endpoint was the rate of hypoglycemia during Ramadan compared to before Ramadan. Secondary endpoints were percentage time spent <4 mmol/L, >10 mmol/L (range, 4-10 mmol/L), episodes of diabetic ketoacidosis (DKA), and acute kidney injury or hospitalization for any cause. Results: Rates of hypoglycemia were significantly reduced during Ramadan compared with rates before Ramadan (0.53 ± 0. 49 vs. 0.81 ± 0.69 episodes/day, p = 0.0015). No episodes of severe hypoglycemia, DKA, acute kidney injury, or hospitalization occurred during Ramadan period. Percentage time spent >10 mmol/L (46.7 ± 17.7% vs. 42.5 ± 16.4%, p = 0.03) was significantly increased, and percentage time [range, 4-10 mmol/L (48.8 ± 15.9% vs. 50.9 ± 15.9%, p = 0.13)] and percentage time spent <4 mmol/L (4.7 ± 5.4.7% vs. 5.7 ± 6.3%, p = 0.09) were reduced, but these differences were not significant. Conclusions: People with uncomplicated T1DM could safely participate in intermittent fasting similar to Ramadan fasting if equipped with structured education and advanced glucose monitoring systems.

Caveolin-1 Variant Is Associated With the Metabolic Syndrome in Kuwaiti Children

Caveolin-1 (CAV1) variants have been suggested to be associated with obesity and related metabolic disorders, but information based on human studies is limited. In the present study, we aimed to investigate the potential association between the CAV1 rs1997623 C/A variant and metabolic syndrome (MetS) in Kuwaiti children. DNA from saliva samples collected from 1313 Kuwaiti children (mean age: 12 years) were genotyped using the TaqMan SNP genotyping assay. The classification of MetS was based on the presence/absence of four indicators; (1) central obesity, (2) elevated systolic or diastolic blood pressure, (3) low salivary high-density lipoprotein cholesterol (HDLC), and (4) high salivary glucose. In this study, children with MetS scored ≥3, children in the intermediate metabolic group scored 1 or 2 and children without MetS scored 0. About one-third of the children were obese. A total of 246 children (18.7%) were classified as having MetS; 834 children (63.5%) were in the intermediate metabolic group, and 233 children (17.7%) had no indication of MetS. Obesity was highly prevalent in the MetS group (91.9%) while 26.8% of children were obese in the intermediate metabolic group. None of the children were obese in the group without MetS. Analysis of the CAV1 rs1997623 variant revealed a significant association of the A-allele (p = 0.01, Odds Ratio (OR) = 1.66) and the heterozygous CA-genotype (p = 0.005, OR = 1.88) with MetS. Consistently, the A-allele (p = 0.002, OR = 1.71) and CA-genotype (p = 0.005, OR = 1.70) also showed significant association with the intermediate metabolic group. Furthermore, the A-allele (p = 0.01, OR = 1.33) and the CA-genotype (p = 0.008, OR = 1.55) were associated with low levels of saliva HDLC. Individuals who were heterozygous or homozygous for the variant (CA/AA) showed significantly lower levels of high HDLC compared to those harboring the CC-genotype (p = 0.023). Our study revealed a novel association of the CAV1 rs1997623 variant with the MetS and with low saliva HDLC levels in young Kuwaiti children and indicated the need for further in-depth studies to unravel the role of CAV1 gene in the genetic etiology of MetS.