Insulin and aging - a disappointing relationship

Experimental studies in animal models of aging such as nematodes, fruit flies or mice have observed that decreased levels of insulin or insulin signaling promotes longevity. In humans, hyperinsulinemia and concomitant insulin resistance are associated with an elevated risk of age-related diseases suggestive of a shortened healthspan. Age-related disorders include neurodegenerative diseases, hypertension, cardiovascular disease, and type 2 diabetes. High ambient insulin concentrations promote increased lipogenesis and fat storage, heightened protein synthesis and accumulation of non-functional polypeptides due to limited turnover capacity. Moreover, there is impaired autophagy activity, and less endothelial NO synthase activity. These changes are associated with mitochondrial dysfunction and oxidative stress. The cellular stress induced by anabolic activity of insulin initiates an adaptive response aiming at maintaining homeostasis, characterized by activation of the transcription factor Nrf2, of AMP activated kinase, and an unfolded protein response. This protective response is more potent in the long-lived human species than in short-lived models of aging research resulting in a stronger pro-aging impact of insulin in nematodes and fruit flies. In humans, resistance to insulin-induced cell stress decreases with age, because of an increase of insulin and insulin resistance levels but less Nrf2 activation. These detrimental changes might be contained by adopting a lifestyle that promotes low insulin/insulin resistance levels and enhances an adaptive response to cellular stress, as observed with dietary restriction or exercise.

Effectiveness of the Telemedical Lifestyle Intervention Program TeLIPro for Improvement of HbA1c in Type 2 Diabetes: A Randomized-Controlled Trial in a Real-Life Setting

The effectiveness of the multimodal Telemedical Lifestyle Intervention Program (TeLIPro) was proven in the advanced stages of type 2 diabetes mellitus (T2DM). Since its therapeutic potential focusing on telemedical coaching without using a formula diet is unknown, we evaluated improvements in HbA1c, HbA1c normalisation rate, cardiometabolic risk factors, quality-of-life, and eating behaviour in real life. In this randomized-controlled trial, AOK Rhineland/Hamburg insured T2DM patients (n = 1163) were randomized (1:1) into two parallel groups, and 817 received the allocated intervention. In addition to routine care, all participants got scales, step counters, and access to an online portal. The TeLIPro group additionally received equipment for self-monitoring of blood glucose and telemedical coaching. Data were collected at baseline, after 6 and 12 months of intervention as well as after a 6-month follow-up. The primary endpoint after 12 months was (i) the estimated treatment difference (ETD) in HbA1c change and (ii) the HbA1c normalisation rate in those with diabetes duration < 5 years. The TeLIPro group demonstrated significantly stronger improvements in HbA1c (ETD -0.4% (-0.5; -0.2); p < 0.001), body weight, body-mass-index, quality-of-life, and eating behaviour, especially in T2DM patients with diabetes duration ≥ 5 years (ETD -0.5% (-0.7; -0.3); p < 0.001). The HbA1c normalisation rate did not significantly differ between groups (25% vs. 18%). Continuous addition of TeLIPro to routine care is effective in improving HbA1c and health-related lifestyle in T2DM patients with longer diabetes duration in real life.

Field trial: disinfection of contaminated anesthetic masks for piglets

This paper aimed to assess the success of cleaning and disinfection on microbiological contamination of anesthetic masks, which were used for automated isoflurane anesthesia for surgical castration of male piglets. Data collection took place on 11 farms in Southern Germany between September 2020 and June 2022. Each farm was visited three times (one farm having two different anesthesia devices was visited six times), and microbiological assessments took place at four sample points (SP): after unpacking the masks (SP0), after disinfection before anesthesia (SP1), after anesthesia of all piglets to be castrated in this run (SP2), and after disinfection after anesthesia (SP3). The microbiological assessment included the determination of total bacteria count, total count of hemolytic and non-hemolytic mesophilic aerotolerant bacteria and a qualitative detection of indicator bacteria Escherichia (E.) coli, extended-spectrum beta-lactamase-producing E. coli (ESBL) and methicillin-resistant Staphylococcus aureus (MRSA). For analysis, a generalized linear mixed model was applied using farms and farm visits as random effects and sampling points nested in farm visits as fixed effect. The fixed effect was highly significant for all three variables (total bacteria count, total count of hemolytic and non-hemolytic mesophilic aerotolerant bacteria) (p < 0.001). The bacterial counts at SP0 were about the same as at SP3. Concerning indicator bacteria, their presence was highest at SP2 and lowest at SP3. No indicator bacteria were present at SP1. It can be concluded that disinfection of anesthetic masks, especially before performing anesthesia, may effectively protect piglets of the following batch against unwanted transmission of pathogens. These findings will help farmers plan cleaning and disinfection activities.

[Diabetes and cardiovascular health literacy in childhood and adolescence - a 12-year follow-up]

BACKGROUND

 The incidence of diabetes mellitus and cardiovascular diseases is increasing worldwide and also in Germany. The aim of the study was to assess the health literacy regarding these diseases in childhood and adolescence.

METHODS

 Students of the 5^th-12^th grade (grammar school ("Gymnasium"), secondary school forms ("Realschule" and "Hauptschule")) were interviewed in 2007 (n = 4383) and 2019 (n = 572) about diabetes and secondary complications. In addition, questions about other cardiovascular risk factors were asked in 2019.

RESULTS

 Diabetes-related questions were answered correctly by 56 % in 2007 as well as 53 % in 2019. Among others, 70 % (2007) as well as 75 % (2019) of the students stated "ate too much sugar" as a cause for type 1 diabetes. Further, questions about major risk factors for heart attack and stroke were answered correctly by only 33 % (for diabetes) and 43 %-53 % (for smoking) of students.Across all questions, a positive association indicated between the rate of correct answers and the educational level of the school institution; however, the differences remained marginal at 5-19 % between Gymnasium and Hauptschule or Realschule at both survey time points. A difference between genders was indicated in 2007 (girls: 59 % vs. boys: 52 %) and 2019 (girls: 56 % vs. boys: 51 %).

CONCLUSION

 Changes in health literacy regarding diabetes and other cardiovascular risk factors among 5^th-12^th grade students over the past 12 years could not be observed. The assumed self-infliction of type 1 diabetes may be perceived as discrimination by those affected.

A High-Protein and Low-Glycemic Formula Diet Improves Blood Pressure and Other Hemodynamic Parameters in High-Risk Individuals

Low-caloric formula diets can improve hemodynamic parameters of patients with type 2 diabetes. We, therefore, hypothesized that persons with overweight or obesity can benefit from a high-protein, low-glycemic but moderate-caloric formula diet. This post-hoc analysis of the Almased Concept against Overweight and Obesity and Related Health Risk- (ACOORH) trial investigated the impact of a lifestyle intervention combined with a formula diet (INT, n = 308) compared to a control group with lifestyle intervention alone (CON, n = 155) on hemodynamic parameters (systolic and diastolic blood pressure (SBP, DBP), resting heart rate (HR), and pulse wave velocity (PWV)) in high-risk individuals with prehypertension or hypertension. INT replaced meals during the first 6 months (1 week: 3 meals/day; 2−4 weeks: 2 meals/day; 5−26 weeks: 1 meal/day). Study duration was 12 months. From the starting cohort, 304 (68.3%, INT: n = 216; CON: n = 101) participants had a complete dataset. Compared to CON, INT significantly reduced more SBP (−7.3 mmHg 95% CI [−9.2; −5.3] vs. −3.3 mmHg [−5.9; −0.8], p < 0.049) and DBP (−3.7 mmHg [−4.9; −2.5] vs. −1.4 mmHg [−3.1; 0.2], p < 0.028) after 12 months. Compared to CON, INT showed a pronounced reduction in resting HR and PWV after 6 months but both lost significance after 12 months. Changes in SBP, DBP, and PWV were significantly associated positively with changes in body weight and fat mass (all p < 0.05) and resting HR correlated positively with fasting insulin (p < 0.001) after 12 months. Combining a lifestyle intervention with a high-protein and low-glycemic formula diet improves hemodynamic parameters to a greater extent than lifestyle intervention alone in high-risk individuals with overweight and obesity.

Ketone bodies: from enemy to friend and guardian angel

During starvation, fasting, or a diet containing little digestible carbohydrates, the circulating insulin levels are decreased. This promotes lipolysis, and the breakdown of fat becomes the major source of energy. The hepatic energy metabolism is regulated so that under these circumstances, ketone bodies are generated from β-oxidation of fatty acids and secreted as ancillary fuel, in addition to gluconeogenesis. Increased plasma levels of ketone bodies thus indicate a dietary shortage of carbohydrates. Ketone bodies not only serve as fuel but also promote resistance to oxidative and inflammatory stress, and there is a decrease in anabolic insulin-dependent energy expenditure. It has been suggested that the beneficial non-metabolic actions of ketone bodies on organ functions are mediated by them acting as a ligand to specific cellular targets. We propose here a major role of a different pathway initiated by the induction of oxidative stress in the mitochondria during increased ketolysis. Oxidative stress induced by ketone body metabolism is beneficial in the long term because it initiates an adaptive (hormetic) response characterized by the activation of the master regulators of cell-protective mechanism, nuclear factor erythroid 2-related factor 2 (Nrf2), sirtuins, and AMP-activated kinase. This results in resolving oxidative stress, by the upregulation of anti-oxidative and anti-inflammatory activities, improved mitochondrial function and growth, DNA repair, and autophagy. In the heart, the adaptive response to enhanced ketolysis improves resistance to damage after ischemic insults or to cardiotoxic actions of doxorubicin. Sodium-dependent glucose co-transporter 2 (SGLT2) inhibitors may also exert their cardioprotective action via increasing ketone body levels and ketolysis. We conclude that the increased synthesis and use of ketone bodies as ancillary fuel during periods of deficient food supply and low insulin levels causes oxidative stress in the mitochondria and that the latter initiates a protective (hormetic) response which allows cells to cope with increased oxidative stress and lower energy availability. KEYWORDS: Ketogenic diet, Ketone bodies, Beta hydroxybutyrate, Insulin, Obesity, Type 2 diabetes, Inflammation, Oxidative stress, Cardiovascular disease, SGLT2, Hormesis.

The Epidemiological Boehringer Ingelheim Employee Study (Part 3): Association of Elevated Fasting Insulin Levels but Not HOMA-IR With Increased Intima Media Thickness and Arteriosclerosis in Middle-Aged Persons

Background: Recently published genetic studies have indicated a causal link between elevated insulin levels and cardiovascular disease (CVD) risk. We, therefore, hypothesized that increased fasting insulin levels are also associated with precursors of CVD such as endothelial lesions. Methods: Middle-aged (≥40 years, n = 1,639) employees were followed up for the occurrence of increased intima media thickness (IMT ≥ 1 mm) or plaques in abdominal or cervical arteries (arteriosclerosis). Multivariable logistic regression analyses determined the incidence of increased IMT or arteriosclerosis. Adjusted relative risk (ARR) for increased IMT and arteriosclerosis was calculated by using Mantel-Haenszel analysis. Results: Increased IMT was diagnosed in 238 participants (15 %) and 328 (20 %) developed arteriosclerosis after 5 years of follow-up. Logistic regression analysis identified fasting insulin, BMI and smoking as risk factors for both cardiovascular endpoints (all p < 0.05), whereas age and diastolic blood pressure were risk factors for increased IMT only, and male sex was associated with incident arteriosclerosis only (all p < 0.01). Additional adjustment for BMI change during follow-up did not modify these associations (including fasting insulin), but adjustment for fasting insulin change during follow-up removed BMI as risk factor for both cardiovascular endpoints. Fasting insulin change during follow-up but not BMI change associated with increased IMT and arteriosclerosis (both p < 0.001). ARR analysis indicated that high fasting insulin and BMI added to age and sex as risk factors. Homeostatic model assessment of insulin resistance (HOMA-IR) did not associate with either cardiovascular endpoint in any model and smoking did not increase the risk conferred by high fasting insulin levels. Conclusions: Higher fasting insulin levels and increases in fasting insulin over time are associated with atherogenic progression and supersede BMI as well as HOMA-IR as risk factors.

Coffee and Lower Risk of Type 2 Diabetes: Arguments for a Causal Relationship

Prospective epidemiological studies concur in an association between habitual coffee consumption and a lower risk of type 2 diabetes. Several aspects of these studies support a cause–effect relationship. There is a dependency on daily coffee dose. Study outcomes are similar in different regions of the world, show no differences between sexes, between obese versus lean, young versus old, smokers versus nonsmokers, regardless of the number of confounders adjusted for. Randomized controlled intervention trials did not find a consistent impact of drinking coffee on acute metabolic control, except for effects of caffeine. Therefore, lowering of diabetes risk by coffee consumption does not involve an acute effect on the post-meal course of blood glucose, insulin or insulin resistance. Several studies in animals and humans find that the ingestion of coffee phytochemicals induces an adaptive cellular response characterized by upregulation and de novo synthesis of enzymes involved in cell defense and repair. A key regulator is the nuclear factor erythroid 2-related factor 2 (Nrf2) in association with the aryl hydrocarbon receptor, AMP-activated kinase and sirtuins. One major site of coffee actions appears to be the liver, causing improved fat oxidation and lower risk of steatosis. Another major effect of coffee intake is preservation of functional beta cell mass via enhanced mitochondrial function, lower endoplasmic reticulum stress and prevention or clearance of aggregates of misfolded proinsulin or amylin. Long-term preservation of proper liver and beta cell function may account for the association of habitual coffee drinking with a lower risk of type 2 diabetes, rather than acute improvement of metabolic control.

Weight Reduction by the Low-Insulin-Method-A Randomized Controlled Trial

Continuous high insulin levels are associated with weight gain and lead to cardiometabolic diseases. Therefore, we have developed the Low-Insulin-Method and integrated it into the multi-component, occupational healthcare program SHAPE-AND-MOTION-Medical-Accompanied-Slimming (SAMMAS) to reduce daily insulin levels for long-term weight reduction in overweight or obesity. Employees were randomized into a starting intervention group (SI, n = 15) or waiting list control group (WL, n = 15). SAMMAS consisted of group-based seminars, low-carbohydrate nutrition including formula diet, continuous glucose monitoring, telemetric monitoring, and telemedical coaching. Both groups received telemetric devices at baseline. Intention-to-treat analyses were performed after 12, 26, and 52 weeks. The estimated treatment difference in weight reduction after 12 weeks, which is the primary endpoint of the study, showed a pronounced effect in favour of SI (−6.3 kg with (95% confidence interval) (−7.4; −4.5) (p < 0.001)) after 12 weeks. Furthermore, SI improved fasting blood glucose, HbA1c, quality of life, fasting insulin, blood pressure, and eating behaviour (all p < 0.05) in the within-group analysis, while WL did not. After 26 and 52 weeks, weight reduction could be maintained in the whole group (both groups together) by −6.7 kg (−9.5; −3.8) (p < 0.001) and −6.1 kg (−9.2; −2.7) (p < 0.01). SAMMAS supports clinically relevant weight reduction and long-term weight loss maintenance in individuals with overweight or obesity.

Health Effects of Coffee: Mechanism Unraveled?

The association of habitual coffee consumption with a lower risk of diseases, like type 2 diabetes mellitus, chronic liver disease, certain cancer types, or with reduced all-cause mortality, has been confirmed in prospective cohort studies in many regions of the world. The molecular mechanism is still unresolved. The radical-scavenging and anti-inflammatory activity of coffee constituents is too weak to account for such effects. We argue here that coffee as a plant food has similar beneficial properties to many vegetables and fruits. Recent studies have identified a health promoting mechanism common to coffee, vegetables and fruits, i.e., the activation of an adaptive cellular response characterized by the upregulation of proteins involved in cell protection, notably antioxidant, detoxifying and repair enzymes. Key to this response is the activation of the Nrf2 (Nuclear factor erythroid 2-related factor-2) system by phenolic phytochemicals, which induces the expression of cell defense genes. Coffee plays a dominant role in that regard because it is the major dietary source of phenolic acids and polyphenols in the developed world. A possible supportive action may be the modulation of the gut microbiota by non-digested prebiotic constituents of coffee, but the available data are still scarce. We conclude that coffee employs similar pathways of promoting health as assumed for other vegetables and fruits. Coffee beans may be viewed as healthy vegetable food and a main supplier of dietary phenolic phytochemicals.

Determination of Postprandial Glycemic Responses by Continuous Glucose Monitoring in a Real-World Setting

BACKGROUND

Self-monitoring of blood glucose using capillary glucose testing (C) has a number of shortcomings compared to continuous glucose monitoring (CGM). We aimed to compare these two methods and used blood glucose measurements in venous blood (IV) as a reference. Postprandial blood glucose levels were measured after 50 g oral glucose load and after the consumption of a portion of different foods containing 50 g of carbohydrates. We also evaluated the associations between postprandial glucose responses and the clinical characteristics of the participants at the beginning of the study.

METHODS

12 healthy volunteers (age: 36 ± 17 years, BMI: 24.9 ± 3.5 kg/m²) ate white bread (WB) and whole grain (WG) bread and drank a 50 g glucose drink as reference. Postprandial glucose responses were evaluated by CGM, IV and C blood glucose measurements. Incremental area under the curve (AUC_i) of postprandial blood glucose was calculated for 1 h (AUC_{i 0-60}) and 2 h (AUC_{i 0-120}).

RESULTS

After the consumption of white bread and whole grain bread, the AUC_{i 0-60 min} did not differ between CGM and IV or C. AUC_{i 0-120 min} of CGM showed no difference compared to C. Correlation analyses revealed a positive association of age with glucose AUC_{i 0-120} (r = 0.768; P = 0.004) and WG AUC_{i 0-120} (r = 0.758; P = 0.004); fasting blood glucose correlated with WG AUC_{i 0-120} (r = 0.838; P < 0.001).

CONCLUSION

Despite considerable inter-individual variability of postprandial glycemic responses, CGM evaluated postprandial glycemic excursions which had comparable results compared to standard blood glucose measurements under real-life conditions. Associations of AUC_{i 0-60} and AUC_{i 0-120} postprandial glucose response with age or fasting blood glucose could be shown.

Telemedical coaching for weight loss in overweight employees: a three-armed randomised controlled trial

OBJECTIVES

We examined the effect of a telemedical coaching (TMC) programme accompanied with or without telemonitoring on weight loss in an occupational healthcare setting with a three-armed randomised controlled trial (NCT01837134 'Pre-results').

METHODS

Overweight employees (n=104, body mass index [BMI] ≥25 kg/m²) were invited by their medical corporate department and randomised into either a TMC group (n=34) or in one of the two control groups (C1, n=34; C2, n=36). TMC and C1 were equipped with telemonitoring devices (scales and pedometers) at baseline, and C2 after 6 months. Telemonitoring devices automatically transferred data into a personalised online portal. TMC was coached with weekly care calls in months 3-6 and monthly calls from months 7 to 12. C2 had a short coaching phase in months 6-9. C1 received no further support. After the 12-month intervention phase, participants could take advantage of further company health promotion offers. Follow-up data were determined after 12 months of intervention and per-protocol (PP) and intention-to-treat (ITT) analyses were performed. Weight change was followed up after 36 months. Estimated treatment difference (ETD) was calculated for weight reduction.

RESULTS

ETD from TMC to C1 (-3.6 kg 95% CI -7.40 to -0.1, p=0.047) and to C2 (-4.2 kg [-7.90 to -0.5], p=0.026) was significantly different at the 12 months follow-up in the PP-analysis, but lost significance in the ITT analysis. All groups reduced weight after 12 months (-3.3 to -8.4 kg [5.5-10.3 kg], all p<0.01) and sustained it during the 36 months follow-up (-4.8 to -7.8 kg [5.6-12.8 kg], all p<0.01). ETD analyses revealed no difference between all groups neither in the PP nor in the ITT analysis at the 3 years follow-up. All groups reduced BMI, systolic and diastolic blood pressure and improved eating behaviour in the PP or ITT analyses.

CONCLUSIONS

TMC and/or telemonitoring support long-term weight reduction in overweight employees. The combination of both interventions points towards an additional effect.

TRIAL REGISTRATION NUMBER

NCT01837134.

TeDia - A Telemedicine-Based Treatment Model for Inpatient and Interprofessional Diabetes Care

INTRODUCTION

The proportion of hospitalized patients with diabetes as a secondary diagnosis increases continuously. Therefore, we have developed a team-based interprofessional and telemedicine-based diabetes management system named TeDia ("Telemedical Diabetology") and implemented it in an inpatient setting. The aim of the retrospective real-world study was to show the clinical impact of TeDia following its implementation.

MATERIAL AND METHODS

TeDia is characterized by an interpersonal and telemedicine-based exchange of hospital routine data between specially trained nurses ("diabetes managers") and external diabetologists. It was implemented in three acute hospitals of the Düsseldorf Catholic Hospital Group in Düsseldorf, Germany. Clinical awareness of diabetes, diabetes-related complications and diagnosis-related group (DRG)-based revenues were analyzed using ICD routine coding. Furthermore, the frequency of HbA1c determinations as well as hospitalization days were investigated.

RESULTS

Before (2010), during (2012) and after the implementation of TeDia (2014), the number of patients with ICD coding for diabetes, decompensated diabetes, diabetic neuropathy, diabetic nephropathy as well as complicated diabetes increased by +18%, +93%, +101%, +113% and +89%, respectively. Using the same DRG grouper, revenues increased by +53% (from 27 (2013) to 42 (2014) DRG points). Frequency of HbA1c determinations rose by +85%, whereas the time for an average length of stay decreased by -12% (-0, 91 days) in comparison to patients without diabetes.

CONCLUSION

TeDia improved clinical awareness for diabetes and its complications. This new treatment model increased revenues and reduced hospital days indicating enhanced treatment quality. Our findings emphasize the necessity of novel technologies in inpatient settings for the improvement of efficacy, safety and efficiency of diabetes care.

Insulin translates unfavourable lifestyle into obesity

Lifestyle factors conferring increased diabetes risk are associated with elevated basal insulin levels (hyperinsulinaemia). The latter predicts later obesity in children and adolescents.A causal role of hyperinsulinaemia for adipose tissue growth is probable because pharmacological reduction of insulin secretion lowers body weight in people who are obese. Genetic inactivation of insulin gene alleles in mice also lowers their systemic insulin levels and prevents or ameliorates high-fat diet-induced obesity. Hyperinsulinaemia causes weight gain because of a physiological property of insulin. Insulin levels that are on the high side of normal, or which are slightly elevated, are sufficient to suppress lipolysis and promote lipogenesis in adipocytes. The effect of insulin on glucose transport or hepatic glucose production requires six or two times higher hormone levels, respectively.It seems justified to suggest a lifestyle that avoids high insulin levels in order to limit anabolic fat tissue activity.

Individualized Meal Replacement Therapy Improves Clinically Relevant Long-Term Glycemic Control in Poorly Controlled Type 2 Diabetes Patients

Background Formula diets can improve glycemic control or can even induce remission in type 2 diabetes. We hypothesized that especially an individualized intense meal replacement by a low-carbohydrate formula diet with accompanied self-monitoring of blood glucose (SMBG) contributes to long-term improvements in HbA1c, weight, and cardiometabolic risk factors in poorly controlled type 2 diabetes. Methods Type 2 diabetes patients were randomized into either a moderate group (M-group) with two meal replacements/day (n = 160) or a stringent group (S-group) with three meal replacements/day (n = 149) during the first week of intervention (1300⁻1500 kcal/day). Subsequently, both groups reintroduced a low-carbohydrate lunch based on individual adaption due to SMBG in weeks 2⁻4. After week 4, breakfast was reintroduced until week 12. During the follow-up period, all of the participants were asked to continue replacing one meal per day until the 52-weeks follow-up. Additionally, an observational control group (n = 100) remained in routine care. Parameters were compared at baseline, after 12 and 52 weeks within and between all of the groups. Results 321 participants (83%) completed the acute meal replacement phase after 12 weeks and 279 participants (72%) the whole intervention after 52 weeks. Both intervention groups achieved improvements in HbA1c, fasting blood glucose, blood pressure, and weight (all p < 0.001) within 12 weeks. However, these results were not significantly different between both of the intervention groups. The estimated treatment difference in HbA1c reduction was (mean (95% confidence interval [CI]) -0.10% with 95% CI [-0.40; 0.21] also (p > 0.05) (S-group vs. M-group) not statistically different after 12 weeks. However, only the S-group showed a clinically relevant improvement in HbA1c of -0.81% [-1.06; -0.55] (p < 0.001) after 52 weeks of follow-up, whereas HbA1c was not statistically different between the M- and control group. Conclusion Individualized meal replacement with SMBG demonstrated beneficial effects on HbA1c and cardiometabolic parameters in type 2 diabetes. Furthermore, the initiation of a weight loss program with one week of full meal replacement (three meals per day) resulted in a clinically relevant long-term HbA1c reduction, as compared to an observational control group that had standard care.

Efficacy of the Telemedical Lifestyle intervention Program TeLiPro in Advanced Stages of Type 2 Diabetes: A Randomized Controlled Trial

OBJECTIVE

Lifestyle interventions are the foundation of treatment in newly diagnosed type 2 diabetes. However, their therapeutic potential in advanced disease stages is unknown. We evaluated the efficacy of the Telemedical Lifestyle intervention Program (TeLiPro) in improving metabolic control in advanced-stage type 2 diabetes.

RESEARCH DESIGN AND METHODS

In this single-blind, active comparator, intervention study, patients with type 2 diabetes (with glycated hemoglobin [HbA_1c] ≥7.5% [58.5 mmol/mol]), and BMI ≥27 kg/m² and on ≥2 antidiabetes medications) were recruited in Germany and randomized 1:1 using an electronically generated random list and sealed envelopes into two parallel groups. The data analyst was blinded after assignment. The control group (n = 100) got weighing scales and step counters and remained in routine care. The TeLiPro group (n = 102) additionally received telemedical coaching including medical-mental motivation, a formula diet, and self-monitored blood glucose for 12 weeks. The primary end point was the estimated treatment difference in HbA_1c reduction after 12 weeks. All available values per patient (n = 202) were analyzed. Analyses were also performed at 26 and 52 weeks of follow-up.

RESULTS

HbA_1c reduction was significantly higher in the TeLiPro group (mean ± SD -1.1 ± 1.2% vs. -0.2 ± 0.8%; P < 0.0001). The estimated treatment difference in the fully adjusted model was 0.8% (95% CI 1.1; 0.5) (P < 0.0001). Treatment superiority of TeLiPro was maintained during follow-up (week 26: 0.6% [95% CI 1.0; 0.3], P = 0.0001; week 52: 0.6% [0.9; 0.2], P < 0.001). The same applies for secondary outcomes: weight (TeLiPro -6.2 ± 4.6 kg vs. control -1.0 ± 3.4 kg), BMI (-2.1 ± 1.5 kg/m² vs. -0.3 ± 1.1 kg/m²), systolic blood pressure (-5.7 ± 15.3 mmHg vs. -1.6 ± 13.8 mmHg), 10-year cardiovascular disease risk, antidiabetes medication, and quality of life and eating behavior (P < 0.01 for all). The effects were maintained long-term. No adverse events were reported.

CONCLUSIONS

In advanced-stage type 2 diabetes, TeLiPro can improve glycemic control and may offer new options to avoid pharmacological intensification.

The Boehringer Ingelheim employee study (Part 2): 10-year cardiovascular diseases risk estimation

BACKGROUND

Cardiovascular disease (CVD) may cause an economic burden to companies, but CVD risk estimations specific to working populations are lacking.

AIMS

To estimate the 10-year CVD risk in the Boehringer Ingelheim (BI) employee cohort and analyse the potential effect of hypothetical risk reduction interventions.

METHODS

We estimated CVD risk using the Framingham (FRS), PROCAM (PRS) and Reynolds (RRS) risk scores, using cross-sectional baseline data on BI Pharma employees collected from 2005 to 2011. Results were compared using Fisher's exact and Wilcoxon tests. The predictive ability of the score estimates was assessed using receiver-operating characteristics analyses.

RESULTS

Among the 4005 study subjects, we estimated 10-year CVD risks of 35% (FRS), 9% (PRS) and 6% (RRS) for men and 10% (FRS), 4% (PRS) and 1% (RRS) for women. One hundred and thirty-four (6%) men and 111 (6%) women employees had current CVD. The best predictors of prevalent CVD were the FRS and the RRS for men [area-under-the-curve 0.62 (0.57-0.67) for both]. A hypothetical intervention that would improve systolic blood pressure, HbA1c (for diabetes), C-reactive protein, triglycerides and total and high-density lipoprotein cholesterol by 10% each would potentially reduce expected CVD cases by 36-41% in men and 30-45% in women, and if smoking cessation is incorporated, by 39-45% and 30-55%, respectively, depending on the pre-intervention risk score.

CONCLUSIONS

There was a substantial risk of developing CVD in this working cohort. Occupational health programmes with lifestyle interventions for high-risk individuals may be an effective risk reduction measure.

Autonomous exercise game use improves metabolic control and quality of life in type 2 diabetes patients - a randomized controlled trial

BACKGROUND

Lifestyle intervention in type 2 diabetes mellitus (T2DM) is effective but needs a special local setting and is costly. Therefore, in a randomized-controlled trial we tested the hypothesis that the autonomous use of the interactive exercise game Wii Fit Plus over a period of 12 weeks improves metabolic control, with HbA1c reduction as the primary outcome, and weight loss, reduction of cardiometabolic risk factors, physical activity and quality of life (secondary outcomes) in T2DM patients.

METHODS

Participants (n = 220) were randomized into an intervention and a control group. The intervention group was provided with a Wii console, a balance board and the exercise game Wii Fit Plus for 12 weeks. The control group remained under routine care and received the items 12 weeks later. At baseline and after 12 weeks (and for the control group additionally after 12 weeks of intervention) the participants' health parameters, medication, physical activity and validated questionnaires for quality of life (PAID, SF12, WHO-5, CES-D) were requested and compared in a complete case analysis using the Mann-Whitney test and the Wilcoxon signed rank test.

RESULTS

80% of participants completed the 12-week study. Patients in the intervention group significantly improved HbA1c (from 7.1 ± 1.3% to 6.8 ± 0.9%; -0.3 ± 1.1%; p = 0.0002) in comparison to the control group (from 6.8 ± 0.9% to 6.7 ± 0.7%; -0.1 ± 0.5%) and also significantly reduced fasting blood glucose (from 135.8 ± 38.9 mg/dl to 126.6 ± 36.6 mg/dl; p = 0.04), weight (from 97.6 ± 19.2 kg to 96.3 ± 18.7 kg; p < 0.001) and body mass index (from 34.1 ± 6.5 kg/m2 to 33.5 ± 6.5 kg/m2; p < 0.001). Daily physical activity increased significantly (p < 0.001). Diabetes-dependent impairment, mental health, subjective wellbeing and quality of life also improved significantly, and the number of patients with depression decreased. Similar improvements were seen in the control group after exercise game intervention.

CONCLUSIONS

In this trial a low-threshold intervention with the interactive exercise game Wii Fit Plus was able to motivate T2DM patients to improve physical activity, glucometabolic control and quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01735643.

Meal replacement reduces insulin requirement, HbA1c and weight long-term in type 2 diabetes patients with >100 U insulin per day

BACKGROUND

Despite high insulin doses, good glycaemic control is often lacking in type 2 diabetes patients and new therapeutic options are needed.

METHODS

In a proof of principle study, an energy-restricted, protein-rich meal replacement (PRMR) was examined as a means of reducing insulin requirement, HbA1C and body weight. Obese type 2 diabetes patients (n = 22) with >100 U insulin per day replaced, in week 1, the three main meals with 50 g of PRMR (Almased-Vitalkost) each (= 4903 kJ day(-1) ). In weeks 2-4, breakfast and dinner were replaced, and, in weeks 5-12, only dinner was replaced. Clinical parameters were determined at baseline, and after 4, 8 and 12 weeks, as well as after 1.5 years of follow-up. The Wilcoxon signed-rank test was used for the intention-to-treat analysis and the Mann-Whitney U-test for subgroup analyses.

RESULTS

The 12-week-programme was completed by 15 participants (68%). After 1 week, the mean insulin dose was reduced from 147 (75) U to 91 (55) U day(-1) (P = 0.0001), and to 65 (32) U (P < 0.0001) after 12 weeks of study. Over a period of 12 weeks, HbA1c decreased from 8.8% (1.4%) to 8.1% (1.6%) (P = 0.048) and weight decreased from 118.0 (19.7) kg to 107.4 (19.2) kg (P < 0.0001). Moreover, body mass index, waist and hip circumference, fasting blood glucose, triglycerides and high-density lipoprotein cholesterol improved significantly. After 1.5 years, insulin requirement and weight remained significantly lower than baseline. Participants who continued PRMR further reduced their HbA1c, weight and insulin dose. Two patients were able to stop insulin therapy altogether.

CONCLUSIONS

Energy-restricted PRMR was effective in reducing insulin requirement of type 2 diabetes patients with intensified insulin therapy accompanied by a reduction of HbA1c, weight and other cardiometabolic risk factors. With the continuous use of PRMR, glycaemic control might be improved in the long term.

[Diagnostic accuracy of a standardized carbohydrate-rich breakfast compared to an oral glucose tolerance test in occupational medicine]

BACKGROUND

Increasing prevalence of type 2 diabetes mellitus is not only a problem for the health care system but also impairs working environment. In order to reduce costs by illness and early retirement and the development of diabetic complications occupational medicine is important for early diabetes detection. However, the diagnostic gold standard, oral glucose tolerance test (oGTT), is rarely accepted. Aim of our investigation was to evaluate diagnostic accuracy of a standardizable and cost-effective test-breakfast in comparison to oGTT which might be accepted in workplace.

METHODS

During a workplace health promotion program diagnostic accuracy (sensitivity and specificity) of a test-breakfast (index test) was analyzed in a random-cross-over-design with healthy volunteers in comparison to an oGTT (reference test).

RESULTS

278 subjects participated and rated the health promotion program to be useful (99%). 74% stated that they preferred the test-breakfast in contrast to the oGTT. Both screening methods showed comparable plasma glucose and insulin curves. The plasma glucose levels measured capillary and venously during test-breakfast and oGTT were very consistent. Differences were only seen for the 2 h plasma glucose values in the fully adjusted model. The test-breakfast demonstrated high sensitivity and specificity for diabetes diagnosis compared to the reference test with highly comparable results, i. e. 8 persons (2,9%) newly diagnosed with diabetes by the test-breakfast vs. 7 (2,5%) by oGTT.

CONCLUSION

A test-breakfast seems to be a useful first screening instrument to increase the compliance of occupational health promotions and might improve early diabetes diagnosis.

Sfrp5 correlates with insulin resistance and oxidative stress

BACKGROUND

Secreted frizzled-related protein 5 (Sfrp5) has been described as novel adipokine in mice with insulin-sensitising and anti-inflammatory properties similar to adiponectin. The aim of this study was to compare serum concentrations and determinants of Sfrp5, its pro-inflammatory antagonist wingless-type MMTV integration site family member (Wnt)5a and adiponectin in humans and their regulation by coffee.

MATERIAL AND METHODS

Serum concentrations of Sfrp5, Wnt5a and adiponectin were measured in 47 individuals who participated in a coffee intervention study. Associations with demographic, metabolic and immunological variables and regulation of serum levels by different amounts of daily coffee intake were analysed.

RESULTS

At baseline, fasting serum Sfrp5 levels ranged between 96 and 4056 ng/mL. Sfrp5 was directly correlated with a surrogate of insulin resistance (homeostasis model assessment of insulin resistance/HOMA-IR; r = 0·32, P < 0·05) and with the oxidative stress markers 8-isoprostane (r = 0·44, P < 0·01) and nitrotyrosine (r = 0·52, P < 0·001). Adiponectin showed inverse correlations with several indices of insulin resistance (e.g. HOMA-IR, Stumvoll index; all P < 0·05) and a direct correlation with the anti-atherogenic apolipoprotein A-I (r = 0·56, P < 0·001). Coffee did not affect serum concentrations of Sfrp5. Serum Wnt5a concentrations were below the detection limit (0·02 ng/mL) in 81% of the study participants.

CONCLUSIONS

In contrast to obese mouse models, serum Sfrp5 was directly related to HOMA-IR and oxidative stress in humans, but not with apolipoproteins, and thus, associations differed from those found for circulating adiponectin. These differences between Sfrp5 and adiponectin might be explained by differences in the investigated species.

ROSSO-in-praxi-international: long-term effects of self-monitoring of blood glucose on glucometabolic control in patients with type 2 diabetes mellitus not treated with insulin

BACKGROUND

Effects of lifestyle change on blood glucose levels can be monitored by self-monitoring of blood glucose (SMBG) in type 2 diabetes mellitus (T2DM) patients. We analyzed whether the SMBG-structured lifestyle intervention program ROSSO-in-praxi-international can improve glucometabolic control in the short and the long term.

SUBJECTS AND METHODS

One hundred twenty-four SMBG-naive ambulatory non-insulin-treated T2DM patients were randomly assigned to an SMBG group (n=63) and a control group (n=61). Both groups received a 12-week structured lifestyle guidance manual. The SMBG group additionally got a blood glucose meter with 150 test strips and was instructed to measure blood glucose regularly as well as event-driven. Glucometabolic parameters were assessed at baseline, after 12 weeks, and after 1.5 years.

RESULTS

During the 12 weeks of intervention the SMBG group significantly improved glycated hemoglobin (HbA1c) levels (from 7.4 ± 1.6% to 6.9 ± 1.1% [P<0.001]) and weight (-0.9 ± 1.9 kg [P<0.05]), whereas HbA1c reduction (from 7.5 ± 1.0% to 7.3 ± 1.0%) and weight loss (-0.6 ± 2.4 kg) were not significant in the control group. Of the 124 patients, 122 completed the 1.5-year follow-up. In the control group HbA1c increased again, reaching baseline values (7.5 ± 0.7%). In the SMBG group HbA1c remained stable (6.9 ± 0.9% [P=0.0003 for trend]), and weight (-1.6 ± 3.0 kg vs. baseline [P=0.0003 for trend]) improved further. Eighty-seven percent of participants in the SMBG group continued to perform SMBG. Those who measured their blood glucose more than three times per week (n=24) demonstrated an overall reduction in HbA1c of 1.0% (P=0.006 vs. three times or fewer per week) after 1.5 years.

CONCLUSIONS

Integration of SMBG into basic therapy of T2DM for monitoring the effect of lifestyle changes improves glucometabolic control and has long-term effects.

The epidemiological Boehringer Ingelheim Employee study--part I: impact of overweight and obesity on cardiometabolic risk

OBJECTIVE

Obesity-dependent diseases cause economic burden to companies. Large-scale data for working populations are lacking. Prevalence of overweight and obesity in the Boehringer Ingelheim (BI) Employee cohort and the relationship between body mass index (BMI) and cardiometabolic risk factors and diseases were estimated.

DESIGN AND METHODS

Employees (≥38 years, employed in Ingelheim ≥2 years; n = 3151) of BI Pharma GmbH & Co. KG were invited by the medical corporate department to participate in intensive health checkups. Cross-sectional analysis of baseline data collected through 2006-2011 was performed.

RESULTS

90% of eligible subjects participated (n = 2849). Prevalences of overweight and obesity were 40% and 18% and significantly higher in men and participants ≥50 years. Cardiometabolic risk factor levels and prevalences of cardiometabolic diseases significantly increased with BMI and were higher in overweight and obese participants. Cut-points for increased risk estimated from ROC curves were ≈ 25 kg/m(2) for hypertension, hypercholesterolemia, arteriosclerosis, and hypertriglyceridemia and 26.7-28.0 kg/m(2) for the metabolic syndrome, insulin resistance, hyperinsulinemia, increased intima media thickness, and type 2 diabetes.

CONCLUSION

This is the first large-scale occupational health care cohort from a single company. Cardiometabolic risk factors and diseases accumulate with increasing BMI. Occupational weight reduction programs seem to be reasonable strategies.

[The Da Vinci Medical-mental motivation program for supporting lifestyle changes in patients with type 2 diabetes]

BACKGROUND AND OBJECTIVE

Healthy diet and physical activity can improve metabolic control in patients with type 2 diabetes mellitus. However, lifestyle change without external help is difficult: an alteration of mental attitude is necessary to achieve long-term success. A computer-based motivational program ("Da Vinci") has been developed to help patients to change their mental attitudes and beliefs.

METHODS

Patients with type 2 diabetes were supervised by psychological trainers in four sessions at ten study centers. The interactive computer program allowed for identification of motivation restraints and overcoming them. Parameters of carbohydrate metabolism were measured at the beginning and end of the three-months program as well as three and six months after end of program.

RESULTS

All participants (n = 61) developed a positive attitude towards the range of their action and by themselves changed their lifestyle. After three months their weight (-4.6 kg; p < 0.0001), body mass index (-1.1 kg/m2; p < 0.0001), waist circumference (-3.5 cm; p < 0.0001), HbA1c (-0.6 %; p < 0.0001), triglycerides (-31.1 mg/dl; p = 0.033), systolic (-4.0 mmHg; p = 0.005) and diastolic blood pressure (-3.0 mmHg; p = 0.006) had been reduced. Short duration of diabetes and high baseline HbA1c values were predictive for successful HbA1c reduction. Three and six months after end of the program participants were able to maintain or even augment achieved improvements.

CONCLUSION

During the motivational program, which is intended to alter mental attitude and beliefs, but not to teach knowledge about diabetes, participants were able to significantly improve their metabolic control. As these improvements were maintained long-term, this points to sustainable lifestyle change.

ROSSO-in-praxi follow-up: long-term effects of self-monitoring of blood glucose on weight, hemoglobin A1c, and quality of life in patients with type 2 diabetes mellitus

BACKGROUND

Self-monitoring of blood glucose (SMBG) is a simple tool to monitor the effects of lifestyle change on blood glucose. Recently, the ROSSO-in-praxi Study demonstrated that addition of SMBG to a 12-week lifestyle intervention was associated with significant improvements in glucometabolic control and quality of life in insulin-naive patients with type 2 diabetes mellitus (T2DM). So far it is unknown if this short-term intervention also has long-term effects. Therefore, participants were followed up for a mean period of 2 years.

METHODS

Participants (n=327) were asked by mail for current weight, hemoglobin A1c (HbA1c), performance of SMBG, and quality of life (SF36 and CES-D questionnaires). Participants who did not reply were contacted by phone.

RESULTS

Two hundred twenty-eight participants (70%) completed the follow-up. During the 12-week lifestyle intervention they had significantly reduced weight (2.2 kg) and HbA1c (0.3%; P<0.001 each). After 2 years they achieved a further reduction of weight (0.2 kg; P<0.001), whereas HbA1c increased again, remaining 0.1% lower than baseline. The numbers of depressed participants remained stable during follow-up, whereas physical and mental health-related quality of life remained better compared with baseline. During follow-up 20% of participants continued SMBG daily, 35% several times a week, and 33% irregularly. It is interesting that participants with daily SMBG demonstrated an HbA1c decrease of 0.3% at time of follow-up, whereas in those who stopped SMBG HbA1c increased by 0.1% (P=0.05).

CONCLUSIONS

Integration of a short-term, motivational, and low-cost intervention into basic therapy of T2DM has had beneficial long-term effects on weight and quality of life and, if SMBG was continued daily, also on HbA1c.