Expert Opinion on Addressing the Gap in Injection Technique and Needle Reuse for People with Diabetes in Indonesia

The use of insulin for patients with diabetes mellitus in Indonesia appears to be under expectation; moreover, there are gaps in knowledge regarding the proper injection technique and pen needle reuse by both healthcare professionals (HCPs) and patients. To address these issues, a scientific expert meeting was held with the participation of endocrinologists and public health specialist from many different organizations in Indonesia to identify the challenges and problem related to injection technique, high pen needle reuse rate, and the need of all stakeholders. The experts agreed that it is necessary to ensure physicians to start the initiation phase as early as indicated, continue optimizing its dosage to reach targeted blood sugar based on guideline, and involve all relevant stakeholders to improve insulin distribution and patient access in every primary care facility in order to optimize the use of insulin or other injectable diabetes medications in Indonesia. Additionally, the experts believed that education on proper injection technique and improved reuse rate of pen needle is necessary. To date, Indonesian Diabetes Educators Association (IDEA/PEDI) has established guideline on injection technique. There are also recommendations on injection technique and needle reuse from Indonesian Society of Endocrinology (PERKENI) and Forum for Injection Technique & Therapy: Expert Recommendations (FITTER); however, this guideline/recommendation should be disseminated more widely among HCPs. In addition, cost-effectiveness studies based on local data are needed to propose and convince the Payors and other stakeholders. This article can be used as a guidance for HCPs and policymakers to improve current practice on injection technique, pen needle reuse, needle prescription and reimbursement policy in Indonesia and elsewhere.

Automated glycemic control with a bionic pancreas for type 1 diabetes mellitus: A systematic review and meta-analysis

BACKGROUND AND AIMS

The use of a bionic pancreas with automated insulin delivery systems to prevent complications of diabetes mellitus shows conflicting results. We aimed to comprehensively discuss the potential use of a bionic pancreas in patients with type 1 diabetes (T1D).

METHODS

A systematic database search was conducted on October 24, 2022, for articles investigating the use of a bionic pancreas in patients with T1D. The hemoglobin A1c (HbA1c) level, mean glucose level, glucose coefficient of variability, time-in-range (TIR), and adverse events were investigated.

RESULTS

Nine studies were included in this review. The data from these studies suggested that the use of a bionic pancreas could reduce the HbA1c (mean difference [MD] = -0.40% [95% confidence interval {CI} = -0.59 to -0.21], I2 = 0%, p < 0.0001) and mean glucose levels (MD = -21.06 [95% CI = -24.66 to -17.46], I2 = 45%, p < 0.00001) and improve the TIR (MD = 14.41% [95% CI = 10.99 to 17.83], I2 = 60%, p < 0.00001). The most common adverse events reported were nausea and vomiting.

CONCLUSIONS

The use of a bionic pancreas shows potential in preventing complications of T1D by improving the TIR and decreasing the HbA1c and mean glucose levels. Furthermore, serious adverse events with the use of a bionic pancreas and standard of care show insignificant results, suggesting a good safety profile.

Mortality among Heart Failure Patients in The Presence of Cachexia

Highlights: Around 38.8% of heart failure patients with cachexia died during the 180-1,876-day follow-up period. Cachexia increases the risk of mortality in heart failure patients. Abstract: Despite the fact that obesity has long been recognized as a risk factor for cardiovascular disease, the mortality rate of heart failure (HF) patients with cachexia is still high. Several studies have been conducted to investigate the association between cachexia and mortality in HF patients. However, the research results vary, as do the diagnostic criteria employed to assess cachexia. This meta-analysis aimed to conclusively summarize the association between cachexia and mortality in HF patients. The data were obtained from prospective or retrospective cohort studies with full texts in English or Indonesian and keywords related to "cachexia," "heart failure," and/ or "mortality". Studies that did not assess mortality in HF patients with cachexia and had no full text accessible were omitted. A literature search was conducted through four databases (PubMed, Web of Science, Scopus, and SAGE Journals) using keywords, reference searches, and/ or other methods on April 2022 in accordance with the Preferred Reported Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data from the selected studies were presented and analyzed using qualitative and quantitative synthesis methods. The Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias in the selected cohort studies. The qualitative synthesis contained nine studies, whereas the quantitative synthesis (meta-analysis) included six studies. Cachexia was found in 16.0% of the 4,697 patients studied. During the 180-1,876-day follow-up period, 33.0% of the patients died, with a mortality rate of 38.8% among the patients with cachexia. The pooled analysis revealed cachexia to be a significant predictor of mortality in HF patients (hazard ratio (HR)=3.84; 95% CI=2.28-6.45; p<0.00001), but with significant heterogeneity (p<0.00001; I2=88%). In conclusion, cachexia worsens HF prognosis.

EFFECT OF MODERATE-INTENSITY TREADMILL EXERCISE ON INCREASED ADIPONECTIN LEVELS IN TYPE 2 DIABETES MELLITUS PATIENTS

ABSTRACT Introduction: Adiponectin plays a significant role in the metabolic system in proinflammatory cytokine inhibition and glucose uptake utilization. The treadmill is an aerobic walking device that stimulates natural walking features. Exercises increase adiponectin levels leading to improvement in insulin sensitivity. Objectives: To analyze the effect of aerobic exercise using a moderate-intensity treadmill with a gradual increase in speed and inclination on adiponectin levels in men with type 2 diabetes mellitus (T2DM). Methods: Twenty-two participants with T2DM were randomized into treadmill exercise and control groups. The experimental group underwent 30-minute sessions of moderate-intensity treadmill exercise with increasing speed and gradual inclination three times a week for four weeks. The control group underwent individual exercise for 150 minutes per week. Participants were assessed for clinical and laboratory parameters before and after the four-week program. Results: There was a significant increase in the adiponectin level from 456.3 ± 42 pg/ml to 586.3 ± 87.8 pg/ml (p=0.04, p<0.05) in the treadmill exercise group. In the control group, adiponectin only increased from 466.7 ± 85 pg/ml to 471.8 ± 59 pg/ml (p=0.646). Conclusions: Moderate-intensity treadmill with increasing speed and gradual inclination was found to lead to a significantly better outcome in improving adiponectin levels than standard individual physical exercise in managing T2DM. Level of evidence II; Therapeutic studies – Investigation of the treatment results.

EFEITO DO EXERCÍCIO EM ESTEIRA DE INTENSIDADE MODERADA NO AUMENTO DOS NÍVEIS DE ADIPONECTINA EM PACIENTES COM DIABETES MELLITUS TIPO 2

RESUMO Introdução: A adiponectina desempenha um papel significativo no sistema metabólico na inibição da citocina pró-inflamatória e na utilização da captação de glicose. A esteira é um aparelho de caminhada aeróbica que estimula as características da caminhada natural. Os exercícios aumentam o nível de adiponectina, resultando na melhora da sensibilidade à insulina. Objetivos: Analisar o efeito de exercícios aeróbicos em uma esteira de intensidade moderada com um aumento gradual de velocidade e inclinação sobre os níveis de adiponectina em homens com diabetes mellitus tipo 2 (DMT2). Método: Vinte e dois participantes com DMT2 foram randomizados para grupos de exercício em esteira e controle. O grupo experimental realizou sessões de 30 minutos de exercício em esteira de intensidade moderada com velocidade crescente e inclinação gradual três vezes por semana durante quatro semanas. O grupo de controle se submeteu a exercício individual durante 150 minutos por semana. Os participantes foram avaliados em relação aos parâmetros clínicos e laboratoriais antes e após o programa de quatro semanas. Resultados: Houve um aumento significativo no nível de adiponectina de 456,3 ± 42 pg/ml para 586,3 ± 87,8 pg/ml (p=0,04, p<0,05) no grupo de exercício em esteira. No grupo de controle, a adiponectina apresentou um pequeno aumento de 466,7 ± 85 pg/ml para 471,8 ± 59 pg/ml (p=0,646). Conclusão: Descobriu-se que exercícios na esteira de intensidade moderada com velocidade crescente e inclinação gradual conduzem a um resultado significativamente superior na melhora dos níveis de adiponectina em relação a exercícios físicos individuais padrão ao tratar o DMT2. Nível de evidência II; Estudos terapêuticos – Investigação de resultados do tratamento.

One-week sorghum (Sorghum bicolor L.) grain consumption is insufficient to increase adiponectin levels in prediabetic adults

Objective. Adiponectin is an internally produced bioactive compound with a protective role against the insulin resistance-related diseases. Finding an adiponectin modifier can play a beneficial role in preventing the progression of the diseases, particularly in the prediabetic patients, as a high-risk population. This study was undertaken to examine the effect of dietary sorghum grain for a week on the plasma adiponectin levels in prediabetic patients. Methods. The study involved 26 (13+13) participants in both control and intervention groups. The control group maintained their habitual diet of white rice, while the intervention group replaced their habitual diet of white rice with sorghum grain for seven consecutive days. In all participants, the adiponectin concentration was measured before and after the intervention period. Results. Most study subjects had central obesity and dyslipidemia. Adiponectin levels after the intervention period decreased from the baseline in the control and sorghum groups including in all BMI groups. The change of decreasing adiponectin level was greater in the control than the sorghum group and in line with greater BMI in the sorghum group, but statistically insignificant. No significant difference in adiponectin concentrations was found among BMI groups. Conclusion. Sorghum grain consumption for a week is insufficient to increase adiponectin levels in the prediabetic patients. Insulin resistance, central obesity, and dyslipidemia may be the confounding variables that alter the favorable effect of sorghum on adiponectin. Longer sorghum consumption or other interventions may be needed to increase the adiponectin levels in people under these conditions.

The role of serum ferritin level and disease severity in COVID-19 with type 2 diabetes mellitus patients

Introduction: The disease progression of coronavirus disease 2019 (COVID-19) in individuals with comorbidities, such as type 2 diabetes mellitus (T2DM) in particular, has been associated with the occurrence of the cytokine storm. Ferritin, an acute-phase protein indicating inflammation, has been linked to T2DM and the severity of COVID-19. Our study aimed to investigate the association between the level of ferritin and the severity of COVID-19 in T2DM patients. Methods: A cross-sectional study was conducted among COVID-19 patients admitted at Dr. Soetomo General Hospital, Surabaya, from April to September 2020. The patients who met the inclusion criteria were enrolled in the study. The data used in this study was secondary data obtained from the medical records at Dr. Soetomo General Hospital, which consisted of serum ferritin levels, the severity of COVID-19, the results of blood analysis, and other demographic and clinical characteristics (age, gender, hypertension, the number of complaints, and vital signs). Data analysis was performed using SPSS software and presented in percentage (%), mean ± standard deviation (SD), or median (min-max). A chi-square test was carried out to identify the association between serum ferritin level and the severity of COVID-19 in T2DM patients at α=0.05. Results: Of the total 159 patients were included and 80.8% of them had moderate severity of COVID-19, whereas the rest (19.5%) had severe COVID-19. Out of total patients, 78.6% had ferritin levels of ≥400 mg/dL, suggesting hyperferritinemia syndrome (mean ± SD: 1177.21 ± 1275.90 mg/dL). The Chi-squared analysis revealed a significant association between serum ferritin levels with the severity of COVID-19 in T2DM patients (p=0.024). Conclusion: There was a significant relationship between serum ferritin levels and the severity of COVID-19 in T2DM patients and further study with a bigger sample size is needed to confirm this finding.

The relationship between diabetes distress and HbA1C level in type 2 diabetes mellitus therapy patients: a systematic review

Introduction: The success of therapy did not follow the increasing number of type 2 diabetes mellitus patients. This systematic review aimed to evaluate the relationship between diabetes distress and HbA1c in type 2 diabetes mellitus patients during therapy. Methods: The authors systematically searched databases (PubMed, Cochrane library, and ScienceDirect) up to January 2021. Articles were screened according to PRISMA 2020 statements. The selection criteria of this study were patients’ characteristics, type of therapy, and outcomes. Results: The search started from 1.303 articles to 17 eligible articles. Furthermore, seventeen studies included 11,976 patients. The mean HbA1c level was around 6.4% to 9.9%. The result of diabetes distress scores were five studies with low scores, eight moderate scores, and two high scores. Emotional burden and regimen-related distress were the highest domain score. Age, health facilities, and type of therapy affected diabetes distress. The correlation between diabetes distress and HbA1c was dominant in the range of 0.15 to 0.26. Conclusion: Diabetes distress had a low-moderate correlation with HbA1c. The dominant domains were emotional burden and regiment-related distress. There were two mechanisms of effect, direct by hormones and indirect through medication adherence, self-management, and 12 months of quality of life.

Effect of High Fat Diet on Body Weight, Visceral Fat Weight, and PPARG Expressions on Visceral Fat in Mice

Obesity becomes a global epidemic nowadays. The high-fat diet is used as an alternative therapy for obesity. The optimal composition of a high-fat diet to reduce body weight is still unknown. This study aimed to determine which components of a high-fat diet can decrease body weight, visceral fat, and PPARG expression of visceral fat. This study was conducted at the Faculty of Veterinary Medicine, Universitas Airlangga, for three months by using a randomized post-test only control group design. Fifty male mice, 2-3 months old, 18-30 grams were adapted for one week given standard diet AIN93-M, then mice were divided into five groups, namely K1 (control group, 12% fat, 20% protein, 62% carbs); K2 (30% fat, 60% proteins, 0% carbs); K3 (45% fat, 45% protein, 0% carbs);  K4 (60% fat, 30% protein, 0% carbs); and K5 (75% fat, 15% protein, 0% carbs). Bodyweight was measured before and after treatment, then the visceral fat and PPARG expressions were evaluated. Statistical comparisons were performed using Statistical Package for the Social Sciences (SPSS) software. After treatment, there were forty-three mice. The body weight and visceral fat weight of the mice with a high-fat diet were decreased. The most significant changes in body weight were in K4 with -9,60 ± 3,806 grams reduction. The bodyweight of mice in K5, slightly increased than K2-K4. This could be caused by the hormesis phenomenon. PPARG expressions decreased in groups with a high-fat diet but increased in K5. The composition of a high-fat diet in group K4 was the most optimal to decrease the body weight, visceral fat, and PPARG expressions in mice

Challenges and unmet needs in basal insulin therapy: lessons from the Asian experience

Basal insulin therapy can improve glycemic control in people with type 2 diabetes. However, timely initiation, optimal titration, and proper adherence to prescribed basal insulin regimens are necessary to achieve optimal glycemic control. Even so, glycemic control may remain suboptimal in a significant proportion of patients. Unique circumstances in Asia (eg, limited resources, management of diabetes primarily in nonspecialist settings, and patient populations that are predominantly less educated) coupled with the limitations of current basal insulin options (eg, risk of hypoglycemia and dosing time inflexibility) amplify the challenge of optimal basal insulin therapy in Asia. Significant progress has been made with long-acting insulin analogs (insulin glargine 100 units/mL and insulin detemir), which provide longer coverage and less risk of hypoglycemia over intermediate-acting insulin (Neutral Protamine Hagedorn insulin). Furthermore, recent clinical evidence suggests that newer long-acting insulin analogs, new insulin glargine 300 units/mL and insulin degludec, may address some of the unmet needs of current basal insulin options in terms of risk of hypoglycemia and dosing time inflexibility. Nevertheless, more can be done to overcome barriers to basal insulin therapy in Asia, through educating both patients and physicians, developing better patient support models, and improving accessibility to long-acting insulin analogs. In this study, we highlight the unique challenges associated with basal insulin therapy in Asia and, where possible, propose strategies to address the unmet needs by drawing on clinical experiences and perspectives in Asia.