Observations of parent-adolescent interactions relate to food parenting practices and adolescent disordered eating in adolescents at risk for adult obesity

Adolescent disordered eating and obesity are interrelated and adversely relate to mental and metabolic health. Parental feeding practices have been associated with adolescent disordered eating and obesity. Yet, observable interactions related to food parenting have not been well characterized. To address this gap, N = 30 adolescents (M ± SD 14 ± 2 year) at risk for adult obesity due to above-average body mass index (BMI ≥70th percentile) or parental obesity (BMI ≥30 kg/m2 ) participated in a video-recorded parent-adolescent task to discuss a food/eating-related disagreement. Interactions were coded for individual/dyadic affect/content using the Interactional Dimensions Coding System. We examined associations of interaction qualities with parent-reported food practices, adolescent disordered eating behaviors/attitudes, and insulin resistance. Reported parenting practices were correlated with multiple interaction qualities (p-values <0.05), with the most consistent correspondence between parent-reported pressure to eat (e.g., pressure to eat more healthy foods) and negative aspects of parent-adolescent interactions. Also, after accounting for adolescent age, sex, and BMI-standard score, parent-adolescent interaction qualities were associated with adolescents' disordered eating and insulin resistance. Specifically, greater adolescent problem-solving related to less adolescent global disordered eating, shape, and weight concern (p-values <0.05); adolescent autonomy related to less weight concern (p = 0.03). Better parent communication skills were associated with less adolescent eating concern (p = 0.04), and observed dyadic mutuality related to adolescents' lower insulin resistance (p = 0.03). Parent-adolescent interaction qualities during food/eating-related disagreements show associations with parent-reported food practices and adolescent disordered eating. This method may offer a tool for measuring the qualities of parent-adolescent food/eating-related interactions. A nuanced understanding of conversations about food/eating may inform family-based intervention in youth at-risk for adult obesity.

Exacerbation of financial burden of insulin and overall glucose-lowing medications among uninsured population with diabetes

BACKGROUND

Approximately 7.4 million Americans with diabetes used insulin. This study aimed to document the 10-year trend of insulin and other glucose-lowering medications expenditure among insured and uninsured populations and to examine the impact of insulin out-of-pocket (OOP) payment and insurance status on glucose-lowering medication OOP expenditure.

METHODS

We extracted data from the Medical Expenditure Panel Survey (2009-2018) to document trends in the expenditure of insulin among people with diabetes. Total expenditures and OOP spending per person were documented on insulin and noninsulin glucose-lowering medications among insured and uninsured populations. Multivariable regression was applied to assess the association of insulin OOP payment and insurance status on glucose-lowering medication OOP expenditure.

RESULTS

Although insulin usage was stable over the decades, total insulin expenditure almost doubled per person per year after the Affordable Care Act (ACA) regardless of the insurance status. The OOP cost of insulin by the uninsured population increased from $1678 per person per year in the pre-ACA period to $2800 per person per year in the post-ACA period. After the ACA was enacted, the uninsured population had $403.96 and $143.64 more on OOP costs than the people with public and private insurance, respectively.

CONCLUSION

For insured people, the rising financial burden of insulin was borne mainly by insurance. The uninsured population is bearing a heavy burden due to the high price of insulin. Policymakers should take action to reduce the insulin price and improve the transparency of the insulin pricing process.

Are U-shaped relationships between risk factors and outcomes artifactual?

BACKGROUND

The objective of this study was to evaluate whether the observed nadir in a U- or J-shaped relationship between a particular risk factor and a future health outcome is a function of the distribution of the risk factor in the sample being analyzed.

METHODS

Data from the ORIGIN trial were used to assess the relationship between three risk factors (weight, systolic blood pressure, and serum insulin) and the hazard of a major cardiovascular event comprising a nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. Three spline curves were generated for each risk factor. The first was based on all available data, the second for a subgroup with a higher mean risk factor level, and the third for a subgroup with a lower mean risk factor level. Nadir levels of the risk factor (i.e., risk factor levels predicting the lowest hazard) were then identified for each spline curve.

RESULTS

When compared to the nadir values based on all available data, nadir values for all three risk factors were higher for the subgroups with higher mean levels and lower for those with lower mean levels.

CONCLUSIONS

The distribution of a risk factor in the population is an important determinant of its nadir value. Populations with high or low values may have high and low nadirs, respectively. Identification of a nadir for a modifiable risk factor from epidemiologic relationships may therefore arise from this distribution bias and is therefore unrelated to therapeutic targets.

Apelin levels in pregnant women with and without gestational diabetes mellitus: a collaborative systematic review and meta-analysis

Aims: This systematic review and meta-analysis investigated maternal apelin levels in pregnant women with and without GDM. Secondary outcomes were glucose- and lipid-related results.Methods: Databases including PubMed, Embase, Cochrane Library, LILACS, CNKI, and Wang Fang were searched. The methodological quality of included studies was evaluated with the Newcastle-Ottawa Scale. Mean differences (MDs) or standardized MDs (SMDs) with their 95% confidence intervals (CIs) were evaluated. Random effect model analyses were carried out and heterogeneity with the I² and Tau² statistics.Results: Fourteen observational studies (sample size: 1033 women with GDM and 1053 for control women) with a low or moderate risk of bias were included in the analysis. During the second half of pregnancy, maternal apelin estimate was significantly higher in women with GDM (SMD = 0.64; 95% CI: 0.03 to 1.25), as well as insulin (SMD = 1.41% CI: 0.84 to 1.99), glucose (SMD = 1.56; 95% CI 1.20 to 1.91), glycated hemoglobin (SMD = 1.11, 95% CI: 0.69 to 1.54), HOMA-IR (MD = 2.25; 95%CI: 1.51 to 2.98), BMI (MD = 0.80 kg/m², 95%CI: 0.52 to 1.08), total cholesterol (SMD = 0.42, 0.12 to 0.73), LDL-cholesterol (SMD = 0.63, 95%CI: 0.23 to 1.02), and triglycerides (SMD = 0.40, 95%CI: 0.19 to 0.61) as compared to control women. There was heterogeneity between studies as evidence by high I² values. Meta-regression analysis indicated statistically significant regression coefficients for age of women, glucose and total cholesterol.Conclusions: GDM was associated with increased circulating apelin, insulin, glucose, glycated hemoglobin, total cholesterol, LDL-cholesterol levels, and HOMA-IR index.

Familial diabetes predisposes PCOS patients to insulin resistance (IR), reproductive impairment and hepatic dysfunction: effects of d-chiro inositol (DCI) and alpha lipoic acid (ALA) administration on hepatic insulin extraction (HIE) index

ObjectivePCOS is a syndrome is characterized by 2 out of 3 of the criteria established during the Rotterdam Consensus Conference. Recently the issue of insulin resistance (IR) has caught attention.SubjectsA group of overweight/obese PCOS patients (n = 30) have been evaluated before and after 3 months of daily integrative administration of d-chiro inositol (DCI) (500 mg) and alpha lipoic acid (ALA) (300 mg).MethodsHormonal and metabolic profiles, oral glucose tolerance test (OGTT) for glucose, insulin and C-peptide response were performed in baseline conditions and after DCI plus ALA treatment. Hepatic Insulin Extraction (HIE) index was computed along the OGTT to evaluate the liver ability in degrading insulin.ResultsThe treatment decreased LH, Androstenedione (A), insulin plasma levels, BMI, HOMA index, AST and ALT. Considering patients for the presence (n = 17) or absence of familial diabetes (n = 13), the greatest improvements occurred in the former patients. Insulin response to OGTT was greatly reduced after the treatment interval in PCOS with familial diabetes. HIE computation disclosed that in presence of familial diabetes liver degradation of insulin is reduced thus leaving a higher amount of circulating insulin. DCI plus ALA administration decreased AST and ALT and restored hepatic insulin clearance since HIE profile was improved.ConclusionOur study demonstrates that in overweight/obese PCOS the predisposition to familial diabetes triggers IR not only through the endogenous impaired DCI and ALA synthesis but also through a reduced hepatic clearance of insulin. DCI plus ALA administration positively improved hormonal, metabolic profiles as well as liver function.

Vitamin E supplementation improves testosterone, glucose- and lipid-related metabolism in women with polycystic ovary syndrome: a meta-analysis of randomized clinical trials

AIM

This systematic review and meta-analysis assessed the effect of vitamin E supplementation on testosterone, glucose, lipid profile, pregnancy rate, hirsutism, and body mass index (BMI) in women with polycystic ovary syndrome (PCOS).

METHODS

A multi-database search was performed from inception to January 2022 for randomized controlled trials (RCTs) reporting the effects of vitamin E supplementation with or without another nutritional supplement on women with PCOS. A random-effects model was used to obtain mean differences (MDs) and its 95% confidence intervals (95%CI). Evidence certainty was assessed with GRADE methodology.

RESULTS

We meta-analyzed eight RCTs reporting vitamin E supplementation alone or combined with other individual substances like omega-3, vitamin D3, or magnesium oxide in adult women ≤40 years old with PCOS. Vitamin E supplementation reduced fasting glucose (MD: -1.92 mg/dL, 95%CI: -3.80 to -0.05), fasting insulin (MD: -2.24 µIU/mL, 95%CI: -3.34 to -1.14), HOMA-IR (MD: -0.42, 95%CI: -0.65 to -0.19), total cholesterol (MD: -18.12 mg/dL, 95%CI: -34.37 to -1.86), LDL-cholesterol (MD: -15.92 mg/dL, 95%CI: -29.93 to -1.90), triglycerides (MD: -20.95 mg/dL, 95%CI: -37.31 to -4.58), total testosterone (MD: -0.42 ng/mL, 95%CI: -0.55 to -0.29), and increased sex hormone-binding globulin (MD: 7.44 nmol/L, 95%CI: 2.68 to 12.20). However, it had no impact on female sex hormones, HDL-cholesterol, BMI, and hirsutism. Two RCTs assessed pregnancy and implantation rates with inconsistent results. The certainty of the evidence was very low to moderate.

CONCLUSION

Vitamin E supplementation improves glucose, lipid, and androgenic-related biomarkers in women with PCOS.

DUAL I China: Improved glycemic control with IDegLira versus its individual components in a randomized trial with Chinese participants with type 2 diabetes uncontrolled on oral antidiabetic drugs

BACKGROUND

DUAL I China, one of the DUAL trials, assessed efficacy/safety of insulin degludec/liraglutide (IDegLira) in Chinese adults with type 2 diabetes (T2D) not controlled by oral antidiabetic drugs (OADs).

METHODS

This phase 3a, treat-to-target multicenter trial randomized participants (glycated hemoglobin [HbA1c] 53.0-85.8 mmol/mol; previous metformin ± another OAD) 2:1:1 to IDegLira (n = 361), degludec (n = 179), or liraglutide (n = 180). Primary endpoint was change in HbA1c after 26 weeks. Secondary endpoints included: HbA1c < 53.0 mmol/mol attainment, weight change, treatment-emergent hypoglycemia, end-of-treatment insulin dose, and safety.

RESULTS

At 26 weeks, HbA1c had decreased by a mean 18.12 mmoL/moL (IDegLira), 12.37 mmoL/moL (degludec) (estimated treatment difference [ETD] -6.50 mmoL/moL; 95% confidence interval [CI] -7.96, -5.04; P < .0001), and 11.33 mmoL/moL (liraglutide) (ETD -6.87 mmoL/moL; 95% CI -8.33, -5.41; P < 0.0001), indicating noninferiority for IDegLira vs degludec and superiority vs liraglutide. HbA1c < 53.0 mmoL/moL attainment was 77.0% (IDegLira), 46.4% (degludec), and 48.3% (liraglutide). Mean weight change with IDegLira (0.1 kg) was superior to degludec (1.2 kg) (ETD -1.08 kg; 96% CI -1.55, -0.62; P < 0.0001). Severe or confirmed hypoglycemic event rates were 0.24 (IDegLira) and 0.17 (degludec) episodes/participant-year (estimated rate ratio 1.46; 95% CI 0.71, 3.02; P = .3008, not significant). At the end of treatment, the IDegLira insulin dose was lower (24.5 U/d) vs degludec (30.3 U/d) (ETD -5.49 U; 95% CI -7.77, -3.21; P < 0.0001). No unexpected safety issues occurred.

CONCLUSIONS

IDegLira is efficacious and well tolerated in Chinese adults with T2D not controlled by OADs.

Association between insulin and post-caesarean resuscitation rates in infants of women with GDM: A retrospective study

BACKGROUND

Gestational diabetes mellitus (GDM) and caesarean deliveries independently increase the risk of postoperative complications. There are limited data on the influence of insulin use on the outcomes of neonates who were delivered via caesarean section. We sought to investigate the impact of insulin use in women with GDM on resuscitation rates of infants post caesarean delivery.

METHODS

A retrospective database review of women with singleton term (≥ 37 weeks) pregnancies who were on insulin for GDM delivering between January 2005 and December 2014 at a major metropolitan hospital in Sydney.

RESULTS

One thousand eight hundred and fifty-seven women with GDM were identified. The mean age was 31.01 ± 5.63 years and mean gestational period of 39.07 ± 1.00 weeks. 31.0% received insulin treatment for GDM. Women who were on insulin were older (31.9 ± 5.7 vs 30.6 ± 5.6 years, P < 0.001), had a higher body mass index (BMI) (31.2 ± 7.7 vs 29.0 ± 7.4 kg/m2, P < 0.001), higher rates of preeclampsia (7.3% vs 4.1%, P = 0.004), lower rates of alcohol consumption (0.4% vs 1.7%, P = 0.014), and had infants with lower resuscitation rates (21.2% vs 28.6%, P = 0.001). Infants who required resuscitation had a lower gestational age, lower five-minute APGAR score, and lower birth weight, length, and head circumferences. On multivariate analysis, women with GDM treated with insulin (odds ratio [OR] = 0.69, CI = 0.54-0.89, P = 0.004), higher gestational age (OR = 0.88, CI = 0.78-0.99, P = 0.032), higher maternal BMI (OR = 1.02, CI = 1.01-1.04, P = 0.005), and emergency caesarean (OR = 2.33, CI = 1.74-3.12, P < 0.001) independently predicted incidence of resuscitation.

CONCLUSIONS

The findings suggest a relationship between insulin use and reduced resuscitation rates of infants born from mothers with GDM. Further studies investigating the role, dosage, and criteria for insulin use in women with GDM are required.

Therapeutic approaches for latent autoimmune diabetes in adults: One size does not fit all

Recent advances in the understanding of latent autoimmune diabetes in adults (LADA) pathophysiology make it increasingly evident that people with LADA comprise a heterogenous group of patients. This makes the establishment of a standard treatment algorithm challenging. On top of its glucose-lowering action, insulin may exert anti-inflammatory effects, rendering it an attractive therapeutic choice for a type of diabetes in which autoinflammation and beta cell insufficiency play major pathogenetic roles. However, there is growing evidence that other antidiabetic drugs, such as metformin, dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists, and thiazolidinediones, might have a role in optimizing glycemic control and preserving beta cell function in individuals with LADA, either alone or in combination with insulin. Although most of these drugs have been routinely used in the daily clinical setting for years, large prospective randomized trials are needed to assess whether they are capable of delaying progression to insulin dependence as well as their effects on diabetic complications. The aim of the present review is to discuss the current state and future perspectives of LADA therapy, emphasizing the need for individualized and patient-centered therapeutic approaches.

Hypoglycemia in diabetes: The dark side of diabetes treatment. A patient-centered review

Hypoglycemia is a frequent occurrence in patients with diabetes who are treated with insulin and insulin secretagogues. Hypoglycemia is the limiting factor that prevents patients from achieving the glycemic control known to reduce the microvascular complications of diabetes. Recurrent episodes of hypoglycemia can lead to impaired awareness of hypoglycemia where the first symptom of a low blood sugar is unconsciousness. The fear of hypoglycemia has a significant effect on the quality of life of patients and their families. In the acute setting, hypoglycemia can kill, and clinical trials have demonstrated that a single episode of severe hypoglycemia increases the risk of subsequent mortality and cardiovascular events. Clinicians must make efforts to recognize and prevent hypoglycemia in order to prevent the adverse events associated with this event. Patient education is central to these efforts. Recent developments in glucose monitoring and drug development have provided more approaches that can be used to reduce the risk of hypoglycemia in patients with diabetes.

Changing environment of hyperglycemia in pregnancy: Gestational diabetes and diabetes mellitus in pregnancy

The diagnosis and treatment of gestational diabetes mellitus (GDM) have been in a state of flux since the World Health Organization accepted and endorsed the International Diabetes and Pregnancy Study Group's diagnostic pathway and criteria in 2013. These new diagnostic criteria identify an increasing number of women at risk of hyperglycemia in pregnancy (HGiP). Maternal hyperglycemia represents a significant risk to the mother and fetus, in both the short and long term. Controversially, metformin use for the treatment of GDM is increasing in Australia. This article identifies the multiple and varied presentations of HGiP, of which GDM is the most commonly encountered. The degree of maternal hyperglycemia experienced affects the outcomes for both the mother and neonate, and specific diagnosis determines the appropriate treatment for the pregnancy. Given the increasing incidence of women with dysglycemia and those developing HGiP, this is an important area for research and clinical attention for all health professionals.

Dapagliflozin as add-on therapy in Asian patients with type 2 diabetes inadequately controlled on insulin with or without oral antihyperglycemic drugs: A randomized controlled trial

BACKGROUND

This 24-week Phase 3 double-blind placebo-controlled study assessed the safety and efficacy of dapagliflozin as add-on to insulin, with or without oral antihyperglycemic drugs (OADs), in Asian patients with inadequately controlled type 2 diabetes mellitus.

METHODS

Adult patients with HbA1c between ≥7.5% and ≤10.5%, body mass index ≤45 kg/m² , and on insulin doses ≥20 IU daily were randomized to dapagliflozin 10 mg (n = 139) or placebo (n = 133) to assess 24-week changes in HbA1c (primary outcome), fasting plasma glucose (FPG), body weight, total daily dose of insulin (TDDI), and seated systolic blood pressure (SeSBP; exploratory outcome).

RESULTS

Baseline characteristics were similar in both groups. At Week 24, compared with placebo, dapagliflozin significantly improved HbA1c (mean [95% confidence interval] 0.03% [-0.11, 0.17] for placebo vs -0.87% [-1.00, -0.74] for dapagliflozin; between-group difference - 0.90% [-1.09, -0.71], P < 0.0001]), FPG, body weight, TDDI, and SeSBP. The incidence of adverse events (AEs) in the dapagliflozin and placebo groups was 80.5% and 71.2%, respectively, with few patients discontinuing due to AEs (dapagliflozin, 2.2%; placebo, 4.2%). The occurrence of hypoglycemia was similar in the dapagliflozin and placebo groups (23.7% and 22.6%, respectively; no major events). The frequency of urinary tract and genital infections was low; no deaths were reported.

CONCLUSIONS

Dapagliflozin as add-on to insulin, with or without OADs, significantly improved glycemic control and reduced body weight and blood pressure in Asian patients. Dapagliflozin was well tolerated, with a similar frequency of hypoglycemia in both groups. These results support the use of dapagliflozin as add-on to insulin, with or without OADs, in this population.

Efficacy of automatic bolus calculator with automatic speech recognition in patients with type 1 diabetes: A randomized cross-over trial

BACKGROUND

Patients using an insulin pump as part of their diabetes treatment need to calculate insulin bolus doses to compensate for a meal. Some patients do not modify their meal boluses according to changes in the amount and composition of food products in a meal. The lack of correct meal boluses leads to unstable, and therefore harmful, blood glucose levels. The aim of the present study was to test a system supporting bolus determination based on a voice description of a meal.

METHODS

The bolus calculator developed (VoiceDiab) consists of a smartphone application and three remote servers for automatic speech recognition, text analysis, and insulin dosage calculation. Forty-four people with type 1 diabetes (T1D) treated with continuous subcutaneous insulin infusion finished the randomized cross-over study. Patients were randomly allocated to the group in which the VoiceDiab system supported bolus calculation or to an unsupported group, in which patients or their caregivers calculated boluses. After a 14-day washout period, patients from the supported group were switched to the unsupported group, whereas those in the unsupported group were switched to the supported group.

RESULTS

There was a significant difference between the supported and unsupported groups in the percentage of patients with 2-h postprandial glycemia within the 70-180 mg/dL range (58.6% vs 46.6%, respectively; P = 0.031).

CONCLUSIONS

The VoiceDiab system improves postprandial glucose control without increasing the time in hyperglycemia or hypoglycemia. Therefore, it may be useful in the treatment of patients with diabetes on intensive insulin therapy.

β-Cell function in postmenopausal women with isolated post-challenge hyperglycemia

BACKGROUND

Isolated post-challenge hyperglycemia (IPH) is an early stage of type 2 diabetes mellitus (T2DM), with fasting glucose <126 mg/dL and 2-h glucose ≥200 mg/dL. Observations of insulin secretion profile in subjects with IPH may provide an insight into the pathogenesis of T2DM in older women.

METHODS

We recruited 555 naturally postmenopausal women without a history of T2DM to the present study. All participants received a 75-g oral glucose tolerance test to determine whether they had IPH. General linear models were used to compare differences in glucose metabolism among subjects.

RESULTS

Early phase insulin responses to oral glucose were significantly decreased in women with IPH versus those with impaired glucose tolerance (IGT) and normal glucose tolerance (geometric mean [95% confidence interval] insulinogenic index 61 [54-79] vs 90 [83-97] and 105 [96-116], respectively; P  < 0.0001). In addition, there were significant decreases in late-phase insulin release as metabolic status shifted from normal glucose tolerance to IGT to IPH. In the present cohort, the relative contribution of early insulin secretion to 2-h glucose was no longer significant ( P  = 0.15) after multiple factors, including indicators of insulin resistance and late-phase insulin release, were entered into the regression model simultaneously.

CONCLUSIONS

The results demonstrate that postmenopausal women with IPH are characterized by impaired β-cell function. There were significant decreases in early and late-phase insulin release as glucose intolerance escalated. Disturbance in β-cell function seems to be an important factor associated with early T2DM in postmenopausal women.

Improving postprandial hyperglycemia in patients with type 2 diabetes already on basal insulin therapy: Review of current strategies

A large number of patients with type 2 diabetes (T2D) on basal insulin do not reach their HbA1c goals and require additional therapy to address postprandial hyperglycemia. Guidelines from expert bodies have outlined several approaches to accomplish postprandial glucose (PPG) control, and recent literature suggests several more. This article provides strategies for primary care physicians caring for patients with T2D who do not achieve glycemic control with basal insulin alone. Current treatment guidelines and strategies for improving PPG control are reviewed, including the efficacy, safety, and cost-effectiveness of rapid-acting insulin (RAI) analogs, premixed insulin, glucagon-like peptide-1 (GLP-1) receptor agonists (RAs), dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, and α-glucosidase inhibitors. Other approaches, such as combinations of newer basal insulin plus RAI and a fixed-ratio combination of basal insulin and a GLP-1 RA, are also described.

胰岛素缓释载体聚乙二醇-聚己内酯-聚甲基丙烯酸-N，N-二乙氨基乙酯的制备及评价

OBJECTIVE

To prepare an insulin-loaded nanoparticle assembled using pH-sensitive poly(ethylene glycol)-poly(ε-caprolactone)-poly(N,N-diethylamino-2-ethylmethaerylate) (mPEG-PCL-PDEAEMA) and investigate its performance of sustained insulin release in vitro and its hypoglycemic effects in diabetic rats. METHDOS: mPEG-PCL-PDEAEMA triblock copolymers with different hydrophobic lengths were synthesized by ring opening polymerization (ROP) combined with atom transfer radical polymerization (ATRP). The copolymers were characterized using Fourier-transform Infrared (FT-IR) spectroscopy and proton nuclear magnetic resonance spectroscopy (¹H-NMR). Insulin-loaded nanoparticles were prepared by nanoprecipitation technique, in which the reversible swelling of the pH-sensitive material was used for insulin loading and release. The obtained nanoparticles were further confirmed by dynamic light scattering (DLS) and transmission electron microscopy (TEM). The entrapment efficiency (EE%), drug loading (DL%) and in vitro release characteristics of the insulin- loaded nanoparticles were assessed using BCA protein assay kit. The hypoglycemic effects of the nanoparticles were evaluated by monitoring the glucose levels.

RESULTS

The size of the nanoparticles decreased as pH value increased within the range of 1.2 to 7.4. Using copolymers mPEG5k-PCL13k- PDEAEMA10k and mPEG5k-PCL10k-PDEAEMA10k as the drug carriers, the nanoparticles prepared with an optimal insulin-coplymer mass ratio of 90% had an average size of 181.9∓6.67 nm and 169∓7.1 nm, maximal EE% of (81.99∓1.77)% and (53.12∓0.62)%, and maximal DL% of (42.46∓0.53)% and (32.34∓0.26)%, respectively. Compared with free insulin, the insulin-loaded nanoparticles was capable of sustained insulin release and the release rate was lowered as the hydrophobic length increases. In diabetic rats, the insulin-loaded nanoparticles based on mPEG5k-PCL13k- PDEAEMA10k maintained a sustained hypoglycemic effect for 48 h, which was significantly longer than the time of free insulin.

CONCLUSION

The pH-sensitive triblock copolymer mPEG-PCL-PDEAEMA can serve as a promising candidate of carrier for sustained release of insulin.

What next after basal insulin? Treatment intensification with lixisenatide in Asian patients with type 2 diabetes mellitus

There is increasing evidence that the pathophysiology of type 2 diabetes mellitus (T2DM) in Asian patients differs from that in Western patients, with early phase insulin deficiencies, increased postprandial glucose excursions, and increased sensitivity to insulin. Asian patients may also experience higher rates of gastrointestinal adverse events associated with glucagon-like peptide-1 receptor agonists (GLP-1RAs), such as nausea and vomiting, compared with their Western counterparts. These factors should be taken into consideration when selecting therapy for basal insulin treatment intensification in Asian patients. However, the majority of studies to establish various agents for treatment intensification in T2DM have been conducted in predominantly Western populations, and the levels of evidence available in Chinese or Asian patients are limited. This review discusses the different mechanisms of action of short-acting, prandial, and long-acting GLP-1RAs in addressing hyperglycemia, and describes the rationale and available clinical data for basal insulin in combination with the short-acting prandial GLP-1RA lixisenatide, with a focus on treatment of Asian patients with T2DM.

Efficacy and safety of coadministration of sitagliptin with insulin glargine in type 2 diabetes

BACKGROUND

The aim of the randomized present study was to compare the therapeutic efficacy and safety of a combination of sitagliptin, a dipeptidyl peptidase (DPP)-4 inhibitor, plus insulin glargine (GL + sita) with that of premixed insulin aspart 30 (NOV) for type 2 diabetes (T2D) patients controlled with oral hypoglycemic drugs (HbA1c 7 %-9 %).

METHODS

Sixty-five patients were randomized (1:  1) to the GL + sita (n = 33) and NOV (n = 32) groups and were treated with the combination regimen or premixed insulin twice a day for 16 weeks. The primary endpoint was mean change in HbA1c. Secondary endpoints included fasting blood glucose, blood glucose profiles (seven time points), rate of achieving target HbA1c (<7 % or ≤6.5 %), insulin dose, incidence of hypoglycemia, and body weight.

RESULTS

After 16 weeks, there was no significant difference in HbA1c between the two groups, although more patients achieved HbA1c <7.0 % in the GL + sita group. There was a significant difference in body weight changes between the GL + sita and NOV groups (-0.45 vs 1.52 kg, respectively; P < 0.001). Mean plasma glucose and the mean amplitude of glycemic excursion were significantly lower in the GL + sita than NOV group (P < 0.005), as was the incidence of symptomatic hypoglycemia (2.85 % vs. 13.3 %, respectively; P < 0.001).

CONCLUSION

The combination of GL + sita greatly improved HbA1c in T2D patients (HbA1c 7 %-9 %) with an efficacy that was equal to that of premixed insulin. Thus, GL + sita treatment is a viable option for patients who fail to achieve glycemic control using oral hypoglycemic drugs.

Prediction of excessive weight gain in insulin treated patients with type 2 diabetes

BACKGROUND

Weight gain is an ongoing challenge when initiating insulin therapy in patients with type 2 diabetes mellitus (T2DM). However, if prediction of insulin-associated weight gain was possible on an individual level, targeted initiatives could be implemented to reduce weight gain. The aim of the present study was to identify predictors of weight gain in insulin-treated patients with T2DM.

METHODS

In all, 412 individuals with T2DM were, in addition to metformin or placebo, randomized into 18-month treatment groups with three different insulin analog treatment regimens (biphasic, aspart, detemir). Participants with excessive weight gain were defined as the group with weight gain in the 4th quartile (>6.2 kg).We developed a pattern classification method to predict individuals prone to excessive weight gain.

RESULTS

Over the 18-month treatment period, median weight gain among all 412 patients was 2.4 kg (95% prediction interval [PI] -5.6, 12.4 kg), whereas median weight gain for those in the upper 4th quartile (n = 103) was 8.9 kg (95% PI 6.3, 15.2 kg). No clinical baseline data were strong predictors of excessive weight gain. However, the weight gain during the first 3 months of the trial and the subsequent dose of insulin yielded a useful predictor for weight gain at the 18-month follow-up. Combining these two predictors into a prediction model with other clinical available information produced a receiver operating characteristic area under the curve of 0.80.

CONCLUSIONS

We have developed a prediction model that could help identify a substantial proportion of individuals with T2DM prone to large weight gain during insulin therapy.

Gestational Diabetes Mellitus:current knowledge and unmet needs

Gestational diabetes mellitus (GDM) is a global health concern, not only because its prevalence is high and on the increase, but also because of the potential implications for the health of mothers and their offspring. Unfortunately, there is considerable controversy in the literature surrounding the diagnosis and treatment of GDM, as well as the possible long-term consequences for the offspring. As a result, worldwide there is a lack of uniformly accepted diagnostic criteria and the advice regarding the treatment of GDM, including diet, insulin therapy, and the use of oral blood glucose-lowering agents, is highly variable. In this review we provide an overview of the important issues in the field of GDM, including diagnostic criteria, different treatment regimens available, and the long-term consequences of GDM in the offspring.

Insulin promotes vascular smooth muscle cell proliferation and apoptosis via differential regulation of tumor necrosis factor-related apoptosis-inducing ligand

BACKGROUND

Insulin regulates glucose homeostasis but can also promote vascular smooth muscle (VSMC) proliferation, important in atherogenesis. Recently, we showed that tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) stimulates intimal thickening via accelerated growth of VSMCs. The aim of the present study was to determine whether insulin-induced effects on VSMCs occur via TRAIL.

METHODS

Expression of TRAIL and TRAIL receptor in response to insulin and glucose was determined by polymerase chain reaction. Transcriptional activity was assessed using wild-type and site-specific mutations of the TRAIL promoter. Chromatin immunoprecipitation studies were performed. VSMC proliferation and apoptosis was measured.

RESULTS

Insulin and glucose exposure to VSMC for 24 h stimulated TRAIL mRNA expression. This was also evident at the transcriptional level. Both insulin- and glucose-inducible TRAIL transcriptional activity was blocked by dominant-negative specificity protein-1 (Sp1) overexpression. There are five functional Sp1-binding elements (Sp1-1, Sp1-2, Sp-5/6 and Sp1-7) on the TRAIL promoter. Insulin required the Sp1-1 and Sp1-2 sites, but glucose needed all Sp1-binding sites to induce transcription. Furthermore, insulin (but not glucose) was able to promote VSMC proliferation over time, associated with increased decoy receptor-2 (DcR2) expression. In contrast, chronic 5-day exposure of VSMC to 1 µg/mL insulin repressed TRAIL and DcR2 expression, and reduced Sp1 enrichment on the TRAIL promoter. This was associated with increased cell death.

CONCLUSIONS

The findings of the present study provide a new mechanistic insight into how TRAIL is regulated by insulin. This may have significant implications at different stages of diabetes-associated cardiovascular disease. Thus, TRAIL may offer a novel therapeutic solution to combat insulin-induced vascular pathologies.

Role of Mig-6 in hepatic glucose metabolism

BACKGROUND

Mitogen-inducible gene 6 (Mig-6) has an important role in the regulation of cholesterol homeostasis and bile acid synthesis. However, the physiological functions of Mig-6 in the liver remain poorly understood.

METHODS

To investigate Mig-6 functioning in the liver, we used conditionally ablated Mig-6 using the Albumin-Cre mouse model (Alb(cre/+) Mig-6(f/f) ; Mig-6(d/d) ). Male mice were killed after a 24-h fast and refed after 24 h fasting. Fasting glucose and insulin levels were measured and western blot analyses were performed to determine epidermal growth factor receptor (EGFR), extracellular signal-regulated kinase (ERK) 1/2, AKT, mammalian target of rapamycin (mTOR), c-Jun N-terminal kinase (JNK), and Insulin receptor substrate-1 (IRS-1) in liver tissue samples. In addition, human hepatocellular carcinoma HepG2 cells were transfected with Mig-6 short interference (si) RNA before western blot analysis.

RESULTS

Serum fasting glucose levels were significantly higher in Mig-6(d/d) versus Mig-6(f/f) mice. On an insulin tolerance test, insulin sensitivity was decreased in Mig-6(d/d) versus Mig-6(f/f) mice. Furthermore, hepatic expression of the glucokinase (Gck), glucose-6-phosphatase (G6pc), and phosphoenolpyruvate carboxykinase 1 (Pck1) genes was decreased significantly in Mig-6(d/d) mice. Phosphorylation of EGFR, ERK1/2, AKT, mTOR, JNK, and IRS-1 was increased in Mig-6(d/d) compared with Mig-6(f/f) mice.

CONCLUSION

Liver-specific ablation of Mig-6 caused hyperglycemia by hepatic insulin resistance. Increased EGFR signaling following Mig-6 ablation activated JNK and eventually induced insulin resistance by increasing phosphorylation of IRS-1 at serine 307. This is the first report of Mig-6 involvement in hepatic insulin resistance and a new mechanism that explains hepatic insulin resistance.