XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

1. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification and diagnosis of diabetes

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Hyperglycemia and Adverse Pregnancy Outcomes

Metformin is a widely-used drug that results in clear benefits in relation to glucose metabolism and diabetes-related complications. The mechanisms underlying these benefits are complex and still not fully understood. Physiologically, metformin has been shown to reduce hepatic glucose production, yet not all of its effects can be explained by this mechanism and there is increasing evidence of a key role for the gut. At the molecular level the findings vary depending on the doses of metformin used and duration of treatment, with clear differences between acute and chronic administration. Metformin has been shown to act via both AMP-activated protein kinase (AMPK)-dependent and AMPK-independent mechanisms; by inhibition of mitochondrial respiration but also perhaps by inhibition of mitochondrial glycerophosphate dehydrogenase, and a mechanism involving the lysosome. In the last 10 years, we have moved from a simple picture, that metformin improves glycaemia by acting on the liver via AMPK activation, to a much more complex picture reflecting its multiple modes of action. More work is required to truly understand how this drug works in its target population: individuals with type 2 diabetes.

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The mechanisms of action of metformin

We aimed to evaluate whether SARS-CoV-2 infection is associated with beta cell dysfunction and progression of glycemic and cardiometabolic variables in an established cohort. Study participants (n = 352, 46.9% men) underwent a detailed evaluation at two time points: (a) pre-COVID (2016–19) and (b) peri-COVID (2020–21). At the second visit, SARS-CoV-2 infection was determined on the basis of a quantitative S1/S2 IgG antibody test (DiaSorin Liaison) and/or a documented history of infection. A total of 159 (45.2%) participants were seropositive for SARS-CoV-2, of whom 122 (76.7%) had mild/asymptomatic infection. Progression in body mass index (BMI) category [34 (21.4%) vs. 22 (11.4%), p = 0.011] was seen in a significantly higher proportion of the participants in the infected group compared to the non-infected group. Progression in glycemic and insulin indices [homeostasis model assessment of insulin resistance (HOMA-IR), Matsuda index, and oral disposition index (oDI)] categories was also evident in a larger proportion of participants in the infected group; however, the difference was not statistically significant. On logistic regression analysis, the association between SARS-CoV-2 infection and BMI category progression was statistically significant [fully adjusted OR 2.14 (95% CI, 1.18–3.90; p = 0.013)]. In this longitudinal study, predominant mild/asymptomatic SARS-CoV-2 infection was associated with increase in BMI, but not with worsening of beta cell function and insulin resistance, nor glycemic progression.

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Impact of SARS-CoV-2 on Progression of Glycemic and Cardiometabolic Variables and Changes in Insulin Indices: A Longitudinal Study.

1 Callaway LK, Prins JB, Chang AM, McIntyre HD. The prevalence and impact of overweight and obesity in an Australian obstetric population. Med J Aust 2006; 184: 56–59. 2 Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002; 25: 1862–1868. 3 Bellamy L, Casas J-P, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet 2009; 373: 1773–1779. 4 Lee AJ, Walker SP, Hiscock RJ, Permezel M, Wein P. Gestational diabetes mellitus: clinical predictors and long-term risk of developing type 2 diabetes. Diabetes Care 2007; 30: 878–883. 5 Whiteman VE, Aliyu MH, August EM, McIntosh C, Duan J, Alio AP et al. Changes in pre-pregnancy body mass index between pregnancies and risk of gestational and type 2 diabetes. Arch Gynecol Obstet 2011; 248: 235–240. 6 Ehrlich SF, Hedderson MM, Feng J, Davenport ER, Gunderson EP, Ferrara A. Change in body mass index between pregnancies and the risk of gestational diabetes in second pregnancy. Obs Gynecol 2011; 117: 1323–1330. 7 Hoffman L, Nolan C, Wilson JD, Oats JJN, Simmons D. Gestational diabetes mellitus – management guidelines. Med J Aust 1998; 169: 93–97. 8 Foster-Powell KA, Cheung NW. Recurrence of gestational diabetes. Aust N Z J Obstet Gynaecol 1998; 38: 384–387.

Response to Lie et al. Preventing Type 2 diabetes after gestational diabetes: women's experiences and implications for diabetes prevention interventions.

Pre-conception management of diabetes implies the optimization of all biological, social, and psychological factors, prior to conception, in a woman with preexisting type 1 or type 2 diabetes. Pre-conception management includes appropriate counseling, investigations, glycaemic and supportive management. This brief communication encapsulates the essential features of pre-conception management.

Pre-conception management of diabetes.

Diabetes and seizures have a multifaceted relationship. An association of diabetes and epilepsy was first described a century ago by Labbe,[1] who suggested acidosis and “degeneracy” as the etiology of seizures. Epilepsia tarda (or onset of seizures after age 40) was noted in insulin‐treated persons as well.[2] Diabetes may be associated with hypomagnesemia, hypocalcemia, and nonketotic hyperglycemia: All these can cause seizures.[3] Diabetes therapy can be proepileptogenic, too, as some glucose‐lowering drugs may cause hypoglycemia. Multiple other hypotheses have been proposed to explain the increased occurrence of seizures in diabetes.[4] These include microvascular damage, local brain damage, immune abnormalities, metabolic factors, and gene mutation.

Epileptogenicity of diabetes and antiepileptogenicity of ketogenic states: Clarity or confusion?

The novel coronavirus (SARS-CoV-2) pandemic has emerged as a major public health challenge, affecting more than 380 million people globally and causing more than 5.6 million deaths This article is protected by copyright. All rights reserved.

Yashdeep Gupta

Papers

Impact of SARS-CoV-2 on Progression of Glycemic and Cardiometabolic Variables and Changes in Insulin Indices: A Longitudinal Study.

Response to Lie et al. Preventing Type 2 diabetes after gestational diabetes: women's experiences and implications for diabetes prevention interventions.

Pre-conception management of diabetes.

Epileptogenicity of diabetes and antiepileptogenicity of ketogenic states: Clarity or confusion?

Mild and asymptomatic SARS‐CoV‐2 infection is not associated with progression of thyroid dysfunction or thyroid autoimmunity