Showing papers in "Diabetic Medicine in 2021"

Increased paediatric presentations of severe diabetic ketoacidosis in an Australian tertiary centre during the COVID-19 pandemic.

Abstract: AIMS: To determine if the frequency of severe diabetic ketoacidosis at presentation of new-onset type 1 diabetes to an Australian tertiary centre increased during the initial period of restrictions resulting from the COVID-19 pandemic (March to May 2020). METHODS: Data were collected on presentations of newly diagnosed type 1 diabetes as well as on all paediatric presentations to the emergency department of a tertiary centre between 2015 and 2020. Data from the period of initial COVID restrictions in Australia (March to May 2020) were compared to the period March to May of the previous 5 years (pre-pandemic periods). RESULTS: The number of new diagnoses of type 1 diabetes was comparable in the pandemic period and pre-pandemic periods (11 in 2020 vs range 6-10 in 2015-2019). The frequency of severe diabetic ketoacidosis was significantly higher in the pandemic period compared to the pre-pandemic periods (45% vs 5%; P <0.003), odds ratio 16.7 (95% CI 2.0, 194.7). The overall frequency of diabetic ketoacidosis was also significantly higher during the pandemic period (73% vs 26%; P <0.007), odds ratio 7.5 (95% CI 1.7, 33.5). None of the individuals tested positive for COVID-19. Presentations of people aged <18 years to the emergency department decreased by 27% in the pandemic period compared to the average of the pre-pandemic periods (4799 vs 6550; range 6268 to 7131). CONCLUSIONS: A significant increase in the frequency of severe diabetic ketoacidosis at presentation of type 1 diabetes was observed during the initial period of COVID-19 restrictions. We hypothesize that concern about presenting to hospital during a pandemic led to a delay in diagnosis. These data have important implications for advocacy of seeking healthcare for non-pandemic-related conditions during a global pandemic.

Predictors of type 2 diabetes remission in the Diabetes Remission Clinical Trial (DiRECT)

Abstract: AIM To identify predictors of type 2 diabetes remission in the intervention arm of DiRECT (Diabetes Remission Clinical Trial). METHODS Participants were aged 20-65 years, with type 2 diabetes duration of <6 years and BMI 27-45 kg/m2 , and were not receiving insulin. Weight loss was initiated by total diet replacement (825-853 kcal/day, 3-5 months, shakes/soups), and weight loss maintenance support was provided for 2 years. Remissions (HbA1c <48 mmol/mol [<6.5%], without antidiabetes medications) in the intervention group (n = 149, mean age 53 years, BMI 35 kg/m2 ) were achieved by 68/149 participants (46%) at 12 months and by 53/149 participants (36%) at 24 months. Potential predictors were examined by logistic regression analyses, with adjustments for weight loss and effects independent of weight loss. RESULTS Baseline predictors of remission at 12 and 24 months included being prescribed fewer antidiabetes medications, having lower triglyceride and gamma-glutamyl transferase levels, and reporting better quality of life with less anxiety/depression. Lower baseline HbA1c was a predictor at 12 months, and older age and male sex were predictors at 24 months. Being prescribed antidepressants predicted non-remission. Some, but not all effects were explained by weight loss. Weight loss was the strongest predictor of remission at 12 months (adjusted odds ratio per kg weight loss 1.24, 95% CI 1.14, 1.34; P < 0.0001) and 24 months (adjusted odds ratio 1.23, 95% CI 1.13, 1.35; P <0.0001). Weight loss in kilograms and percentage weight loss were equally good predictors. Early weight loss and higher programme attendance predicted more remissions. Baseline BMI, fasting insulin, fasting C-peptide and diabetes duration did not predict remission. CONCLUSIONS Other than weight loss, most predictors were modest, and not sufficient to identify subgroups for which remission was not a worthwhile target.

Dexamethasone therapy in COVID-19 patients: implications and guidance for the management of blood glucose in people with and without diabetes.

Abstract: The RECOVERY (Randomised Evaluation of COVid‐19 thERapY) trial found that dexamethasone 6 mg once per day for 10 days reduced deaths by one‐third in ventilated patients and by one‐fifth in other patients, receiving oxygen therapy. This equates to the prevention of one death in around eight ventilated patients, or one in around 25 patients requiring oxygen.

The SARS-CoV-2 pandemic is associated with increased severity of presentation of childhood onset type 1 diabetes mellitus: A multi-centre study of the first COVID-19 wave.

Abstract: OBJECTIVE: Children are usually mildly affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19). However, the pandemic has caused collateral damage to those with non-COVID-19 diseases. We aimed to determine the impact of the COVID-19 pandemic on the presentation of newly diagnosed childhood onset type 1 diabetes. METHODS: This was a cross-sectional study conducted over a 1-year period. We compared the severity of presentation of new-onset type 1 diabetes in children under the age of 18 presenting to the multi-centre North Central London diabetes network before (1 July 2019 to 22 March 2020) and during (23 March 2020 to 30 June 2020) the first wave of the COVID-19 pandemic in the United Kingdom. RESULTS: Over the 1-year study period, a total of 30 children presented with new-onset type 1 diabetes during the pre-pandemic period and 17 presented during the first COVID-19 wave. Children presented more frequently in diabetic ketoacidosis (DKA) during the first COVID-19 wave compared with pre-pandemic (pre-pandemic: mild 13%, moderate 6.7%, severe 10%; first COVID-19 wave: mild 5.9%, moderate 24%, severe 47%; p = 0.002). During the first COVID-19 wave, DKA presentations in children with a family history of type 1 diabetes were fewer compared to those without a family history (33.3% vs. 100.0%; p = 0.006). Children presenting in severe DKA pre-pandemic were younger than those not in severe DKA (3.9 years vs. 12.2 years, p < 0.001) but this difference was not significant during the first COVID-19 wave (10.1 years vs. 11.2 years, p = 0.568). Presenting HbA1c measurement was higher in those presenting during the first COVID-19 wave (13.0 ± 1.7 vs. 10.4 ± 3.2%; 119 ± 19 vs. 90 ± 35 mmol/mol; p = 0.008). CONCLUSION: The COVID-19 pandemic is associated with increased severity of presentation of childhood onset type 1 diabetes. Whatever the context, young people with suspected new-onset type 1 diabetes should be referred for urgent clinical review.

Assessment of the effect of the COVID-19 lockdown on glycaemic control in people with type 1 diabetes using flash glucose monitoring.

Abstract: AIM: To describe the effect of the stringent lockdown measures, introduced in the UK on 23 March 2020 to curtail the transmission of COVID-19, on glycaemic control in people with type 1 diabetes using flash glucose monitoring. METHODS: We undertook an observational study of 572 individuals with type 1 diabetes for whom paired flash glucose monitoring data were available between early March and May 2020. The primary outcome was change in flash glucose monitoring variables. We also assessed clinical variables associated with change in glycaemic control. RESULTS: Percentage of time in range increased between March and May 2020 [median (interquartile range) 53 (41-64)% vs 56 (45-68)%; P < 0.001], with associated improvements in standard deviation of glucose (P <0.001) and estimated HbA1c (P <0.001). There was a small reduction in the number of individuals meeting the hypoglycaemia target of <5% per day (64% vs 58%; P = 0.004). Comparing changes in flash glucose monitoring data from March to May in 2019 with the same period in 2020 confirmed that these differences were confined to 2020. Socio-economic deprivation was an independent predictor of a ≥5% reduction in time in range during lockdown (odds ratio 0.45 for people in the two most affluent Scottish Index of Multiple Deprivation quintiles; P <0.001). CONCLUSIONS: Lockdown was not associated with a significant deterioration in glycaemic control in people with type 1 diabetes using flash glucose monitoring. However, socio-economic deprivation appeared to increase the risk of decline in glycaemic control, which has implications for how support is focused in challenging times.

The impact of the COVID-19 pandemic on people with diabetes and diabetes services: A pan-European survey of diabetes specialist nurses undertaken by the Foundation of European Nurses in Diabetes survey consortium.

Abstract: Aim To describe diabetes nurses' perspectives on the impact of the COVID-19 pandemic on people with diabetes and diabetes services across Europe. Methods An online survey developed using a rapid Delphi method. The survey was translated into 17 different languages and disseminated electronically in 27 countries via national diabetes nurse networks. Results Survey responses from 1829 diabetes nurses were included in the analysis. The responses indicated that 28% (n = 504) and 48% (n = 873) of diabetes nurses felt the COVID-19 pandemic had impacted 'a lot' on the physical and psychological risks of people with diabetes, respectively. The following clinical problems were identified as having increased 'a lot': anxiety 82% (n = 1486); diabetes distress 65% (n = 1189); depression 49% (n = 893); acute hyperglycaemia 39% (n = 710) and foot complications 18% (n = 323). Forty-seven percent (n = 771) of respondents identified that the level of care provided to people with diabetes had declined either extremely or quite severely. Self-management support, diabetes education and psychological support were rated by diabetes nurse respondents as having declined extremely or quite severely during the COVID-19 pandemic by 31% (n = 499), 63% (n = 1,027) and 34% (n = 551), respectively. Conclusion The findings show that diabetes nurses across Europe have seen significant increases in both physical and psychological problems in their patient populations during COVID-19. The data also show that clinical diabetes services have been significantly disrupted. As the COVID-19 situation continues, we need to adapt care systems with some urgency to minimise the impact of the pandemic on the diabetes population.

Continuous glucose monitoring: A review of the evidence in type 1 and 2 diabetes mellitus

Abstract: CONTEXT AND AIM: Continuous glucose monitoring (CGM) is becoming widely accepted as an adjunct to diabetes management. Compared to standard care, CGM can provide detailed information about glycaemic variability in an internationally standardised ambulatory glucose profile, enabling more informed user and clinician decision making. We aimed to review the evidence, user experience and cost-effectiveness of CGM. METHODS: A literature search was conducted by combining subject headings 'CGM' and 'flash glucose monitoring', with key words 'type 1 diabetes' and 'type 2 diabetes', limited to '1999 to current'. Further evidence was obtained from relevant references of retrieved articles. RESULTS: There is a strong evidence for CGM use in people with type 1 diabetes, with benefits of reduced glycated haemoglobin and hypoglycaemia, and increased time in range. While the evidence for CGM use in type 2 diabetes is less robust, similar benefits have been demonstrated. CGM can improve diabetes-related satisfaction in people with diabetes (PWD) and parents of children with diabetes, as well as the clinician experience. However, CGM does have limitations including cost, accuracy and perceived inconvenience. Cost-effectiveness analyses have indicated that CGM is a cost-effective adjunct to type 1 diabetes management that is associated with reduced diabetes-related complications and hospitalisation. CONCLUSIONS: Continuous glucose monitoring is revolutionising diabetes management. It is a cost-effective adjunct to diabetes management that has the potential to improve glycaemic outcomes and quality of life in PWD, especially type 1 diabetes.

Dietary pattern, colonic microbiota and immunometabolism interaction: new frontiers for diabetes mellitus and related disorders.

Abstract: In this review, the numerous possible mechanisms that provide supportive evidence for how colonic dysbiosis denotes metabolic dysfunction, dysregulates glucose homeostasis and leads to diabetes mellitus and related metabolic disorders are defined. Information was gathered from articles identified by systematic reviews and searches using Google, PubMed and Scopus. The composition of the colonic microbiota plays an integral role in maintaining host homeostasis by affecting both metabolic activities and underlying functional gene transcription in individuals with diabetes and related metabolic disorders. Increased colonic microbiome-derived concentrations of lipopolysaccharides, also known as 'metabolic endotoxaemia', as well as alterations in bile acid metabolism, short-chain fatty acids, intestinal hormones and branched-chain amino acid secretion have been associated with the diverse production of pro-inflammatory cytokines and the recruitment of inflammatory cells. It has been shown that changes to intestinal bacterial composition are significant even in early childhood and are associated with the pathogenesis of both types of diabetes. We hope that an improved understanding of related mechanisms linking the colonic microbiome with glucose metabolism might provide for innovative therapeutic approaches that would bring the ideal intestinal ecosystem to a state of optimal health, thus preventing and treating diabetes and related metabolic disorders.

Time in range: A best practice guide for UK diabetes healthcare professionals in the context of the COVID-19 global pandemic.

Abstract: The emergence of continuous glucose monitoring has driven improvements in glycaemic control and quality of life for people with diabetes. Recent changes in access to continuous glucose monitoring systems within UK health services have increased the number of people able to benefit from these technologies. The COVID-19 pandemic has created an opportunity for diabetes healthcare professionals to use continuous glucose monitoring technology to remotely deliver diabetes services to support people with diabetes. This opportunity can be maximized with improved application and interpretation of continuous glucose monitoring-generated data. Amongst the diverse measures of glycaemic control, time in range is considered to be of high value in routine clinical care because it is actionable and is visibly responsive to changes in diabetes management. Importantly, it is also been linked to the risk of developing complications associated with diabetes and can be understood by people with diabetes and healthcare professionals alike. The 2019 International Consensus on Time in Range has established a series of target glucose ranges and recommendations for time spent within these ranges that is consistent with optimal glycaemic control. The recommendations cover people with type 1 or type 2 diabetes, with separate targets indicated for elderly people or those at higher risk from hypoglycaemia, as well as for women with type 1 diabetes during pregnancy. The aim of this best practice guide was to clarify the intent and purpose of these international consensus recommendations and to provide practical insights into their implementation in UK diabetes care.

Impact of the COVID-19 pandemic and lockdown restrictions on psychosocial and behavioural outcomes among Australian adults with type 2 diabetes: findings from the PREDICT cohort study

Abstract: AIM: To examine psychosocial and behavioural impacts of the novel coronavirus disease 2019 (COVID-19) pandemic and lockdown restrictions among adults with type 2 diabetes. METHODS: Participants enrolled in the PRogrEssion of DIabetic ComplicaTions (PREDICT) cohort study in Melbourne, Australia (n = 489 with a baseline assessment pre-2020) were invited to complete a phone/online follow-up assessment in mid-2020 (i.e., amidst COVID-19 lockdown restrictions). Repeated assessments that were compared with pre-COVID-19 baseline levels included anxiety symptoms (7-item Generalised Anxiety Disorder scale [GAD-7]), depressive symptoms (8-item Patient Health Questionnaire [PHQ-8]), diabetes distress (Problem Areas in Diabetes scale [PAID]), physical activity/sedentary behaviour, alcohol consumption and diabetes self-management behaviours. Additional once-off measures at follow-up included COVID-19-specific worry, quality of life (QoL), and healthcare appointment changes (telehealth engagement and appointment cancellations/avoidance). RESULTS: Among 470 respondents (96%; aged 66 ± 9 years, 69% men), at least 'moderate' worry about COVID-19 infection was reported by 31%, and 29%-73% reported negative impacts on QoL dimensions (greatest for: leisure activities, feelings about the future, emotional well-being). Younger participants reported more negative impacts (p < 0.05). Overall, anxiety/depressive symptoms were similar at follow-up compared with pre-COVID-19, but diabetes distress reduced (p < 0.001). Worse trajectories of anxiety/depressive symptoms were observed among those who reported COVID-19-specific worry or negative QoL impacts (p < 0.05). Physical activity trended lower (~10%), but sitting time, alcohol consumption and glucose-monitoring frequency remained unchanged. 73% of participants used telehealth, but 43% cancelled a healthcare appointment and 39% avoided new appointments despite perceived need. CONCLUSIONS: COVID-19 lockdown restrictions negatively impacted QoL, some behavioural risk factors and healthcare utilisation in adults with type 2 diabetes. However, generalised anxiety and depressive symptoms remained relatively stable.

At multiple fronts: Diabetes stigma and weight stigma in adults with type 2 diabetes.

Abstract: Aim The diabetes and obesity fields have called for attention to the harmful role of stigma in obesity and diabetes, especially given that little is known about the extent and nature of diabetes stigma facing adults with type 2 diabetes, or the experience of weight stigma in this population This study addresses this research gap by examining the prevalence and demographic correlates of weight stigma and diabetes stigma in individuals with type 2 diabetes Methods Adults (N = 1212, Mage = 52) with type 2 diabetes living in the USA were recruited by a healthcare-oriented market research firm, and completed online questionnaires to assess their experiences with weight stigma and diabetes stigma, as well as their internalization of both forms of stigma Rates of stigma and sociodemographic correlates (years with type 2 diabetes, age, education, income, gender, race and BMI) were examined Results More than half of participants reported prior experiences of weight stigma, and 40-60% reported experiencing weight stigma in a healthcare context Participants reported frequent experiences with diabetes-related stigma including blame and judgement, self-stigma and differential treatment Women reported more weight stigma than men, and White women appeared particularly at risk for experiencing weight and diabetes related stigma relative to Black women Conclusions Individuals with type 2 diabetes reported higher rates of weight stigma than the general population, experienced high rates of diabetes-related stigma, and many internalized these forms of stigma Increased attention to stigma reduction is essential to ensuring equitable care for individuals with type 2 diabetes

Impact of routine clinic measurement of serum C-peptide in people with a clinician-diagnosis of type 1 diabetes.

Abstract: Aims/hypothesis The aim of this study was to determine the impact of the routine use of serum C-peptide in an out-patient clinic setting on individuals with a clinician-diagnosis of type 1 diabetes. Methods In this single-centre study, individuals with type 1 diabetes of at least 3 years duration were offered random serum C-peptide testing at routine clinic review. A C-peptide ≥200 pmol/L prompted further evaluation of the individual using a diagnostic algorithm that included measurement of islet cell antibodies and genetic testing. Where appropriate, a trial of anti-diabetic co-therapies was considered. Results Serum C-peptide testing was performed in 859 individuals (90% of the eligible cohort), of whom 114 (13.2%) had C-peptide ≥200 pmol/L. The cause of diabetes was reclassified in 58 individuals (6.8% of the tested cohort). The majority of reclassifications were to type 2 diabetes (44 individuals; 5.1%), with a smaller proportion of monogenic diabetes (14 individuals; 1.6%). Overall, 13 individuals (1.5%) successfully discontinued insulin, while a further 16 individuals (1.9%) had improved glycaemic control following the addition of co-therapies. The estimated total cost of the testing programme was £23,262 (~€26,053), that is, £27 (~€30) per individual tested. In current terms, the cost of prior insulin therapy in the individuals with monogenic diabetes who successfully stopped insulin was approximately £57,000 (~€64,000). Conclusions/interpretation Serum C-peptide testing can easily be incorporated into an out-patient clinic setting and could be a cost-effective intervention. C-peptide testing should be strongly considered in individuals with a clinician-diagnosis of type 1 diabetes of at least 3 years duration.

Approaches to screening for hyperglycaemia in pregnant women during and after the COVID-19 pandemic.

Abstract: AIM: To evaluate the diagnostic and prognostic performance of alternative diagnostic strategies to oral glucose tolerance tests, including random plasma glucose, fasting plasma glucose and HbA1c , during the COVID-19 pandemic. METHODS: Retrospective service data (Cambridge, UK; 17 736 consecutive singleton pregnancies, 2004-2008; 826 consecutive gestational diabetes pregnancies, 2014-2019) and 361 women with ≥1 gestational diabetes risk factor (OPHELIA prospective observational study, UK) were included. Pregnancy outcomes included gestational diabetes (National Institute of Health and Clinical Excellence or International Association of Diabetes and Pregnancy Study Groups criteria), diabetes in pregnancy (WHO criteria), Caesarean section, large-for-gestational age infant, neonatal hypoglycaemia and neonatal intensive care unit admission. Receiver-operating characteristic curves and unadjusted logistic regression were used to compare random plasma glucose, fasting plasma glucose and HbA1c performance. RESULTS: Gestational diabetes diagnosis was significantly associated with random plasma glucose at 12 weeks [area under the receiver-operating characteristic curve for both criteria 0.81 (95% CI 0.79-0.83)], fasting plasma glucose [National Institute of Health and Clinical Excellence: area under the receiver-operating characteristic curve 0.75 (95% CI 0.65-0.85); International Association of Diabetes and Pregnancy Study Groups: area under the receiver-operating characteristic curve 0.92 (95% CI 0.85-0.98)] and HbA1c at 28 weeks' gestation [National Institute of Health and Clinical Excellence: 0.83 (95% CI 0.75-0.90); International Association of Diabetes and Pregnancy Study Groups: 0.84 (95% CI 0.77-0.91)]. Each measure predicts some, but not all, pregnancy outcomes studied. At 12 weeks, ~5% of women would be identified using random plasma glucose ≥8.5 mmol/l (sensitivity 42%; specificity 96%) and at 28 weeks using HbA1c ≥39 mmol/mol (sensitivity 26%; specificity 96%) or fasting plasma glucose ≥5.2-5.4 mmol/l (sensitivity 18-41%; specificity 97-98%). CONCLUSIONS: Random plasma glucose at 12 weeks, and fasting plasma glucose or HbA1c at 28 weeks identify women with hyperglycaemia at risk of suboptimal pregnancy outcomes. These opportunistic laboratory tests perform adequately for risk stratification when oral glucose tolerance testing is not available.

Developmental programming by maternal obesity: Lessons from animal models.

Abstract: The obesity epidemic has led to more women entering pregnancy overweight or obese. In addition to adverse short-term outcomes, maternal obesity and/or gestational diabetes predisposes offspring to developing obesity, type 2 diabetes and cardiovascular disease in adulthood through developmental programming. Human epidemiological studies, although vital in identifying associations, are often unable to address causality and mechanistic studies can be limited by the lack of accessibility of key metabolic tissues. Furthermore, multi-generational studies take many years to complete. Integration of findings from human studies with those from animal models has therefore been critical in moving forward this field that has been termed the "Developmental Origins of Health and Disease". This review summarises the evidence from animal models and highlights how animal models provide valuable insight into the maternal factors responsible for developmental programming, potential critical developmental windows, sexual dimorphism, molecular mechanisms and age-related offspring outcomes throughout life. Moreover, we describe how animal models are vital to explore clinically relevant interventions to prevent adverse offspring outcomes in obese or glucose intolerant pregnancy, such as antioxidant supplementation, exercise and maternal metformin treatment.

An overview of COVID-19 in people with diabetes: Pathophysiology and considerations in the inpatient setting.

Abstract: INTRODUCTION: The coronavirus disease (COVID-19) pandemic has continued to have a devastating impact on health worldwide. There has been a rapid evolution of evidence, establishing an increased risk of morbidity and mortality associated with diabetes and concurrent COVID-19. The objective of this review is to explore the current evidence for inpatient assessment and management of diabetes during the COVID-19 pandemic and highlight areas requiring further exploration. METHODS: A literature search of databases was conducted to November 2020 using variations on keywords SARS-CoV-2, COVID-19, SARS, MERS and diabetes. Information relating to the impact of diabetes on severity of COVID-19 infection, the impact of COVID-19 infection on diabetes management and diabetes-related complications was integrated to create a narrative review. DISCUSSION: People with diabetes and COVID-19 are at an increased risk of morbidity and mortality. It is important that people with both known and previously unrecognised diabetes and COVID-19 be promptly identified and assessed during acute illness, with close monitoring for clinical deterioration or complications. People with diabetes may require titration or alteration of their glycaemic management due to the potential for worse outcomes with hyperglycaemia and COVID-19 infection. Comprehensive discharge planning is vital to optimise ongoing glycaemic management. CONCLUSION: Further understanding of the risk of adverse outcomes and optimisation of glycaemic management for people with diabetes during COVID-19 is required to improve outcomes. Increased glucose and ketone monitoring, substitution of insulin for some oral anti-hyperglycaemic medications and careful monitoring for complications of diabetes such as diabetic ketoacidosis should be considered.

Association of British Clinical Diabetologists and Renal Association guidelines on the detection and management of diabetes post solid organ transplantation.

Abstract: Post-transplant diabetes mellitus (PTDM) is common after solid organ transplantation (SOT) and associated with increased morbidity and mortality for allograft recipients. Despite the significant burden of disease, there is a paucity of literature with regards to detection, prevention and management. Evidence from the general population with diabetes may not be translatable to the unique context of SOT. In light of emerging clinical evidence and novel anti-diabetic agents, there is an urgent need for updated guidance and recommendations in this high-risk cohort. The Association of British Clinical Diabetologists (ABCD) and Renal Association (RA) Diabetic Kidney Disease Clinical Speciality Group has undertaken a systematic review and critical appraisal of the available evidence. Areas of focus are; (1) epidemiology, (2) pathogenesis, (3) detection, (4) management, (5) modification of immunosuppression, (6) prevention, and (7) PTDM in the non-renal setting. Evidence-graded recommendations are provided for the detection, management and prevention of PTDM, with suggested areas for future research and potential audit standards. The guidelines are endorsed by Diabetes UK, the British Transplantation Society and the Royal College of Physicians of London. The full guidelines are available freely online for the diabetes, renal and transplantation community using the link below. The aim of this review article is to introduce an abridged version of this new clinical guideline ( https://abcd.care/sites/abcd.care/files/site_uploads/Resources/Position-Papers/ABCD-RA%20PTDM%20v14.pdf).

Understanding the relationship between type 2 diabetes and depression: lessons from genetically informative study designs

Abstract: Aims To conduct a systematic review in order to comprehensively synthesize the findings from a diverse range of genetically informative studies on comorbid depression and type 2 diabetes. Methods Database searches (1 January 2008 to 1 June 2020) in PubMed and EMBASE were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible reports employed any type of genetically informed design, including twin modelling, Mendelian randomization, genome-wide association studies, polygenetic risk scores, or linkage disequilibrium score regression. Searches generated 451 unique citations, and 16 manuscripts met the inclusion criteria. Results The included studies addressed three aetiological models of the depression-diabetes relationship: uni- or bi-directional phenotypic causation; shared genetic liability; or gene-environment interaction. From these studies, there is modest evidence that type 2 diabetes is causally related to risk of developing depression, but much more limited evidence that depression is causally related to risk of diabetes. There is little evidence of shared genetic liability between depression and diabetes or of gene-environment interaction. Conclusions Findings from genetically informed studies are mixed but provide some support for the uni- or bi-directional phenotypic model of depression and type 2 diabetes. Future studies should also explore the hypothesis that this relationship may be influenced by shared environmental risk factors. Findings can inform multifaceted approaches to diabetes prevention and care that reflect how psychosocial factors contribute to type 2 diabetes risk and outcomes.

Rates, determinants and success of implementing deprescribing in people with type 2 diabetes: A scoping review.

Abstract: Background Individualizing goals for people with type 2 diabetes may result in deintensification of medication, but a comprehensive picture of deprescribing practices is lacking. Aims To conduct a scoping review in order to assess the rates, determinants and success of implementing deprescribing of glucose-, blood pressure- or lipid-lowering medications in people with diabetes. Methods A systematic search on MEDLINE and Embase between January 2007 and January 2019 was carried out for deprescribing studies among people with diabetes. Outcomes were rates of deprescribing related to participant characteristics, the determinants and success of deprescribing, and its implementation. Critical appraisal was conducted using predefined tools. Results Fourteen studies were included; eight reported on rates, nine on determinants and six on success and implementation. Bias was high for studies on success of deprescribing. Deprescribing rates ranged from 14% to 27% in older people with low HbA(1c)levels, and from 16% to 19% in older people with low systolic blood pressure. Rates were not much affected by age, gender, frailty or life expectancy. Rates were higher when a reminder system was used to identify people with hypoglycaemia, which led to less overtreatment and fewer hypoglycaemic events. Most healthcare professionals accepted the concept of deprescribing but differed on when to conduct it. Deprescribing glucose-lowering medications could be successfully conducted in 62% to 75% of participants with small rises in HbA(1c). Conclusions Deprescribing of glucose-lowering medications seems feasible and acceptable, but was not widely implemented in the covered period. Support systems may enhance deprescribing. More studies on deprescribing blood pressure- and lipid-lowering medications in people with diabetes are needed.

Trends in prevalence and incidence of type 2 diabetes among adults in Beijing, China, from 2008 to 2017

Abstract: AIMS To describe secular trends in diagnosed type 2 diabetes prevalence and incidence in Beijing, China. METHODS Using health insurance claims for 17.7 million adults ≥20 years in 2008-2017, we identified people with diabetes using hospital diagnoses and drug prescriptions. Results were age-standardised using data for Beijing from China's 2010 census. Trends in prevalence and incidence were analysed using Joinpoint regression analysis. RESULTS From 2008 to 2017, we identified 2,104,159 people diagnosed with type 2 diabetes. Type 2 diabetes prevalence increased from 3.7% [95% CI: (3.6, 3.8)] to 6.6% (6.4, 6.7), but the annual rate of increase slowed from 18.1% (14.4, 22.0) to 1.5% (0.8, 2.2) before and after 2011 respectively. Women had a higher diabetes prevalence than men, for all years. The yearly increase in prevalence was greater in people younger than 40 years, with an average annual percentage change of 13.6% (10.7, 16.5) compared to 6.5% (5.6, 7.4) in those over 40 years. Over the 10 years, the overall incidence decreased from 24.3 (24.2, 24.4) to 11.5 (11.5, 11.6) per 1000 person-years, but it increased in people younger than 40 years. The average age at diabetes diagnosis dropped from 62 to 56 years (p < 0.001). Among incident cases of diabetes, the percentage of people under 40 years increased from 3.0% to 10.9% (p < 0.001). CONCLUSIONS The prevalence of diagnosed type 2 diabetes in Beijing increased continuously over the 10 years, the incidence decreased, except in people under 40 years. Continuous efforts are needed to prevent diabetes in China.

Metabolic phenotypes of early gestational diabetes mellitus and their association with adverse pregnancy outcomes.

Abstract: Aims To describe the metabolic phenotypes of early gestational diabetes mellitus and their association with adverse pregnancy outcomes. Methods We performed a post hoc analysis using data from the Vitamin D And Lifestyle Intervention for gestational diabetes prevention (DALI) trial conducted across nine European countries (2012-2014). In women with a BMI ≥ 29 kg/m2 ), insulin resistance and secretion were estimated from the oral glucose tolerance test values performed before 20 weeks, using homeostatic model assessment of insulin resistance and Stumvoll first-phase indices, respectively. Women with early gestational diabetes, defined by the International Association of Diabetes and Pregnancy Study Groups criteria, were classified into three groups: GDM-R (above-median insulin resistance alone), GDM-S (below-median insulin secretion alone), and GDM-B (combination of both) and the few remaining women were excluded. Results Compared with women in the normal glucose tolerance group (n = 651), women in the GDM-R group (n = 143) had higher fasting and post-load glucose values and insulin levels, with a greater risk of having large-for-gestational age babies [adjusted odds ratio 3.30 (95% CI 1.50-7.50)] and caesarean section [adjusted odds ratio 2.30 (95% CI 1.20-4.40)]. Women in the GDM-S (n=37) and GDM-B (n = 56) groups had comparable pregnancy outcomes with those in the normal glucose tolerance group. Conclusions In overweight and obese women with early gestational diabetes, higher degree of insulin resistance alone was more likely to be associated with adverse pregnancy outcomes than lower insulin secretion alone or a combination of both.

Evaluation of the SPECTRUM training programme for real‐time continuous glucose monitoring: A real‐world multicentre prospective study in 120 adults with type 1 diabetes

Abstract: AIMS Comprehensive knowledge, specific skills and data-analysis competences are prerequisites for the successful use of continuous glucose monitoring (CGM) systems. SPECTRUM is a structured training programme for real-time CGM (rtCGM) consisting of a web-based introduction and six group sessions of 90 min each. The 'CGM-TRAIN study' evaluated the efficacy and acceptance of SPECTRUM and rtCGM systems among adults with insulin therapy. METHODS Participants (n = 120) were recruited from 10 German diabetes centres in which they were treated under usual care conditions. Outcome measures were rtCGM knowledge, practical skills, satisfaction with the training programme, satisfaction and acceptance of rtCGM system and glycaemic control. Data were collected at study entry, after training completion and at 6-month follow-up. RESULTS All participants were diagnosed with type 1 diabetes (56% women, mean age 42.4 ± 13.4 years, diabetes duration 21.6 ± 11.6 years), 110 participants completed the course. After training completion, rtCGM-specific knowledge had improved by 43% (scale: 0-40 points) from 21.2 ± 7.6 to 30.4 ± 4.5 points; p < 0.001. The knowledge-level persisted until follow-up (29.4 ± 4.5). Participants were able to master nearly all the practical requirements of the technology. In addition, rtCGM was highly accepted, and participants were motivated to use their systems continuously. HbA1c improved slightly from 61 ± 14 mmol/mol (7.7 ± 1.3%) before training to 60 ± 14 mmol/mol (7.6 ± 1.3%) at follow-up (p = 0.04). The training programme itself was favourably rated by participants. CONCLUSIONS Under usual out-patient daily care conditions, the training programme SPECTRUM improved knowledge and skills about rtCGM in adults with type 1 diabetes. This was associated with a reduced HbA1c , high satisfaction and acceptance of rtCGM (Clinical Trials Registry no.: DRKS00014380).

A systematic review of illness perception interventions in type 2 diabetes: Effects on glycaemic control and illness perceptions.

Abstract: Aims This systematic review sought to synthesize the evidence regarding the effectiveness of illness perception interventions compared with control conditions at changing illness perceptions and improving glycaemic control in individuals with type 2 diabetes. Methods Seven electronic databases were searched between October 2018 and May 2020. Randomized controlled trials that tested interventions informed by the Common-Sense Model in adults with type 2 diabetes, and measured illness perceptions and glycaemic control at pre- and post-intervention were included. The Cochrane risk of bias tool was used to assess risk of bias. Results A total of 4095 articles were identified, of which nine randomized control trials (2561 participants) across 12 publications were included in this review. Findings showed that all the illness perception domains were modified in at least one trial, with the exception of cyclical timeline perceptions. Coherence, personal control, treatment control and chronic timeline perceptions were the most frequently modified perceptions. Glycaemic control demonstrated an improvement in the intervention group compared to the control group at 3 and 6 months post-intervention in two trials. Risk of bias assessment showed high risk of bias especially for the blinding of participants and the personnel domain. Conclusions There is limited evidence that interventions informed by the Common-Sense Model can improve glycaemic control in individuals with type 2 diabetes through changing inaccurate illness perceptions. Recommendations for future research are to tailor intervention content based on baseline perceptions, measure the emotional and causal domains, and involve family members in the intervention. (PROSPERO registration: CRD42019114532).

Living with diabetes alongside a severe mental illness: A qualitative exploration with people with severe mental illness, family members and healthcare staff

Abstract: AIMS Diabetes is two to three times more prevalent in people with severe mental illness, yet little is known about the challenges of managing both conditions from the perspectives of people living with the co-morbidity, their family members or healthcare staff. Our aim was to understand these challenges and to explore the circumstances that influence access to and receipt of diabetes care for people with severe mental illness. METHODS Framework analysis of qualitative semi-structured interviews with people with severe mental illness and diabetes, family members, and staff from UK primary care, mental health and diabetes services, selected using a maximum variation sampling strategy between April and December 2018. RESULTS In all, 39 adults with severe mental illness and diabetes (3 with type 1 diabetes and 36 with type 2 diabetes), nine family members and 30 healthcare staff participated. Five themes were identified: (a) Severe mental illness governs everyday life including diabetes management; (b) mood influences capacity and motivation for diabetes self-management; (c) cumulative burden of managing multiple physical conditions; (d) interacting conditions and overlapping symptoms and (e) support for everyday challenges. People living with the co-morbidity and their family members emphasised the importance of receiving support for the everyday challenges that impact diabetes management, and identified barriers to accessing this from healthcare providers. CONCLUSIONS More intensive support for diabetes management is needed when people's severe mental illness (including symptoms of depression) or physical health deteriorates. Interventions that help people, including healthcare staff, distinguish between symptoms of diabetes and severe mental illness are also needed.

Sustained type 1 diabetes self-management: Specifying the behaviours involved and their influences.

Abstract: Aims Sustained engagement in type 1 diabetes self‐management behaviours is a critical element in achieving improvements in glycated haemoglobin (HbA1c) and minimising risk of complications. Evaluations of self‐management programmes, such as Dose Adjustment for Normal Eating (DAFNE), typically find that initial improvements are rarely sustained beyond 12 months. This study identified behaviours involved in sustained type 1 diabetes self‐management, their influences and relationships to each other. Methods A mixed‐methods study was conducted following the first two steps of the Behaviour Change Wheel framework. First, an expert stakeholder consultation identified behaviours involved in self‐management of type 1 diabetes. Second, three evidence sources (systematic review, healthcare provider‐generated ‘red flags’ and participant‐generated ‘frequently asked questions’) were analysed to identify and synthesise modifiable barriers and enablers to sustained self‐management. These were characterised according to the Capability‐Opportunity‐Motivation‐Behaviour (COM‐B) model. Results 150 distinct behaviours were identified and organised into three self‐regulatory behavioural cycles, reflecting different temporal and situational aspects of diabetes self‐management: Routine (e.g. checking blood glucose), Reactive (e.g. treating hypoglycaemia) and Reflective (e.g. reviewing blood glucose data to identify patterns). Thirty‐four barriers and five enablers were identified: 10 relating to Capability, 20 to Opportunity and nine to Motivation. Conclusions Multiple behaviours within three self‐management cycles are involved in sustained type 1 diabetes self‐management. There are a wide range of barriers and enablers that should be addressed to support self‐management behaviours and improve clinical outcomes. The present study provides an evidence base for refining and developing type 1 diabetes self‐management programmes.

The impact of COVID-19 restrictions on accelerometer-assessed physical activity and sleep in individuals with type 2 diabetes.

Abstract: AIMS: Restrictions during the COVID-19 crisis will have impacted on opportunities to be active. We aimed to (a) quantify the impact of COVID-19 restrictions on accelerometer-assessed physical activity and sleep in people with type 2 diabetes and (b) identify predictors of physical activity during COVID-19 restrictions. METHODS: Participants were from the UK Chronotype of Patients with type 2 diabetes and Effect on Glycaemic Control (CODEC) observational study. Participants wore an accelerometer on their wrist for 8 days before and during COVID-19 restrictions. Accelerometer outcomes included the following: overall physical activity, moderate-to-vigorous physical activity (MVPA), time spent inactive, days/week with ≥30-minute continuous MVPA and sleep. Predictors of change in physical activity taken pre-COVID included the following: age, sex, ethnicity, body mass index (BMI), socio-economic status and medical history. RESULTS: In all, 165 participants (age (mean±S.D = 64.2 ± 8.3 years, BMI=31.4 ± 5.4 kg/m2 , 45% women) were included. During restrictions, overall physical activity was lower by 1.7 mg (~800 steps/day) and inactive time 21.9 minutes/day higher, but time in MVPA and sleep did not statistically significantly change. In contrast, the percentage of people with ≥1 day/week with ≥30-minute continuous MVPA was higher (34% cf. 24%). Consistent predictors of lower physical activity and/or higher inactive time were higher BMI and/or being a woman. Being older and/or from ethnic minorities groups was associated with higher inactive time. CONCLUSIONS: Overall physical activity, but not MVPA, was lower in adults with type 2 diabetes during COVID-19 restrictions. Women and individuals who were heavier, older, inactive and/or from ethnic minority groups were most at risk of lower physical activity during restrictions.

Real-world evidence on clinical outcomes of people with type 1 diabetes using open-source and commercial automated insulin dosing systems: A systematic review.

Abstract: Aims Several commercial and open-source automated insulin dosing (AID) systems have recently been developed and are now used by an increasing number of people with diabetes. This systematic review explored the current status of real-world evidence on the latest available AID systems in helping to understand their safety and effectiveness. Methods A systematic review of real-world studies on the effect of commercial and open-source AID system use on clinical outcomes was conducted employing a devised protocol (PROSPERO ID 257354). Results Of 441 initially identified studies, 21 published 2018-2021 were included: 12 for Medtronic 670G; 1 for Tandem Control-IQ; 1 for Diabeloop DBLG1; 2 for AndroidAPS; 1 for OpenAPS; 1 for Loop; 3 comparing various types of AID systems. These studies found that several types of AID systems improve Time-in-Range and haemoglobin A1c (HbA1c) with minimal concerns around severe hypoglycaemia. These improvements were observed in open-source and commercially-developed AID systems alike. Conclusions Commercially developed and open-source AID systems represent effective and safe treatment options for people with diabetes of several age groups and genders. Alongside evidence from randomised clinical trials, real-world studies on AID systems and their effects on glycaemic outcomes are a helpful method for evaluating their safety and effectiveness.

Device-measured physical activity and its association with physical function in adults with type 2 diabetes mellitus.

Abstract: AIM To quantify how differences in metrics characterizing physical activity and sedentary behaviour in type 2 diabetes are associated with physical function. METHODS This analysis included participants' data from the Chronotype of Patients with Type 2 Diabetes and Effect on Glycaemic Control (CODEC) cross-sectional study. Data were stratified into two groups according to their short physical performance battery (SPPB) score (impaired physical function = SPPB < 10 and normal physical function = SPPB ≥ 10). Hand-grip strength, sit-to-stand 60 (STS-60) and the Duke Activity Status Index (DASI) score were used to assess functional capacity, while physical activity metrics were measured with a wrist-worn accelerometer. The associations between physical activity metrics and measures of functional capacity were analysed using generalized linear modelling. RESULTS Some 635 adults (median age 66 years, 34% female) were included in this analysis. Overall, 29% of the cohort scored < 10 in the SPPB test indicating impaired physical function. This group spent more time in prolonged sedentary behaviour (600.7 vs. 572.5 min) and undertook less-intense physical activity. Each sd increase in physical activity volume and intensity gradients for those with impaired physical function was associated with 17% more repetitions for STS-60 with similar associations seen for DASI score. Each sd in sedentary time was associated with 15% fewer repetitions in STS-60 and 16% lower DASI score in those with impaired physical function, whereas in normal physical function group it was 2% and 1%, respectively. CONCLUSIONS The strength of the associations for physical activity measures and functional capacity were modified by physical function status, with the strongest association seen in those with impaired physical function.

Trends in diabetic retinopathy screening attendance and associations with vision impairment attributable to diabetes in a large nationwide cohort

Abstract: AIMS: To investigate diabetic retinopathy screening attendance and trends in certified vision impairment caused by diabetic eye disease. METHODS: This was a retrospective study of attendance in three urban UK diabetic eye screening programmes in England. A survival analysis was performed to investigate time from diagnosis to first screen by age and sex. Logistic regression analysis of factors influencing screening attendance during a 15-month reporting period was conducted, as well as analysis of new vision impairment certifications (Certificate of Vision Impairment) in England and Wales from 2009 to 2019. RESULTS: Of those newly registered in the Routine Digital Screening pathway (n = 97 048), 80% attended screening within the first 12 months and 88% by 36 months. Time from registration to first eye screening was longer for people aged 18-34 years, and 20% were unscreened after 3 years. Delay in first screen was associated with increased risk of referable retinopathy. Although 95% of participants (n = 291 296) attended during the 15-month reporting period, uptake varied considerably. Younger age, social deprivation, ethnicity and duration of diabetes were independent predictors of non-attendance and referable retinopathy. Although the last 10 years has seen an overall reduction in vision impairment certification attributable to diabetic eye disease, the incidence of vision impairment in those aged <35 years was unchanged. CONCLUSIONS: Whilst the majority of participants are screened in a timely manner, there is considerable variation in uptake. Young adults, have sub-optimal attendance, and levels of vision impairment in this population have not changed over the last 10 years. There is an urgent need to explore barriers to/enablers of attendance in this group to inform policy initiatives and tailored interventions to address this issue.

Parental expectations before and after 12-month experience with video consultations combined with regular outpatient care for children with type 1 diabetes: a qualitative study.

Abstract: AIM To explore parents' expectations of the perceived barriers to and benefits of 1 year of monthly video consultations combined with regular outpatient care of children with type 1 diabetes. METHODS The Virtual Diabetes Outpatient Clinic for Children and Youth (VIDIKI) study was a controlled, multicentre, perennial study with 240 participants from northern Germany. Fifty-four qualitative interviews with parents were analysed using qualitative content analysis. Before the intervention, 30 interviews were conducted to assess parents' expectations, and after 1 year, 24 interviews evaluated the experienced benefits and barriers to video consultations. RESULTS Four main topics were identified from parents' responses to the video consultation. The main advantages of the video consultation compared with standard care were a higher frequency of contact for optimized insulin dosing and saving time; difficulties with internet connections were identified as the main barrier. A feeling of increased confidence with respect to insulin dosing was directly associated with telemedicine. Digital prescriptions and meeting the same diabetologist in both outpatient and telemedical care were mentioned as important improvements. The majority of interviewees preferred intervals of 4-6 weeks between video consultations. CONCLUSION The higher frequency of contact with the diabetes team was considered a great relief by parents of children with type 1 diabetes. Apart from the time savings and flexibility in appointments, the most important advantages were the higher frequency of contact leading to short-term therapy adjustments and an increase in the ability to adjust therapy independently. (German Clinical Trials Registry No: DRKS00012645).