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Take a look at a selection of our recent media coverage:

Elevated arterial stiffness an effective predictor of diabetes in hypertensive patients

20th May 2022

An elevated arterial stiffness in patients with existing hypertension has good predictive power for the development of diabetes

Higher arterial stiffness (AS) rather than the presence of hypertension is a better predictor for the development of diabetes according to the findings of a prospective study by a team of Chinese researchers.

The World Health Organization estimates that there are approximately 422 million people worldwide that have diabetes. The most common form of diabetes is type 2 and in 2017, it was estimated that approximately 462 million individuals were affected by the condition, corresponding to 6.28% of the world’s population. Hypertension is common in those with type 2 diabetes and reportedly affects over two-thirds of patients and a Chinese study has suggested that a higher blood pressure is a risk factor for type 2 diabetes in both middle-aged and elderly patients.

Furthermore, the presence of arterial stiffness, especially in the aorta, has been shown to be an independent predictor of all-cause and cardiovascular mortality in patients with essential hypertension. In addition, other work has suggested that the presence of arterial stiffness is associated with an increased incidence of diabetes, independent of other risk factors and may represent an early risk marker for developing diabetes. However, whether arterial stiffness among hypertensive patients is a useful prognostic marker for the development of diabetes compared with hypertension alone is unclear.

For the present study, the Chinese researchers looked at data obtained from the Kailuan study, which is an ongoing prospective study following patients initially free of hypertension and examines factors associated with development of the condition. In a subgroup of patients, brachial-ankle pulse wave velocity measurements, which is a widely used technique to assess arterial stiffness, were taken. The researchers set the primary outcome as the development of diabetes during the follow-up period. Participants blood pressure and arterial stiffness was categorised as ideal vascular function (IVF) and normotensive, normotensive with AS, hypertensive and with normal AS and hypertensive and with elevated AS (HTAS).

Arterial stiffness and the development of type 2 diabetes

A total of 11,166 participants were enrolled in the study and followed for 6.16 years during which time 768 (6.88%) of incident cases of type 2 diabetes were identified.

After adjustment for covariates (e.g., age, gender, co-morbidities), compared to the IVF group, individuals in the HTAS group had the highest risk developing type 2 diabetes (hazard ratio, HR = 2.42, 95% CI 1.93 – 3.03). This was followed by the normotensive, elevated AS group (HR = 2.11, 95% CI 1.64 – 2.61). Interestingly, the lowest risk was associated with those who were hypertensive and with normal AS (HR = 1.48). These results did not change when further adjusted for mean arterial or diastolic pressure.

The researchers then examined whether an elevated AS or hypertension, or both, increased the predictive power of a conventional model, i.e., with age, sex, BMI, smoking status etc, for the development of diabetes The results showed that the C statistic increased from 0.690 to 0.707 (p = 0.0003), i.e., had more predictive power, after addition of AS. However, the predictive power increased to 0.709 when both hypertension and AS were added, in other words, there was little additional benefit to the model by adding hypertension alone.

The authors concluded that an elevated AS performed better than hypertension for the prediction of type 2 diabetes and suggested that future strategies for the prevention of type 2 diabetes should focus on both hypertension and AS.

Citation

Tian X et al. Hypertension, Arterial Stiffness, and Diabetes: a Prospective Cohort Study Hypertension 2022

Study suggests increased coffee consumption lowers rate of kidney function decline in diabetics

11th May 2022

A higher level of coffee consumption in type 2 diabetics significantly reduces the rate of decline in estimated glomerular filtration rate

A greater coffee consumption in those with type 2 diabetes is significantly associated with a reduction in the rate of decline in the estimated glomerular filtration rate (eGFR). This was the key finding from a prospective study by researchers from the Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Chronic kidney disease (CKD) is a non-communicable disease and which usually develops as a consequence of diabetes and hypertension. Disease severity in CKD can be assessed by a low serum creatinine-based eGFR, which indicates excretory kidney function and by a raised urinary albumin. Lifestyle management is deemed to be a fundamental aspect of diabetes care and this encompasses self-management education and support, medical nutrition therapy, physical activity, smoking cessation counselling and psychosocial care. Nutritional therapy, however, does not just include what foods to eat but also what should be drunk. One commonly consumed beverage is coffee and a higher coffee consumption, as well as green tea, has been found to be associated with a reduction in all-cause mortality, particularly in patients with type 2 diabetes. Furthermore, some data suggests that a higher coffee consumption is associated with lower risk for incident CKD. Nevertheless, this finding is not consistent, with other work undertaken in men, find that there was no significant association between coffee consumption and CKD.

What remains unclear though, is if a higher level of coffee consumption in patients with type 2 diabetes would reduce the decline in kidney function. For the present study, the Japanese team carried out a prospective study of adult diabetic patients attending diabetic clinics throughout the country. They carried out a dietary survey which asked about coffee consumption but also had access to clinical measurements such as blood pressure and eGFR taken at the clinics. Coffee consumption was recorded as none, less than 1 cup/day, one cup/day or two or more cups/day. The primary outcome was set as a decline in eGFR to <60 mL/min/ 1.73 m2, based on two consecutive measures of eGFR during the follow-up period.

Coffee consumption and decline in eGFR rate

In total, 3,805 patients with type 2 diabetes and a mean age of 64.2 years (44.4% female) and eGFR ≥60ml/min/1.73 m2 were followed-up for a median of 5.3 years.

During the period of follow-up, 840 participants experienced a decline in eGFR of < 60 mL/min/1.73 m2. Using multivariate analysis, the researched found that compared to those who drank no coffee, the adjusted hazard ratio (aHR) for a decline in eGFR associated with drinking less than one cup/day was 0.77 (95% CI 0.63 – 0.97) and this increased slightly to 0.75 (95% CI 0.62 – 0.91) for those drinking two or more cups/day.

The mean eGFR change per year was -2.16ml/min/1.73 m2 with no coffee consumption, and -1.78ml/min/1.73 m2 with two or more cups per day (p for trend 0.03).

There was also no significant effect on coffee drinking and the decline in eGFR based on age, gender, body mass index, smoking status, those who exercised regularly or blood pressure.

The authors concluded that coffee consumption is significantly associated with a lower risk of a decline in eGFR, which suggested a progressive impairment in renal function, in patients with type 2 diabetes.

Citation
Komorita Y et al. Relationship of coffee consumption with a decline in kidney function among patients with type 2 diabetes: The Fukuoka Diabetes Registry J Diabetes Investig 2022

Fish diet best for reducing risk of developing type 2 diabetes

27th April 2022

A fish diet rather than any other type of diet appears to be associated with the greatest reduction in the risk of developing type 2 diabetes

A fish diet appears to be the best way of reducing the risk of developing type 2 diabetes in comparison to either a poultry, meat-based or even a vegetarian diet. This was the conclusion of an analysis of the UK Biobank by researchers from the UK, Thailand and Chile.

Type 2 diabetes is a metabolic disorder that results in hyperglycaemia and is a global health concern. One estimate from 2017 suggested that approximately 462 million individuals were affected (6.28% of the world’s population), leading to 1 million deaths per year. Many cases of type 2 diabetes could potentially be prevented by lifestyle changes, including maintaining a healthy body weight, consuming a healthy diet, staying physically active, not smoking and drinking alcohol in moderation.  In fact, a 2017 systemic review identified how the risk of diabetes is reduced by increased consumption of whole grains, fruits and dairy, but that the risk is increased by greater consumption of red meat, processed meat and sugar sweetened beverages. However, there is some uncertainty over whether any specific type of eating pattern e.g., fish diet, poultry or vegetarianism, has a greater impact on the risk of developing diabetes.

For the present analysis, the team turned to the UK Biobank database to explore the associations between different diets and the risk of incident type 2 diabetes. In addition, the researchers examined the extent to which adiposity might impact on these associations. Within the UK Biobank, participants complete food frequency questionnaires and based on responses, individuals were categorised as vegetarian, fish eaters, fish and poultry eaters and finally meat eaters. A number of participants reported eating a varied diet and the effect on this type of diet was analysed separately. The results were analysed using Cox-proportional hazard models which provided a measure of the association between the different diets and the risk of type 2 diabetes and models were adjusted for several factors including age, sex, alcohol intake, smoking status etc.

Fish diet and the risk of type 2 diabetes

A total of 203,790 individuals were included in the analysis with 1.6% who were vegetarian, 2.2% fish diet, 1.1% fish and poultry eaters, 87.3% meat eaters and 7.8% who reported eating a varied diet. The mean age of the groups ranged from 52.8 to 56.5 years and after excluding the first two years, individuals were followed-up for a median of 5.4 years. During the follow-up, 5,067 (2.5%) participants developed type 2 diabetes.

Using meat eaters as the reference, a fish diet had the lowest risk of developing type 2 diabetes (hazard ratio, HR = 0.41, 95% CI 0.31 – 0.55, p < 0.0001), followed by fish and poultry eaters (HR = 0.61, 95% CI 0.44 – 0.86). However, the association with vegetarian and a varied diet were non-significant. However, in the fully adjusted models, a significant association remained only for a fish diet but not for fish and poultry eaters or any of the other diets.

Interestingly, general obesity was a partial mediator for fish diets, accounting for 49.8% of their lower risk of developing type 2 diabetes.

The authors concluded that fish diets produced the greatest reduction in the risk of developing diabetes and that this effect was largely due to the fact that fish eaters had a lower level of adiposity.

Citation
Boonpor J et al. Types of Diet, Obesity, and Incident Type 2 Diabetes: Findings from The UK Biobank Prospective Cohort Study Diabetes Obes Metab 2022

Early glycaemic control in type 2 diabetes reduces subsequent adverse CV outcomes

22nd April 2022

Early glycaemic control in type 2 diabetes reduces the incidence of adverse cardiovascular outcomes in the first year after diagnosis

Early glycaemic control in patients with type 2 diabetes leads to a reduction in the incidence of adverse cardiovascular outcomes according to the findings of a retrospective analysis by a team from the Department of Clinical & Experimental Medicine, University of Surrey, UK.

Patients with diabetes are deemed to be at a higher risk of death and adverse cardiovascular outcomes than those without the condition. Furthermore, poor control of diabetes defined by an increased level of glycated haemoglobin levels (HbA1c) is also a risk factor for myocardial infarction (MI). In fact, one study found that each 1% higher HbA1c was associated with an 18% greater risk of MI. In addition, the HbA1c levels 3 months post-diabetes diagnosis, has been found to be a strong predictor of subsequent mortality.

However, there is some uncertainty over whether tight glycaemic control in patients with a high HbA1c after diagnosis is associated with a subsequent reduction in adverse cardiovascular outcomes. For the present study, the UK researchers examined the effect of changes in HbA1c levels in the first year after a diagnosis of type 2 diabetes and how this impacted on the incidence of cardiovascular events. A further consideration was the effect of glycaemic variability on cardiovascular events as there is some evidence to show that having consistent glycaemic control reduces the risk of vascular events and death in type 2 diabetes.

The team reviewed the records of adults with a diagnosis of type 2 diabetes and an HbA1c level recorded at diagnosis and after 1 year and with an additional five measurements recorded over time. The HbA1c values were categorised into three groups: group A (HbA1c < 7.5%), group B (HbA1c 7.5% – 9.0%) and group C (HbA1c > 9.0%). The team then recorded the individual patient’s group status at the end of the first year, for instance, a status of A to A, meant that the person’s levels remained in group A, a C to A status meant that values transitioned from C to A during the first year and so on. A glycaemic variability score was also calculated, based on the number of times the HbA1c reading differed by more than 0.5% and the results categorised into 5 groups, depending on the level of variability (e.g., 0 – 20, 21 – 40 up to 81 – 100). The primary outcome of interest was the first occurrence of a major adverse cardiovascular event (MACE) which included myocardial infarction, coronary intervention, stroke, amputation/limb revascularisation.

Early glycaemic control and MACE

A total of 26,180 individuals with type 2 diabetes and a mean age of 68.7 years (43.9% female) were identified and included in the analysis.

The proportion of individuals categorised as A to A was 48%, whereas only 1.5% were categorised as C to A. A total of 2,300 MACE events occurred in the 26,180 individuals with type 2 diabetes and the median time to the first MACE was 635 days. Compared to those in the A to A group after the first year, individuals who transitioned from C to A had a significantly reduced risk of MACE (hazard ratio, HR = 0.75, 95% CI 0.60 – 0.94, p = 0.014). In addition, individuals who displayed the greater glycaemic variability (81 – 100) also had the highest risk for MACE (HR = 1.51, 95% CI 1.11 – 2.06, p = 0.0096) compared to those in the lowest (0 – 20) group.

The authors concluded that both transitioning to an HbA1c <7.5% within the first year after a type 2 diabetes diagnosis and lack of substantial glycaemic variability were both associated with reduced MACE events.

Citation
Whyte MB et al. Early and ongoing stable glycaemic control is associated with a reduction in major adverse cardiovascular events (MACE) in people with type 2 diabetes: primary care cohort study Diabetes Obes Metab 2022

Study suggests risk of type 2 diabetes is as much as 50% higher after COVID-19 infection

31st March 2022

Infection with COVID-19 increases the risk of type 2 diabetes by 50% compared to other acute upper respiratory tract infections

The type 2 diabetes risk after an acute infection with COVID-19 is as much as 50% higher in comparison to other acute upper respiratory tract infections. This was the main finding from a retrospective analysis by researchers from the Institute for Biometrics and Epidemiology, German Diabetes Center, Düsseldorf, Germany.

The development of type 2 diabetes after infection with COVID-19 has been recognised and evidenced by impaired glucose homoeostasis due to a viral-associated β-cell destruction. Moreover, other work has found that infection with COVID-19 potentially increases type 2 diabetes risk by induction of insulin resistance, leading to clinically evident hyperglycaemia detectable even in the post-acute phase.

However, there is uncertainty over whether or not these adverse metabolic disturbances are merely transient or if infection with COVID-19 does ultimately increase an individual’s subsequent risk of developing type 2 diabetes. For the present study, the German team retrospectively examined the incidence of type 2 diabetes over a longer time frame, after infection with COVID-19, among patients with mild infections, i.e., those managed in primary care. In order to show that the development of type 2 diabetes was a unique feature of COVID-19 as opposed to a general response to viral infections, the team included a control group of individuals who experienced other acute upper respiratory tract infections (AURIs). Propensity score matching was carried out based on sex, age and co-morbidities and the presence of newly diagnosed type 2 diabetes was extracted from the electronic medical records.

Type 2 diabetes risk and infection with COVID-19

A total of 35,865 individuals with a mean age of 42.6 years (45.6% women) were propensity-matched and followed-up for a median of 119 days (COVID-19) or 161 days (AURI patients). Although disease severity was generally mild, a similar proportion from each cohort were hospitalised due to their infection (3.2% COVID-19 vs AURI 3.1%).

After matching 1:1 COVID-19 and AURI individuals (9823 pairs) the type 2 diabetes incidence after recovery from both infections was 20.5 per 1000 person-years in the COVID-19 group and 13.6 in the AURI group (incidence rate ratio, IIR = 1.51, 95% CI 1.05-2.18). However, the risk of developing all other forms of diabetes were not significantly different between COVID-19 and any other AURI (IIR = 1.25, 95% CI 0.60 – 2.59).

Whether or not the incident cases of type 2 diabetes uncovered in the study would resolve over time could not be determined due to the retrospective nature of the study. However, based on these findings, the authors concluded that if other studies confirmed their own results, active monitoring of glucose dysregulation should be instigated after recovery, even from mild forms of COVID-19 infection.

Citation
Rathermann W et al. Incidence of newly diagnosed diabetes after Covid-19 Diabetologia 2022

Sodium-glucose cotransporter 2 inhibitors associated with cardiovascular benefits

26th January 2022

Sodium-glucose cotransporter 2 inhibitors (SGLT2-Is) reduce adverse cardiovascular outcomes according to a meta-analysis of clinical trials

SGLT2-Is can be considered as an effective class of drugs to improve cardiovascular morbidity and mortality. This was the conclusion of a meta-analysis by researchers from the Division of Cardiology, Southern Illinois University School of Medicine, US.

SGLT2-Is were developed and licensed as a class of drugs for the management of type 2 diabetes and one agent in particular, dapagliflozin, has been shown, as an add-on drug to conventional anti-diabetic drugs, to improve glycaemic control. However, with more widespread use of these drugs, it became apparent that there were potential cardioprotective effects, such as a reduction in the worsening of heart failure, irrespective of whether or not the patients were diabetic.

For the present study, the US researchers, set out to establish whether the magnitude of any cardiovascular benefit from SGLT2-Is were generalisable to patients of different ages and ethnicities. They searched for placebo-controlled randomised clinical trials in patients with existing atherosclerotic cardiovascular disease (ASCVD) or the presence of risk factors for ASCVD such as diabetes or heart failure. They set the primary outcome as cardiovascular death or hospitalisation for heart failure (HHF) and major cardiovascular events (MACE), HHF, cardiovascular death, acute myocardial infarction and all-cause mortality as secondary outcomes. They included gender, age (< 65 or > 65) and ethnicity as subgroups for separate analyses.

Findings

A total of 10 trials including 71,553 patients were analysed with 39,053 who received SGLT2-Is.

The primary outcome of cardiovascular death or HHF was reported in all trials and there were 6921 incidents, 8.1% occurring in those given SGLT2-Is and 11.6% in the placebo group. The use of SGLT2-Is was calculated to be associated with 33% reduced risk of the primary outcome (odds ratio, OR = 0.67, 95% CI 0.55 – 0.80, p < 0.01).

There was also a reduced risk of MACE in those taking SGLT2-Is (OR = 0.90, 95% CI 0.81 – 0.99, p = 0.03). However, there was no difference in the rate of acute myocardial infarction in those taking SGLT2-Is compared to placebo (OR = 0.95, 95% CI 0.87 – 1.03). Moreover, subgroup analysis favoured the use of SGLT2-Is in all groups compared and all-cause mortality was also lower in those taking SGLT2-Is (OR = 0.87, 95% CI 0.80 – 0.96, p = 0.04).

The authors concluded that the ‘cardiovascular outcomes of SGLT2-I therapy can be compared across all trials, and it demonstrates remarkable consistency of class benefit, despite the variations in populations enrolled.’

Citation

Bhattarai M et al. Association of Sodium-Glucose Cotransporter 2 Inhibitors With Cardiovascular Outcomes in Patients With Type 2 Diabetes and Other Risk Factors for Cardiovascular Disease: A Meta-analysis. JAMA 2022

Diabetes-associated ocular complication risk higher in children with type 2 than type 1 disease

7th December 2021

The diabetes-associated ocular complication risk is higher in children with type 2 compared with type 1 over the first 15 years of the disease

Rates of diabetes-associated ocular complications (DAOC) in children have been found to be much higher in children diagnosed with type 2 as opposed to type 1 disease over the first 15 years after diagnosis. This was the finding of a retrospective analysis by a team from the Department of Ophthalmology, Mayo Clinic,
Rochester, US.

Diabetes is a common childhood condition, with a recent UK study finding that in 2019, there were an estimated 36,000 children with diabetes under the age of 19, an increase from from 31,500 in 2015. In children, type 1 disease accounts for the vast majority of cases although there is evidence to suggest that the prevalence of type 2 diabetes has increased between 2001 and 2009, in 10 – 19 year olds. Diabetes is associated with the development of micro-vascular complications including retinopathy, which remains the most common cause of blindness in working-age adults in the developed world. While sight loss in children due to diabetic retinopathy is much less common, guidance does recommend retinopathy screening of children with type 1 diabetes. However, far less is known about the development and progression of diabetic retinopathy among children with type 2 diabetes.

For the present study, the US researchers were interested in comparing the DAOC rates in children with both forms of diabetes. They turned to the medical records of children newly diagnosed with diabetes between 1970 and 2019 in Minnesota. They collected demographic and clinical data such as HbA1C and whether the individuals had undergone an eye examination and followed-up on these examinations. The researchers catalogued diabetic-associated ocular complications including non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), diabetic macular oedema (DME), a visually significant cataract (VSC) and the need for pars plana vitrectomy (PPV).

Findings

A total of 606 children were diagnosed with diabetes during the 50-year period, of whom, 525 (87.8%) had undergone at least one eye examination and were diagnosed with either type 1 (461) or type 2 (64) diabetes. The mean age of diagnosis among those with type 1 disease was 10.8 years (53.4% male) and 17.3 years (28.1% male) for type 2 disease. A DAOC occurred in 147 (31.9%) of those with type 1 disease,14 years after diagnosis and in 17 (26.6%) of those with type 2 disease. The hazard ratio, HR for developing any diabetic retinopathy between type 2 and type 1 disease was 1.88 (95% CI 1.13 – 3.12, p = 0.02).

Overall, 30.6% of those with type 1 disease developed a DAOC within 15 years compared to 52.7% of those with type 2 disease. While the risk of developing any of the other retinopathy complications included in the analysis was numerically higher among those with type 2 disease, the only statistically significant effect was the need for pars plana vitrectomy (HR = 4.06, 95% CI 1.34 – 12.33, p = 0.07), 15 years after the initial diagnosis.

The authors concluded that children with type 2 diabetes developed vision threatening retinopathy a shorter time after diagnosis than those with type 1 disease and suggested that such children should have ophthalmoscopy evaluations at least as frequently, or even more frequently, than those with type 1 disease.

Citation

Bai P et al. Ocular Sequelae in a Population-Based Cohort of Youth Diagnosed With Diabetes During a 50-Year Period. JAMA Ophthalmol 2021

Intermittent very-low calorie diet achieves remission in nearly a third of type 2 diabetics

14th September 2021

An intermittent very-low calorie diet either two or four days per week achieved similar levels of remission in patients with type 2 diabetes.

Type 2 diabetes is characterised by a progressive loss of beta-cell function in the pancreas and recent data have shown that intermittent very-low calorie diets (IVLCD) can result in a marked metabolic improvement in as little as seven days. However, maintenance of a IVLCD can be difficult over time and one study found that after 12 months of intensive weight management, less than half (46%) of patients were in diabetic remission. Among obese patients, the use of intermittent very-low calorie diets (500 – 600 kcal/d) for three days each week, was found to be an effective weight loss strategy. Moreover, a similar strategy, using a IVLCD for two days per week has been successfully used in patients with type 2 diabetes.

Nevertheless, the optimal IVLCD for those with type 2 diabetes remains to be determined and this led a team from the Division of Endocrinology and Metabolism, Chulalongkorn University, Thailand, to compare different protocols of IVLCD among those with type 2 diabetes. The team undertook a randomised controlled trial that compared the impact of a two-day/week and a four-day/week IVLCD versus a control group, on glycaemic control and diabetes remission in a group of obese type 2 patients. Included patients were between 30 and 60 years of age and with type 2 diabetes diagnosed within the last 10 years. Enrolled patients had a body mass index (BMI) > 23 and a HbA1c level between 6.5 and 10%. Individuals were then randomised to either the two, or four-days/week IVLCD arm or a control group (in which they received a normal diet of 1500 – 2000 kcal/day). The IVLCD groups had an intake of 600 kcal/day on either two or four days each week. Patients were assessed every two weeks for the duration of the study (20 weeks). The primary outcome of interest was a change in glycaemic control (glucose and HbA1c) and rate of diabetes remission, defined as a HbA1c of < 6.5% in the absence of pharmacological therapy at the end of the study.

Findings
A total of 40 participants with a mean age range of 49.6 years (73% female) and a mean BMI of 30.1 were included in the final analysis. The mean duration of diabetes was 4.9 years and the baseline HbA1c was 7.4% with 90.6% of participants prescribed metformin. There were significant reductions compared to baseline in HbA1c levels in both IVLCD groups with 64% of those in the 4-day/week and 29% in the 2-day/week achieving levels < 6.5%. Furthermore, diabetes remission was achieved in 29% of patients in both the 2-day and 4-day groups. In addition, complete withdrawal of all diabetic medication occurred in 64% of the 2 day/week group and 86% of those in the 4 day/week group. The mean reduction in BMI in the 4 day/week group was 3.6 and 2.1 kg in the 2 day/week group although this difference between the two groups was not-significant.

The authors concluded that given the similar level of diabetes remission in both groups, either would be beneficial to obese type 2 diabetic patients.

Citation
UmPhonsathien M et al. Effects of intermittent very-low calorie diet on glycemic control and cardiovascular risk factors in obese patients with type 2 diabetes mellitus: A randomised controlled trial. J Diabetes Investig 2021

CGM associated with better control in type 2 diabetics receiving basal insulin

14th June 2021

Whether continuous glucose monitoring improves outcomes for type 2 diabetics compared with self-testing is uncertain.

The monitoring of blood glucose is paramount to the safe and effective management of all diabetic patients. Typically, insulin regimes can be basal only (i.e., long-acting agents used once or twice daily) or a combination of basal and prandial, i.e., rapid-acting agents used to control the mead-induced glucose spikes. Moreover, assessment of blood glucose levels is achieved through the use of either testing strips or real-time continuous glucose monitoring (CGM). However, in practice self-testing has been shown to be under-utilised and while the latter has been shown to improve diabetic control in type 2 diabetes using a combined insulin regime, little is known about the effectiveness of CGM in patients with less intensive insulin regimes. Therefore, a team of researchers from the International Diabetes Centre, Minneapolis, US, performed a randomised controlled trial to determine the effectiveness of CGM in primary care adults with type 2 diabetes using only basal insulin compared with the use of traditional blood glucose monitoring (BGM). Included patients had a baseline HbA1c level of 7.8% to 11.5%, self-reported BGM monitoring of at least 3 or more times per week and possession of a smartphone compatible with the CGM device for uploading data. The primary outcome measure was the HbA1c level after 8 months and key secondary outcomes were CGM-measured time in the target glucose range (70–180mg/dl) and the time with glucose levels above 250mg/dl.

Findings
A total of 175 participants with a mean age of 57 years (50% women) and with a mean HbA1c level of 9.1% were randomised in a 2:1 fashion to CGM or BGM. After 8 months, the mean HbA1c reduced to 8.0% in the CGM group and to 8.4% in the BGM group (p = 0.02). In the GCM group, the mean percentage of time in the target glucose range was 59% compared to 43% in the BGM group (p < 0.001). Similarly, there was a significantly lower time where glucose levels exceeded 250mg/dl (11% vs 27%, CGM vs BMG, p < 0.01).

In discussing their findings, the authors noted that the greater improvements seen in HbA1c in the CGM group were due to an increased period of time for which glucose levels remained with the target range. Nevertheless, a limitation recognised by the authors was the use of diabetic specialists, which is not standard practice in primary care and that this may have limited the generalisability of their findings. Despite this, they concluded that the use of CGM resulted in superior diabetic control compared with self-monitoring.

Citation
Martens T et al. Effect of Continuous Glucose Monitoring on Glycemic Control in Patients with Type 2 Diabetes Treated with Basal Insulin. A Randomised Clinical Trial JAMA 2021

Smartphone app leads to weight loss in Asian adults with type 2 diabetes

8th June 2021

Whether a culturally appropriate smartphone app could replace face-to-face support for weight loss is uncertain.

Weight loss in patients with type 2 diabetes improves metabolic outcomes such as insulin resistance and glycaemic control. This is particularly important in Asian populations where data indicate an increased prevalence of obesity. While traditionally lifestyle interventions have been delivered in face-to-face sessions, potential barriers such as the need for formal appointments, travel and associated costs, together with potential time constraints, can limit the value of these sessions.

In recent years, the development of smartphone technology has enabled the delivery of lifestyle interventions for patients with long-term conditions and which circumvent some of the problems encountered with face-to-face meetings. However, the effectiveness of smartphone-based apps can depend, to some extent, on the cultural appropriateness of the material provided. In an attempt to examine the value of a culturally and contextualised smartphone app, designed to deliver lifestyle interventions, a team from the Department of Dietetics, National University Hospital, Singapore, undertook a randomised, controlled trial to compare a smartphone-based intervention with usual care. Included participants were adults with type 2 diabetes with a body mass index (BMI) of 23 or greater and at the start of the study, all participants received a single advisory session from a dietician concerning weight and physical activity. Intervention participants were then required to use the app for at least 6 months (to track weight and activity levels) and to communicate (via the app) regularly with a dietician. The primary outcome was the change in body weight after six months, whereas secondary outcomes were changes in metabolic profiles (e.g., HbA1c, fasting blood glucose, blood pressure).

Findings
In total, 204 participants were enrolled and randomised to the intervention (99) or control. The mean age of intervention participants was 51.6 years (33.3% female) with an average weight of 84 kg and BMI of 30.3. After six months, participants in the intervention group had a significantly greater mean weight loss (3.6 kg vs 1.2kg, intervention vs control, p < 0.01). In addition, there was a greater change in mean HbA1c levels (-0.7% vs 0.03%, intervention vs control) and in the proportion of participants seeing a reduction in their use of diabetic medications (23.3% vs 5.4%, intervention vs control). There were also favourable changes in fasting glucose levels and diastolic blood pressure. Finally, nearly two-thirds (62%) of intervention participants used the smartphone app at least 75% of the days during the 6-month period.

Commenting on their findings, the authors noted how the intervention group’s weight loss was comparable to the results achieved from face-to-face sessions and, more importantly, this loss was sustained over a six-month period. The authors concluded that the smartphone app led to significant weight loss and metabolic parameters and that future work should focus on the lifestyle factors more likely to achieve successful outcomes.

Citation
Lim SL et al. Effect of a Smartphone App on Weight Change and Metabolic Outcomes in Asian Adults with Type 2 Diabetes. A Randomised Clinical Trial. JAMA Netw Open 2021