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

Type 2 diabetes remission associated with reduction of CVD and CKD complications, study finds

16th February 2024

Patients who successfully reversed a type 2 diabetes diagnosis though lifestyle changes substantially reduced their cardiovascular disease (CVD) and chronic kidney disease (CKD) risk in the long term, a study has found.

Published in the journal Diabetologia, the results came from a large trial of almost 4,500 participants in which doctors were comparing an intensive lifestyle programme with standard diabetes education and support.

Taking no diabetes medications and having a HbA1c of less than 48 mmol/mol (6.5%) at a single point in time was classed as remission.

Overall, those who achieved remission through the lifestyle changes – in whichever group – had a 33% lower rate of CKD and a 40% lower rate of CVD.

But those who had the most intensive support were more likely to be in remission from their diabetes, with 12% meeting the criteria at least one follow-up and falling to 7% over time compared with around 2% in the regular support group.

Being in remission overall was significantly linked to changes in weight and risk factors over the years, the study found.

Average weight loss associated with remission was 7.3kg after one year and 4.5kg after four years.

There were also significantly greater improvements in HDL-cholesterol and fitness after one and four years, and significantly greater systolic blood pressure improvements after one year among participants with remission compared with those without remission, the team said.

The analysis also showed systolic blood pressure decreased more and HDL-cholesterol increased more among participants who achieved a greater duration of diabetes remission.

There was a dose-response relationship with those who had remission for at least four visits seeing the most impact, the researchers said.

Those taking part in the study – which ran between 2001 and 2016 – had a mean age of 59 years and on average were in the range of severe obesity.

It was noted that while 18% of participants achieved remission at some point during follow-up, the percentage of participants with current remission had decreased to 3% by the eighth year of the study.

The figures underline, the challenges of keeping weight off using lifestyle interventions, the researchers said.

But for those with at least four years of remission the risk of CKD and CVD was reduced by 55% and 49% respectively.

The analysis also noted participants with a short duration of diabetes, low starting HbA1c and a large magnitude of weight loss were most likely to experience remission.

Study lead Professor Edward Gregg, head of the School of Population Health, RCSI University of Medicine and Health Sciences in Dublin, said: ‘As the first intervention study to associate remission with reduction of diabetes-related complications, this is encouraging news for those who can achieve remission from type 2 diabetes.

‘While our study is also a reminder that maintenance of weight loss and remission is difficult, our findings suggests any success with remission is associated with later health benefits.’

Another recent study has found that regular bouts of moderate to vigorous physical activity can protect patients with type 2 diabetes from developing kidney disease.

A version of this article was originally published by our sister publication Pulse.

Physical activity reduces chronic kidney disease risk in type 2 diabetes, study finds

12th February 2024

Regular bouts of moderate to vigorous physical activity can protect patients with type 2 diabetes from developing kidney disease, a new study has found.

Overweight and obese people with type 2 diabetes who undertook moderate to vigorous physical activity every week were significantly less likely to progress to chronic kidney disease than those who undertook minimal physical activity.

Increasing cumulative exercise by just over an hour a week is linked to a 33% reduction in risk of renal disease. The researchers showed that the increase in physical activity is just as effective whether the extra exercise is undertaken in short bursts of less than 10 minutes or for long periods of 10 minutes and over.

The findings, published in the British Journal of Sports Medicine, show that being physically active is one of the most effective ways to prevent kidney disease in people with type 2 diabetes and can even help patients unable or unwilling to engage in physical activity for over 10 minutes.

Diabetes accounts for 30-50% of chronic kidney disease cases globally, making it the leading cause of renal disease. Patients who have diabetes and chronic kidney disease have a 10-fold higher risk of death from any cause compared with those who have diabetes alone.

To determine whether there was an association between physical activity and chronic kidney disease risk in patients with type 2 diabetes, the researchers undertook a secondary analysis of an activity tracker study, which was part of the US Look AHEAD trial.

The study involved 1,746 participants, with an average age of 58.

The participants were monitored for moderate to vigorous levels of physical activity and the extent of chronic kidney disease at the start of the study and again at one, four and eight years later.

Chronic kidney disease was defined as a deterioration of at least 30% in the estimated glomerular filtration rate, the rate at which kidneys remove waste and extra water from the blood to make urine (less than 60 ml/min).

On average, participants undertook 329 minutes of moderate to vigorous physical activity every week. Over 80% of this was accumulated in periods of less than 10 minutes, with the remaining 12.5% in periods of more than 10 minutes.

Over the duration of the study, around one in three of the participants developed chronic kidney disease.

The participants who undertook the most moderate to vigorous physical activity, between 329 to 469 mins per week, were significantly less likely to progress to chronic kidney disease than those who did the least physical activity (under 220 mins).

The researchers found that for every 100 minutes of moderate to vigorous activity, there was a 9% lower risk of developing chronic kidney disease. This increased to 19% if the exercise sessions lasted for at least 10 minutes.

Participants who increased their weekly exercise tally by 63 minutes over the first four years of the study had a 33% lower risk of kidney disease than those with the most significant decrease of minutes per week. The improvement was seen whether the physical activity sessions were greater than or less than 10 minutes.

The researchers stated: ‘These findings are consistent with evidence that regular [physical activity] has direct anti-inflammatory effects, and can promote glycaemic control, improve insulin sensitivity, blood pressure, lipid profiles and other metabolic and cardiovascular risk factors, all of which are associated with renal function.’

The researchers suggest that all patients with diabetes should be encouraged to engage in as much exercise intensity as they can tolerate to maximise the benefits.

Just over an hour a day of walking, cycling, jogging or swimming could help overweight and obese adults with type 2 diabetes reduce their risk of progression to chronic kidney disease.

A previous study from 2022 showed that increased coffee consumption lowered rate of kidney function decline in people with type 2 diabetes.

A version of this article was originally published by our sister publication Nursing in Practice.

Meal timings are important modifiable factor in type 2 diabetes risk, study confirms

7th August 2023

Eating breakfast after 9am increases the risk of developing type 2 diabetes by 59 per cent compared to people who eat breakfast before 8am, according to a new study.

Researchers from the Barcelona Institute for Global Health (ISGlobal) found that modifying the time at which people eat can reduce the risk of developing type 2 diabetes.

Eating breakfast before 8am and dinner before 10pm and eating more frequently throughout the day were associated with a lower incidence of type 2 diabetes.

The findings are published in the International Journal of Epidemiology and suggest meal timings are an important modifiable factor in managing the incidence of type 2 diabetes.

Type 2 diabetes incidence

The researchers analysed data from 103,312 participants who were part of the French NutriNet-Santé cohort between 2009 and 2021. Each participant recorded what they ate and drank over a 24-hour period on three non-consecutive days for an average of 5.7 days in the first two years of the study.

The researchers then assessed the participant’s health for an average of seven years and looked at the association between meal frequency and timing, the duration of night-time fasting between meals and the incidence of type 2 diabetes.

During the study, there were 963 new cases of type 2 diabetes, and the researchers found that the time at which food was eaten impacts the risk of developing diabetes.

Incidence of type 2 diabetes was higher in the participants who ate their breakfast after 9am compared to those who ate an early breakfast before 8am. Participants who ate an early breakfast and those who ate regularly throughout the day had a lower incidence of type 2 diabetes.

The researchers found no link between fasting and the incidence of type 2 diabetes and found that prolonged fasting was only beneficial if it included having an early breakfast before 8am and an early dinner.

Meals and glucose control

Dr Anna Palomar-Cros, a researcher from ISGlobal and first author of the study, said: ‘We know that meal timing plays a key role in regulating circadian rhythms and glucose and lipid control, but few studies have investigated the relationship between meal timing or fasting and type 2 diabetes.

‘Biologically, this makes sense, as skipping breakfast is known to affect glucose and lipid control, as well as insulin levels.’

The researchers suggest that a first meal before 8am and a last meal before 7pm may help reduce the incidence of type 2 diabetes.

Some 4.3 million people in the UK live with type 2 diabetes, and estimates from Diabetes UK suggest that 2.4 million more people are at high risk of developing the disease. Type 2 diabetes is associated with several modifiable risk factors, including obesity and overweight and smoking.

A version of this story was originally published by our sister publication Nursing in Practice.

Lung disorders are complication of type 2 diabetes, says new study

4th May 2023

Type 2 diabetes has been shown to cause lung disorders for the first time in a new study funded by Diabetes UK.

In the largest-ever genetic study to explore how genes affect blood sugar levels and health outcomes, researchers from Imperial College London concluded that lung disorders should now be considered a complication of type 2 diabetes.

When examining the impact of blood sugar levels on lung function, the researchers found that people with type 2 diabetes who had a three-fold increase in average blood sugar levels, experienced a 20% drop in lung capacity and function.

The findings, presented at the recent Diabetes UK Professional Conference 2023, highlight the need for healthcare professionals to be alert to lung complications within patients with type 2 diabetes, alongside kidney disease, heart attack and strokes.

More than five million people in the UK live with diabetes, and 90% have type 2. These patients often have dangerously high blood sugar levels caused by the body either not making enough insulin or not responding to the insulin that is made.

Chronically high blood sugar levels can damage organs and tissues, causing kidney failure, eye and foot problems, heart attacks and strokes. Previous research has shown that lung conditions, including restrictive lung disease, fibrosis and pneumonia, are more common in people with type 2 diabetes, but no causal link had been established.

Using statistical techniques, the researchers analysed data from almost 500,000 participants on 17 major studies, including the UK BioBank, to determine whether there was a causal link between impaired lung function and high blood sugar levels. Lung function was measured using two standard spirometry tests used to diagnose lung conditions.

High blood sugar levels in people with type 2 diabetes were shown to impair lung function directly. Statistical modelling of the study data showed that an increase in average blood sugar levels from 4 mmol/L to 12 mmol/L could result in a 20% drop in lung capacity and function.

Dr Elizabeth Robertson, director of research at Diabetes UK, said: ‘These results are a reminder of the seriousness of type 2 diabetes and the importance of supporting people with the condition to manage their blood sugar levels so they can live well with the condition and avoid future complications.

‘Lung conditions can be life-changing and life-limiting, and it is crucial that healthcare professionals are aware of the impact of high blood sugar levels on lung health.’

This news story was originally published by our sister publication Nursing in Practice.

Osteoarthritis risk lower in type 2 diabetics taking metformin

2nd May 2023

The risk of developing osteoarthritis is lower in type 2 diabetic patients taking metformin than among those taking sulfonylureas

Osteoarthritis (OA) is a common form of arthritis which globally affects 528 million people. Treatment focuses on drug therapy, self-management and exercise. In addition, there are currently no preventative therapies available. Metformin is an oral hypoglycaemic agent for the treatment of type 2 diabetes. The drug also appears to have other actions including the ability to suppress inflammation. In fact, there appears to be a beneficial effect on long-term knee joint outcomes in those with osteoarthritis and obesity. However, whether metformin can prevent the development OA is less clear.

In the current study, US researchers explored if metformin was able to lower the risk of developing OA as well as the need for joint replacement in type 2 diabetics. The team undertook a retrospective analysis using sulfonylureas as a comparator anti-diabetic therapy. Individuals with a prior diagnosis of OA were not included in their analysis. Researchers propensity-matched metformin and sulfonylurea patients 1:1. The primary outcome of interest was the time to an incident diagnosis of OA, 90 days after starting either medication.

Osteoarthritis development and anti-diabetic therapy

There were 41,874 individuals with a mean age of 62 years (41.8% female) with usable data for analysis. Among this total, 20,937 were receiving metformin.

The risk of developing osteoarthritis was 24% lower in those using metformin than a sulfonylurea (Hazard ratio, HR = 0.76, 95% CI 0.68 – 0.85, p < 0.001). However, there was no significant difference between the two groups in the risk for joint replacement (HR = 0.80, 95% CI 0.50 – 1.27, p = 0.34). Similar findings were obtained in a sensitivity analysis (HR = 0.77, 95% CI 0.65 – 0.90, p < 0.001) for OA.

These findings led the authors to suggest that metformin may have a protective effect against the development of OA.

Cumulative HbA1c levels above 9% linked to greater dementia risk

25th April 2023

HbA1c levels in type 2 diabetics remaining above 9% for extended periods of time poses a risk of developing dementia

Type 2 diabetes increases the risk for developing dementia. Both elevated HbA1c levels and diabetic complications also linked to an increased dementia risk. Moreover, intensive glycaemic control does not seem to reduce cognitive decline. But how long-term glycaemic control affects the risk of dementia is uncertain and was the subject of the current study.

Using a large US healthcare database, researchers looked at type 2 diabetics older than 50 with HbA1c levels recorded over time. Researchers categorised HbA1c measurements as < 6%; 6% to < 7%; 7% to < 8%, 8% to < 9%, 9% to < 10% and 10% or more. They also identified those diagnosed with dementia during follow-up.

HbA1c levels and development of dementia

There were 253,211 eligible participants with a mean age of 61.5 years. The participants were followed for a mean of 5.9 years. During this time, participants with the majority (i.e., > 50%) of HbA1c measurements between 9 and 10%, had an increased the risk of dementia (hazard ratio, HR = 1.31, 95% CI 1.15 – 1.51). Similarly, with most measurements of 10% or above, the risk was also significantly higher (HR = 1.74, 95% CI 1.62 – 1.86).

In contrast, among participants with more than 50% of HbA1c measurements that were less than 6%, the dementia risk was lower (HR = 0.92, 95% CI 0.88 – 0.97). This also held true for HbA1c levels of 6 to 7% and between 7 and 8%. Thus in type 2 diabetics, keeping cumulative HbA1c levels below 8% was associated with a lower risk for developing dementia. The researchers called for further research to determine if these associations were causal.

Citation
Moran C et al. Glycemic Control Over Multiple Decades and Dementia Risk in People With Type 2 Diabetes. JAMA Neurol 2023

Higher plasma caffeine levels linked to reduced body fat and type 2 diabetes risk according to genetic study

23rd March 2023

Increased plasma caffeine levels may help reduce body mass index as well as fat mass and the risk of developing type 2 diabetes.

A higher plasma caffeine (PC) concentration may produce a lower body mass index (BMI) as well as reducing body fat and the risk of type 2 diabetes, according to the findings of a genetic study by Swedish and UK researchers.

Caffeinated beverages such as coffee, tea and soda drinks are widely consumed across the world. Given that caffeine has a known thermogenic effect and which might help lower body weight, there is the potential that caffeine-containing beverages may have a role in lowering the risk of disease related to adiposity.

In fact, there is already some data to suggest that caffeine-containing drinks such as coffee are inversely associated with risk of type 2 diabetes.

It is recognised the caffeine metabolism occurs mainly in the liver by the cytochrome P450 isoform 1A2 (CYP1A2) and how genetic variations near two genes, CYP1A2 and AHR (which regulates the expression of CYP1A2) are linked to PC concentrations. In fact, individuals with genetic variants linked to slower caffeine metabolism, although generally consuming less caffeine-related beverages, do have higher plasma caffeine levels.

Using Mendelian randomisation, researchers sought to investigate the effects of long-term exposure to higher plasma caffeine concentrations on adiposity, type 2 diabetes and major cardiovascular diseases. 

They used data from a genome-wide association meta-analysis of 9876 individuals of European ancestry from six population-based studies and which identified genome-wide significant associations of single nucleotide polymorphisms near CYP1A2 and AHR loci with plasma caffeine concentrations.

Researchers identified that genetically predicted higher PC concentrations in those carrying the two gene variants, were in fact, associated with a lower BMI, with one standard deviation (SD) increase in predicted PC equal to about 4.8 kg/m2 in BMI (p < 0.001).

Similarly, for whole-body fat mass, one SD increase in PC equated to a reduction of about 9.5 kg (p < 0.001), although interestingly, there was no association with fat-free body mass (p= 0.17).

Again among genetically predicted higher PC concentrations, there were also significant and lower associations with the risk of developing type 2 diabetes, with the combined odds ratio of type 2 diabetes per SD increase in PC concentration being 0.81 (95% CI 0.74 – 0.89, p < 0.001).

The authors concluded that while their study found evidence of a causal association between a higher plasma caffeine concentration and lower levels of adiposity and a reduced risk of type 2 diabetes, they called for randomised trials to further examine the role of caffeine in reducing the risk of obesity and diabetes.

Citation
Larrson SC et al. Appraisal of the causal effect of plasma caffeine on adiposity, type 2 diabetes, and cardiovascular disease: two sample mendelian randomisation study. BMJ 2023.

GLP-1 agonists associated with modest weight loss in real-world setting

18th February 2023

The use of glucagon-like peptide-1 (GLP-1) agonists in patients who have type 2 diabetes and are overweight is associated with a small but significant weight loss after 72 weeks, according to a retrospective analysis of electronic health records by US researchers.

It has long been recognised that obesity is an independent risk factor for cardiovascular disease. In addition, cardiovascular disease is often present in those with type 2 diabetes and presents a major cause of death among such patients.

Despite this elevated risk, lifestyle modification, in particular weight loss, has been shown to be associated with better control of diabetes and and a reduction in cardiovascular risk factors.

Clinical trials in overweight, type 2 diabetic patients have demonstrated that drugs such as semaglutide, which is one of the GLP-1 agonists, achieves superior and clinically meaningful reductions in body weight in comparison to placebo.

However, most of the weight loss clinical trials have included a lifestyle intervention to support patients but in the absence of such support, GLP-1 agonist-associated weight loss is no better than that achieved with other agents such as metformin.

In the current study, US researchers from the University of Pittsburgh, wanted to understand the degree to which GLP-1 agonists induced weight loss when used as a part of routine clinical care, i.e. in the absence of a specific behavioural weight loss intervention.

The team retrospectively examined the electronic health records of those prescribed any drugs from the GLP-1 agonist class and the subsequent weight loss after 72 weeks of therapy.

GLP-1 agonists and real-world weight loss

Outcomes were available for 2,405 participants with a mean age of 48 years (47.4% male) and of whom, 92.1% had type 2 diabetes and a mean baseline body mass index of 37.

Only eight weeks after the first dispensing of a GLP-1 agonist, the mean weight loss was 1.1% and this increased to 2.2% after 72 weeks.

However, some patients did even better. For instance, 11.2% had lost at least 5% of their body weight after eight weeks, but after 72 weeks, this proportion increased to just over a third (33.3%).

In fact, at the 72 week mark, nearly half of the entire cohort (42.7%) had lost weight, with a small proportion of patients (10.5%) managing to lose 10% or more of their body weight.

The authors concluded that the use of GLP-1 agonists prescribed at standard doses led to a modest degree of weight loss in a real-world setting and in the absence of any specific patient support.

Citation
White GE et al. Real-world weight-loss effectiveness of glucagon-like peptide-1 agonists among patients with type 2 diabetes: A retrospective cohort study. Obesity (Silver Spring) 2023.

Continued exercise for 10 years linked to reduced risk type 2 diabetes

15th February 2023

Continued moderate or vigorous exercise over a 10-year period is associated with a significantly reduced risk of incident type 2 diabetes

Participants who continued to exercise for up to 10 years following completion of a 12 month randomised trial, had a significantly lower risk of developing incident type 2 diabetes according to the findings of a study by Chinese researchers.

Globally, type 2 diabetes affects around 462 million people or just over 6% of the entire population. Lifestyle modifications such as diet or increased exercise are known to reduce the risk of developing the disease. However, most of the available evidence for effects of lifestyle modification has been derived from high-risk individuals, for instance, those with elevated fasting glucose levels, or those who are both overweight and having impaired glucose tolerance. A further problem is that many of these intervention studies were of a relatively short duration. It is therefore less unclear whether maintenance of lifestyle modifications such as increased physical activity, over the longer term, still reduces the risk of developing T2D.

In the current study, Chinese researchers reported the longer term outcomes of a 12 month randomised trial they had undertaken. In the original trial, participants with non-alcoholic fatty liver disease, were randomised to vigorous to moderate physical activity, moderate exercise (brisk walking) or no exercise for 12 months. The results of the trial showed that both forms of exercise were effective at reducing intrahepatic triglyceride levels compared to those who did not exercise.

Following the trial, the majority of the study participants were followed-up after 2 and 10 years to assess the incidence of T2D, defined as a fasting plasma glucose of 6.9 mmol/L and a HBA1c of > 6.5% and or the use of anti-diabetic treatment.

Continued exercise and incident type 2 diabetes

From an original cohort of 208 participants who completed the year long trial, 195 and 179 remained for subsequent assessment after 2 and 10 years respectively.

The cumulative incidence of T2D was 2.1 per 100 person-years, 1.9 and 4.1 in those who continued with vigorous, moderate or no exercise respectively. In fact, the risk of T2D was reduced by 49% among those performing vigorous exercise (relative risk, RR = 0.51, 95% CI 0.27 – 0.94, p = 0.01) and by 53% among moderate level intensity exercise (RR = 0.47, 95% CI 0.25 – 0.89, p = 0.01) compared to the non-exercising group.

While both exercise groups had significant reductions in HBA1c levels compared to non-exercisers during the follow-up period, fasting plasma glucose levels while numerically lower in the two exercising groups than the non-exercise control group, these differences were non-significant.

The authors suggested that vigorous to moderate aerobic physical activity could be used to prevent T2D, particularly in those with obesity.

Citation
Chen Y et al. Effect of Moderate and Vigorous Aerobic Exercise on Incident Diabetes in Adults With Obesity: A 10-Year Follow-up of a Randomized Clinical Trial. JAMA Intern Med 2023

Analysis finds vitamin D supplementation potentially beneficial for type 2 diabetes

14th February 2023

A meta-analysis suggests that vitamin D supplementation reduces fasting plasma glucose and HbA1c levels in patients with type 2 diabetes

Vitamin D supplementation may be of value to patients with type 2 diabetes, especially if they have suboptimal levels of the vitamin according to a meta-analysis undertaken by US and Iranian researchers.

It has been estimated that in 2017, a staggering 462 million individuals had type 2 diabetes, corresponding to just over 6% of the global population. While there are several therapies available for the management of type 2 diabetes, new treatments will always be needed, given the high prevalence of the disorder. One such potential treatment is vitamin D supplementation and while this is usually given to regulate calcium and phosphorus levels, in recent years, a purported role has been suggested for several diseases. For example, data from the prospective Nurses’ Health study found that higher vitamin D and calcium intake was associated with a 33% lower risk of type 2 diabetes. Nevertheless, studies that involved actual vitamin D supplementation produced mixed findings. For example, one study 6-month trial found that supplementing with the vitamin in patients with type 2 diabetes, failed to affect either insulin sensitivity or secretion. In contrast, an 8-week intervention study demonstrated significant reductions in fasting plasma glucose, insulin and HOMA-IR.

As a result, in the current study, researchers performed a meta-analysis to examine the effect of using the vitamin on indices of glycaemic control including fasting plasma glucose (FPG), HbA1c and HOMA-IR.

Vitamin D supplementation and glycaemic measures

A total of 46 eligible trials were identified including 4,313 patients with type 2 diabetes and a mean age of 56.5 years and of whom 2,164 received the vitamin intervention. The majority of the studies (42) used an oral supplement, whereas in four trials, it was given via intramuscular injection.

The pooled analysis for HbA1c showed a significant reduction compared to placebo for vitamin D (weighted mean difference, WMD = -0.20, p < 0.001). Similarly, there was a significant reduction in FPG (WMD = -0.28 mmol/L, p < 0.001) and HOMA-IR (WMD = -0.42, p = 0.019) in those given vitamin D.

The authors concluded that although vitamin D supplementation had a positive impact of glycaemic indices, they cautioned that the substantial heterogeneity between the included studies, raised the possibility of publication bias.

Citation
Farahmand MA et al. What is the impact of vitamin D supplementation on glycemic control in people with type-2 diabetes: a systematic review and meta-analysis of randomized controlled trails. BMC Endocr Disord 2023

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