Journal Watch

Prepared for IDDT by Jim Young

July 2016

Disturbed eating behaviors in adolescents with type 1 diabetes. How to screen for yellow flags in clinical practice?
Minke MA Eilander et al. Pediatric Diabetes. Doi: 10.1111/pedi.12400

The aim of this study was to explore the prevalence of disturbed eating behaviors (DEBs) and associated ‘yellow flags’. Of the 103 adolescents (aged 11 to 16 years. 51.5% girls) who participated, the answers from 47 (46.5%) raised psychological yellow flags, indicating body and weight concerns. A total of 8% scored above cut-off for DEBs. The clinical yellow flags were: elevated glycated hemoglobin HbA1c, older age, dieting frequency, reduced quality of life, less diabetes self-confidence, worsened diabetes management, and body dissatisfaction. Body Mass Index (BMI) and gender were not found to be yellow flags. In summary, half of the adolescents reported body and weight concerns, less than 1 in 10 reported DEBs. The authors recommend that screening for yellow flags for DEBs should be a part of clinical routine using a stepwise approach, and early assistance is recommended to prevent onset or deterioration of DEBs.


Distinct clinical characteristics and therapeutic modalities for diabetic ketoacidosis in type 1 and type 2 diabetes mellitus
Yuji Kamata et al. Journal of Diabetes and Its Complications. Doi:

Although it has been reported that diabetic ketoacidosis (DKA) in type 2 diabetes has higher mortality despite its limited occurrence, the exact clinical characteristics and therapeutic modalities yielding successful outcomes in DKA type 2 diabetes remain unknown. This retrospective study compared the clinical features and detailed treatment of consecutive type 1 and type 2 diabetes patients hospitalized with DKA between January 2001 and December 2014. It looked at 127 patients with type 1 and 74 patients with type 2 diabetes whose DKA was successfully treated. The most frequent precipitating cause for DKA was infectious disease for patients with type 1 diabetes and consumption of sugar-containing beverages for those with type 2 diabetes. It was found that type 2 diabetes patients showed higher mean plasma glucose levels than those with type 1 diabetes and higher serum creatinine, blood urea nitrogen, and hemoglobin levels, which normalized after DKA resolution. Compared with type 1 diabetes patients, those with type 2 diabetes required distinctly higher daily total insulin dosage, larger replacement fluid volumes and greater potassium supplementation to resolve DKA and reduce plasma glucose levels. The conclusion being that DKA patients with type 2 diabetes required management with a modified treatment protocol to resolve their profound hyperglycemia and dehydration compared with those with type 1 diabetes.


Individualized prediction of the effect of angiotensin receptor inhibition on renal and cardiovascular outcomes in patients with diabetic nephropathy
Nicolette G.C. van der Sand et al. Diabetes, Obesity and Metabolism. Doi: 10.1111/dom.12708

The authors of this paper posit that predicting individualized treatment effect of angiotensin receptor inhibition (ARBs) on cardiovascular and renal complications may help clinicians and patients to assess the benefit of treatment (or adherence) and to estimate remaining disease risk. The findings were that the combined effects of ARBs on end-stage renal disease and cardiovascular disease and mortality in patients with diabetic nephropathy varied considerably between patients. A substantial proportion of patients remain at high risk for both outcomes despite ARB treatment.


Urinary biomarkers in the assessment of early diabetic nephropathy
Cristina Gluhovschi et al. Journal of Diabetes Research. Doi:

New researches are pointing that some new biomarkers (i.e., glomerular, tubular, inflammation markers, and biomarkers of oxidative stress) precede albuminuria in some patients. However, their usefulness is widely debated in the literature and has not yet led to the validation of a new “gold standard” biomarker for the early diagnosis of diabetic nephropathy (DN). This review provided an overview of the current biomarkers used for the diagnosis of early DN. Although the elucidation of these biomarkers is interesting in itself, the paper concludes that:
Microalbuminuria, although frequently contested as a biomarker of early DN, has been used so far as reference biomarker in assessing other urinary biomarkers in early DN. Up to now there is no other biomarker that can substitute in practice for microalbuminuria, the new biomarkers being sustained by limited studies and requiring validation. The concomitant assessment of several urinary biomarkers in relationship with microalbuminuria could represent at present a method of diagnosing early DN. The great progress in discovering new biomarkers could lead to the development of an “ideal” urinary biomarker to detect early diabetic DN in the future. Progresses in the field of urinary biomarkers in DN, is promising both in proteomics and in other modern techniques, and is developing remarkably at present.


The evolving frontier of diabetes therapy: the renaissance of glycemology
Antonio Ceriello et al. Diabetes Research and Clinical Practice. Doi:

The abstract to this paper captures the essence of glycemic control:
 It was previously proposed that diabetes could be a “cardiovascular disease”. This concept was based on evidence showing that controlling hypertension and dyslipidemia could be more effective than controlling hyperglycemia. At that time, it was concluded that the real need to focus on reaching optimal glycemic control had lost its appeal. However, the concept of glycemic control was strictly correlated to levels of glycated hemoglobin (HbA1c), the integrated measure of mean glycemia over the previous 2–3 months, while recent evidence suggests that the concept of hyperglycemia has profoundly changed, and it is more appropriate to speak of different kinds or aspects of hyperglycemia. A modern, updated approach to glycemic control in people with diabetes, in fact, must focus not only on reaching and maintaining optimal HbA1c levels as soon as possible, but to obtain this result by reducing postprandial hyperglycemia and glycemic variability, while avoiding hypoglycemia.


Kindness Matters: a randomized controlled trial of a mindful self-compassion intervention improves depression, distress, and HbA1c among patients with diabetes
Anna M. Friis et al. Diabetes Care. Doi:

Mood difficulties are common among patients with diabetes and are linked to poor blood glucose control and increased complications. Evidence on psychological treatments that improve both mood and metabolic outcomes is limited. This randomized controlled trial (RCT) evaluated the effects of self-compassion training on mood and metabolic outcomes among patients with diabetes. It considered the effects of a standardized 8-week mindful self-compassion (MSC) program in patients with type 1 and type 2 diabetes. Measures of self-compassion, depressive symptoms, diabetes-specific distress, and HbA1c were taken at baseline (pre-intervention), at week 8 (post-intervention), and at 3-month follow-up. It found that MSC training increased self-compassion and produced statistically and clinically significant reductions in depression and diabetes distress, with results maintained at 3-month follow-up. MSC participants also averaged a clinically and statistically meaningful decrease in HbA1c between baseline and follow-up of greater than 10 mmol/mol (nearly 1%). So the conclusion was that learning to be kinder to oneself (rather than being harshly self-critical) may have both emotional and metabolic benefits among patients with diabetes.


Prevalence and comorbidities of double diabetes
S.R. Merger et al. Diabetes Research and Clinical Practice. Doi:

A growing number of people with type 1 diabetes (T1DM) are identified with features of metabolic syndrome (MS) known as “double diabetes”, but epidemiologic data on the prevalence of MS in T1DM and its comorbidities are still lacking. This cross sectional study of 31,119 persons with autoimmune diabetes estimated the prevalence of MS in T1DM, and assessed its association with comorbidities. It found that 25.5% (7,926) of persons with T1DM presented with MS. These persons with double diabetes showed significantly more macrovascular comorbidities (coronary heart disease, stroke, diabetic foot syndrome). Also microvascular diseases were increased in people with double diabetes (retinopathy, nephropathy). Both macrovascular and microvascular comorbidities were increased independent of glucose control. The conclusions were that double diabetes seemed to be an independent and important risk factor for persons with T1DM in developing macrovascular and microvascular comorbidities, and these patients need to be identified so that the development of MS can be avoided.


Corneal endothelial morphology in children with type 1 diabetes
Mohamed Anbar et al. Journal of Diabetes Research. Doi:

This study investigated corneal endothelial cell morphology in children with type 1 diabetes and to determine the systemic and local factors that contributed to these changes. Eighty children with type 1 diabetes and 40 normal children underwent full clinical and ophthalmologic examination. Corneal thickness (CCT), endothelial cell density (ECD), and pleomorphism were recorded using a noncontact specular microscope. [Pleomorphism is the variability in the size and shape of cells and/or their nuclei]. It found that the mean CCT was significantly higher in the diabetic group compared to the control group. The mean ECD in patients with type 1 diabetes was significantly lower than in the control group. Furthermore, pleomorphism was significantly lower in the group with diabetes compared to the control group. In addition, as would be expected, all of these changes are significantly correlated with the duration of diabetes. The authors recommend that the degree to which these changes affect visional function on long term needs to be investigated in further studies.


National Diabetes Inpatient Audit 2015

National Diabetes Inpatient Audit report (NaDIA) presents the 2015 results and analyses the changes in activity and outcomes over the last four contributory years (2010 to 2013). The full report (large PDF) is available to download. The 134 pages are packed with data. The conclusions states that the NaDIA is an invaluable tool for diabetes teams to reflect on the care they provide, to address areas of weakness and to take pride in areas in which they excel. From its introduction, the audit has driven small but important improvements in inpatient care year upon year. Due to funding issues there was a break between 2013 and 2015. Over this time improvements have halted, and in several areas, including medication errors and the activities of the multi-disciplinary foot team, the gains made have slightly reversed, although results remain significantly better than in the first audit. Whether this is the result of diabetes teams ‘taking their eye off the ball’ during the break is speculative but quite possible. The data from NaDIA 2015 should help teams refocus their efforts. What is clear is the lack of investment and indeed in some areas disinvestment in diabetes inpatient services. This is shortsighted as the prevalence of diabetes in hospital is relentlessly increasing such that it may account for one in four occupied hospital beds in 2025. Investing in diabetes inpatient teams would reap rewards in reduced bed days and reduced harms to patients. The 50 per cent reduction in hospital acquired foot ulcers seen since the introduction of NaDIA on its own would provide sufficient savings to fund the inpatient diabetes specialist team.


Long-term excess mortality associated with diabetes following acute myocardial infarction
O A Alabas et al. Journal of Epidemiology & Community Health. Doi:10.1136/jech-2016-207402

Because the long-term excess risk of death associated with diabetes following acute myocardial infarction is unknown, this study looked at the excess risk of death associated with diabetes among patients with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). [ST elevations refers to a finding on an electrocardiogram wherein the trace in the ST segment is abnormally high above the baseline]. The investigators interrogated the nationwide population-based cohort (STEMI with 281,259 subjects and NSTEMI with 422,661 subjects) using data from the UK acute myocardial infarction registry, MINAP, between 1 January 2003 and 30 June 2013. In a total over 1.94 million person-years follow-up including 120,568 (17.1%) patients with diabetes, there were 187,875 (26.7%) deaths. Overall, unadjusted (all cause) mortality was higher among patients with than without diabetes (35.8% vs 25.3%). After adjustment for age, sex and year of acute myocardial infarction, diabetes was associated with a 72% and 67% excess risk of death following STEMI and NSTEMI. The conclusion was that at index acute myocardial infarction, diabetes was common and associated with significant long-term excess mortality, over and above the effects of comorbidities, risk factors and cardiovascular treatments.