Journal Watch

Prepared for IDDT by Jim Young

June 2016

Retinal blood flow is increased in type 1 diabetes mellitus patients with advanced stages of retinopathy
Hoang-Ton Nguyen et al. BMC Endocrine Disorders. Doi: 10.1186/s12902-016-0105-y

Diabetic retinopathy (DRP) is a common microvascular complication seen in patients with type 1 diabetes mellitus (T1DM). The effects of T1DM and concomitant (proliferative) DRP on retinal blood flow are currently unclear. This study measured retinal vascular blood flow in T1DM patients with and without DRP and non-diabetic controls. It also assessed the acute effects of panretinal photocoagulation (pDRP) on retinal microvascular bloodflow in eight patients with diabetes. It was found that retinal blood flow was higher in previously treated (pDRP) compared with the patients without DRP (nDRP) and controls. Furthermore, there was a positive linear trend for blood flow with lowest blood flow in the control group and highest in the pDRP. The conclusions were that in comparison with controls and nDRP patients, retinal blood flow significantly increased in the pDRP group, which previously underwent photocoagulation treatment. The authors suggest that these changes may be a consequence of a failing vascular autoregulation in advanced diabetic retinopathy.


Sustained efficacy of insulin pump therapy in type 2 diabetes: 9-Year Follow-up
Julia Morera et al. Diabetes Care. Doi:

Continuous subcutaneous insulin infusion (CSII) is a valuable option for patients with type 2 diabetes in whom glycemic targets are not met despite multiple daily injections (MDIs) at high insulin doses. However, data on the durability of glucose control with CSII are lacking. This study looked at the long-term efficacy of CSII in a cohort of 161 patients. The authors report that their retrospective analysis demonstrated the sustained efficacy of insulin pump therapy in patients with type 2 diabetes with MDI failure. They posit that their results are unique and may have important implications for long-term insulin intensification strategies in type 2 diabetes. Their methods and results sections provide a detailed description of their study.


Techniques for exercise preparation and management in adults with type 1 diabetes
Jordan E. Pinsker et al. Canadian Journal of Diabetes. Doi:

People with type 1 diabetes are at risk for early- and late-onset hypoglycemia following exercise. Reducing this risk may be possible with strategic modifications in carbohydrate intake and insulin use. This study examined exercise preparations and management techniques used by individuals with type 1 diabetes before and after physical activity. It studied 502 adults who had completed an online survey that focused on diabetes self-management and exercise. Many of the respondents reported increasing carbohydrate intake before (79%) and after (66%) exercise as well as decreasing their meal boluses before (53%) and after (46%) exercise. Most reported adhering to a target glucose level before starting exercise (77%). However, despite these accommodations, the majority reported low blood glucose (BG) levels after exercise (70%). The majority of users of both insulin pump therapy (CSII) and continuous glucose monitoring (CGM) (Combined) reported reducing basal insulin around exercise (55%), with fewer participants adjusting basal insulin when using other devices. However, CSII and Combined users reported that exercise made their BG levels harder to control and made them feel less able to predict their BG levels while exercising. They all agreed that fear of low BG levels kept them from exercising. The authors say that their findings highlight the need for exercise-management strategies tailored to individuals’ overall diabetes management, for despite making exercise-specific adjustments for care, many people with type 1 diabetes still report significant difficulties with BG control when it comes to exercise.


Identification of novel changes in human skeletal muscle proteome following roux-en-y gastric bypass
Latoya E. Campbell et al. Diabetes. Doi:

Because the mechanisms of metabolic improvements following Roux-en Y gastric bypass (RYGB) surgery are not entirely clear, this study investigated the role of obesity and RYGB on the human skeletal muscle proteome. [The proteome is the entire set of proteins expressed by a genome, cell, tissue, or organism at a certain time] Basal muscle biopsies were obtained from seven obese female subjects pre and 3 months post-RYGB, and insulin sensitivity was assessed. Four age-matched lean females served as controls. It was found that there were significant improvements in fasting plasma glucose (FPG) and BMI pre- vs. post-RYG. In addition, proteomic analysis identified 2,877 quantifiable proteins, and of these, 395 proteins were significantly altered in obesity before surgery, and 280 proteins differed significantly post-RYGB. Post-RYGB, 49 proteins were returned to normal levels. The authors assert that their results provide evidence that obesity and RYGB have a dynamic effect on the skeletal muscle proteome.


Dynamics in insulin requirements and treatment safety
R. Harper et al. Journal of Diabetes and Its Complications. Doi:

The introduction to this paper reminds us that the majority of insulin users have elevated HbA1c. That there is growing recognition that the low success rates are due to variations in insulin requirements, and that frequent dosage adjustments are needed. This research investigated intra-individual dynamics of insulin requirements. Events of considerable and persistent decrease in insulin requirements were identified by drops in total daily insulin greater than 25%. The study looked at 62 patients for an average period of 2 years. Events were identified in 56.5% of the patients. On average, each affected patient had 0.8 events per year, lasting 9.7 weeks, while total daily insulin dosage decreased by 41.4 %. The authors concluded that their findings drew attention to a major contributing factor to hypoglycemia among insulin users. In reality, insulin dosage is seldom adjusted and thus transient periods of decrease in insulin requirements and overtreatment are usually overlooked.


Nutritional follow-up of patients after obesity surgery
Mary O’Kane and Julian H. Barth. Medscape. 2016;84(5):658-661.

Obesity surgery is an appropriate treatment option for patients with severe and complex obesity and helps in the improvement of comorbidities. In the first 2 years following surgery, follow-up is provided by the obesity surgery centre. Ongoing care is then usually returned to the general practitioner. Patients need access to ongoing support and monitoring otherwise may be at risk of developing nutritional deficiencies such as anaemia or protein malnutrition. The British Obesity and Metabolic Surgery Society have developed guidelines on nutritional monitoring and nutritional supplements to support both bariatric centres and general practitioners. The Royal College of General Practitioners and BOMSS have worked collaboratively to develop Ten Top Tips for the management of obesity surgery patients to aid with the long-term management in primary care. Women, planning to get pregnant, need access to preconception advice and additional monitoring during pregnancy. It is essential that long-term data are collected and inputted into the National Bariatric Surgery Register. Obesity surgery improves comorbidities; however, patients must have access to long-term nutritional monitoring. This interesting 8-page article from Medscape elaborates on this theme and lists the ten tips from the RCGP.


Intensive treatment and severe hypoglycemia among adults with type 2 diabetes
Rozalina G. McCoy et al. JAMA. Doi:10.1001/jamainternmed.2016.2275

This study estimated the prevalence of intensive treatment and the association between intensive treatment, clinical complexity, and incidence of severe hypoglycemia among adults with type 2 diabetes who were not using insulin. Of the 31,542 patients eligible for inclusion, 3,910 had clinical complexity. The probability of intensive treatment was 25.7% in patients with low clinical complexity and 20.8% in patients with high clinical complexity. In patients with low clinical complexity, the probability of severe hypoglycemia during the subsequent 2 years was 1.02% with standard treatment and 1.30% with intensive treatment. In patients with high clinical complexity, intensive treatment significantly increased the risk-adjusted probability of severe hypoglycemia from 1.74% with standard treatment to 3.04% with intensive. The authors posit that more than 20% of patients with type 2 diabetes received intensive treatment that may be unnecessary. Among patients with high clinical complexity, intensive treatment nearly doubles the risk of severe hypoglycemia.


Diabetes treatment intensification and associated changes in HbA1c and body mass index
Christianne L. Roumie et al. BMC Endocrine Disorders. Doi: 10.1186/s12902-016-0101-2

This study looked at a national retrospective cohort of veterans initially treated for diabetes with either metformin or sulfonylurea from 2001 through 2008. Patients were followed through to September, 2011 to identify common diabetes treatment intensification regimens. Changes in HbA1c and BMI post-intensification was recorded for metformin-based regimens. The investigators identified 323,857 veterans who initiated diabetes treatment. Of these, 55 % initiated metformin, 43 % sulfonylurea and 2 % other regimens. Fifty percent of metformin initiators remained on metformin monotherapy over a median follow-up 58 months. Among 80,725 patients who intensified metformin monotherapy, the four most common regimens were addition of sulfonylurea (79 %), thiazolidinedione [TZD] (6 %), or insulin (8 %), and switch to insulin monotherapy (2 %). Across these regimens, median HbA1c values declined from a range of 7.0–7.8 % (53–62 mmol/mol) at intensification to 6.6–7.0 % (49–53 mmol/mol) at 1 year, and remained stable up to 3 years afterwards. Median BMI ranged between 30.5 and 32 kg/m2 at intensification and increased very modestly in those who intensified with oral regimens, but 1–2 kg/m2 over 3 years among those who intensified with insulin-based regimens. The conclusions were that by 1-year post-intensification of metformin monotherapy, HbA1c declined in all four common intensification regimens, and remained close to 7 % in subsequent follow-up. BMI increased substantially for those on insulin-based regimens.


Trends in hospital admissions for hypoglycaemia in England
Francesco Zaccardi et al. The Lancet Diabetes & Endocrinology. Doi:

This study gathered information about long-term trends in hospital admission for hypoglycaemia and subsequent outcomes in England to help widen understanding for the global burden of hospitalisation for hypoglycaemia. Data was collected for all hospital admissions listing hypoglycaemia as primary reason of admission between Jan 1, 2005, and Dec 31, 2014. It found that 79,172 people had 101,475 admissions for hypoglycaemia between 2005 and 2014, of which 72,568 (72%) occurred in people aged 60 years or older. 13,924 (18%) people had more than one admission for hypoglycaemia during the study period. The number of admissions increased steadily from 7,868 in 2005, to 11,756 in 2010 (49% increase) and then remained more stable until 2014. Admissions for hypoglycaemia per 100,000 total hospital admissions increased from 63·6 to 78·9 between 2005–06 and 2010–11 (24% increase), and then fell to 72·3 per 100 000 in 2013–14 (14% overall increase). Accounting for diabetes prevalence data, rates declined from 4·64 to 3·86 admissions per 1,000 person-years with diabetes between 2010–11 and 2013–14. The authors conclude by saying that accounting for diabetes prevalence, there was a reduction of admission rates. Hospital length of stay, mortality, and 1 month readmissions decreased progressively and consistently during the study period. They also suggest that given the continuous rise of diabetes prevalence, ageing population, and costs associated with hypoglycaemia, individual and national initiatives should be implemented to reduce the burden of hospital admissions for hypoglycaemia.


Statin use and cardiovascular risk factors in diabetic patients developing a first myocardial infarction
Martin Bødtker Mortensen et al. Cardiovascular Diabetology. Doi: 10.1186/s12933-016-0400-y

The introduction to this paper asserts that the risk for a first myocardial infarction (MI) in people with diabetes has been shown to be as high as the risk for a new MI in non-diabetic patients with a prior MI.
Consequently, risk-reducing statin therapy is recommended for nearly all patients with diabetes 40 years of age or older, regardless of cholesterol level. The purpose of this study was to assess the recommended and real-life use of statins for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in diabetic patients. It found that primary prevention with statins had been initiated in less than half of diabetic patients destined for a first MI, despite the presence of one or more markers of very high cardiovascular risk in nearly all. These results highlight an urgent need for optimizing statin therapy and global risk factor control in diabetic patients.