Disparities Between Teleretinal Imaging Findings and Patient-Reported Diabetic Retinopathy Status and Follow-up Eye Care Interval: A 10-Year Prospective Study.

OBJECTIVE: To assess self-reported awareness of diabetic retinopathy (DR) and concordance of eye examination follow-up compared with findings from concurrent retinal images. RESEARCH DESIGN AND METHODS: We conducted a prospective observational 10-year study of 26,876 consecutive patients with diabetes who underwent retinal imaging during an endocrinology visit. Awareness and concordance were evaluated using questionnaires and retinal imaging. RESULTS: Awareness information and gradable images were available in 25,360 patients (94.3%). Severity of DR by imaging was as follows: no DR (n = 14,317; 56.5%), mild DR (n = 6,805; 26.8%), or vision-threatening DR (vtDR; n = 4,238; 16.7%). In the no, mild, and vtDR groups, 96.7%, 88.5%, and 54.9% of patients, respectively, reported being unaware of any prior DR. When DR was present, reporting no prior DR was associated with shorter diabetes duration, milder DR, last eye examination >1 year before, no dilation, no scheduled appointment, and less specialized provider (all P < 0.001). Among patients with vtDR, 41.2%, 58.1%, and 64.2% did not report being aware of any DR and follow-up was concordant with current DR severity in 66.7%, 41.3%, and 25.4% (P < 0.001) of patients when prior examination was performed by a retinal specialist, nonretinal ophthalmologist, or optometrist (P < 0.001), respectively. CONCLUSIONS: Substantial discrepancies exist between DR presence, patient awareness, and concordance of follow-up across all DR severity levels. These discrepancies are present across all eye care provider types, with the magnitude influenced by provider type. Therefore, patient self-report should not be relied upon to reflect DR status. Modification of medical care and education models may be necessary to enhance retention of ophthalmic knowledge in patients with diabetes and ensure accurate communication between all health care providers.

Clinical Considerations When Initiating and Titrating Insulin Degludec/Liraglutide (IDegLira) in People with Type 2 Diabetes.

Therapeutic inertia is a substantial obstacle to the initiation of insulin therapy in people with uncontrolled type 2 diabetes (T2D). This effect has in part been perpetuated by concerns over the impact of a burdensome regimen and the increased risk of hypoglycemia and body weight gain often associated with insulin use. An effective, yet simple, less burdensome regimen with a lower risk of body weight gain and hypoglycemia compared with an insulin-only regimen, may help to address these concerns more effectively. We review the available clinical and real-world data on IDegLira, a once-daily, injectable, fixed-ratio combination of insulin degludec (degludec) and the glucagon-like peptide-1 receptor agonist (GLP-1RA) liraglutide, in people with T2D. Evidence from the comprehensive DUAL clinical trial program suggests an advantage of IDegLira over traditional insulin therapies in a number of clinical outcomes, including maintenance of glycemic control, achievement of glycemic targets, reducing the risk of hypoglycemia, and body weight loss. These findings were demonstrated in participants with T2D irrespective of prior GLP-1RA and insulin use. Furthermore, the individual components of IDegLira have confirmed safety (degludec) or significant benefit in terms of improvement of cardiovascular risk (liraglutide). As an injectable therapy that is simple to titrate, IDegLira has the potential to optimize the ability to achieve relevant glycemic targets, and offers a suitable treatment option for people with T2D requiring insulin therapy who are at risk of hypoglycemia or weight gain.

Effect of diabetes-specific nutrition formulas on satiety and hunger hormones in patients with type 2 diabetes.

OBJECTIVES: Diabetes-specific nutritional formulas (DSNFs) are frequently used by patients with type 2 diabetes (T2D) as part of nutrition therapy to improve glycemic control and reduce body weight. However, their effects on hunger and satiety hormones when compared to an isocaloric standardized breakfast are not fully understood. This study aims to evaluate the postprandial effects of two DSNFs-Glucerna (GL) and Ultra Glucose Control (UGC)-versus oatmeal on selected satiety and hunger hormones. METHOD: After an overnight fast, 22 patients with T2D (mean age 62.3 ± 6.8 years, A1C 6.8 ± 0.7%, body weight 97.4 ± 21.3 kg, and BMI 33.2 ± 5.9 kg/m²) were given 200 kcal of each meal on three separate days. Blood samples for amylin, cholecystokinin (CCK), ghrelin, glucagon, leptin, and peptide-YY (PYY) were collected at baseline and 30, 60, 90, 120, 180, and 240 min after the start of each meal. Incremental area under the curve (iAUC0-240) for each hormone was calculated. RESULTS: iAUC0-240 for glucagon and PYY were significantly higher after GL and UGC than after oatmeal (p < 0.001 for both). No difference was observed between the three meals on postprandial amylin, CCK, ghrelin, and leptin hormones. CONCLUSIONS: Intake of DSNFs significantly increases secretion of PYY and glucagon, two important satiety hormones. While subjective satiety was not directly evaluated, the increased effect on satiety hormones may partially explain the mechanism of body weight loss associated with DSNF use.

Improving patients' home cooking - A case series of participation in a remote culinary coaching program.

This case series describes and examines the outcomes of a remote culinary coaching program aimed at improving nutrition through home cooking. Participants (n = 4) improved attitudes about the perceived ease of home cooking (p < 0.01) and self-efficacy to perform various culinary skills (p = 0.02); and also improved in confidence to continue online learning of culinary skills and consume healthier food. We believe this program might be a viable response to the need for effective and scalable health-related culinary interventions.

Changes in HbA1c and Weight Following Transition to Continuous Subcutaneous Insulin Infusion Therapy in Adults With Type 1 Diabetes.

BACKGROUND: Historically, intensive insulin therapy for type 1 diabetes (T1D) has improved glycemic control at the risk of adverse weight gain. The impact of continuous subcutaneous insulin infusion therapy (CSII) on weight in the current era remains unknown. We assessed changes in hemoglobin A1c (HbA1c) and weight in adults with T1D transitioning to CSII at 2 diabetes centers in Denmark and the United States. METHODS: Patients with T1D, aged ≥18 years, managed with multiple daily injections (MDI) who transitioned to CSII between 2002 and 2013 were identified using electronic health record data from the Steno Diabetes Center (n = 600) and Joslin Diabetes Center (n = 658). Changes in HbA1c and weight after 1 year was assessed overall and by baseline HbA1c cut points. Multivariate regression assessed correlates of HbA1c reduction. RESULTS: In adults with T1D transitioning to CSII, clinically significant HbA1c reductions were found in patients with baseline HbA1c 8.0-8.9% (Steno, -0.7%; Joslin, -0.4%) and baseline HbA1c ≥9.0% (Steno, -1.1%; Joslin, -0.9%) ( P < .005 for all). Overall, there was no significant change in weight after 1 year at either center. Modest (<2%) weight gain was noted in patients with baseline HbA1c ≥9% at Steno (1.1 ± 0.3 kg, P < .0001) and Joslin (1.7 ± 1.1, P < .005). In multivariate models, HbA1c reduction was associated with higher HbA1c, older age, female sex at Steno ( R2 = .28, P < .005), but only higher baseline HbA1c at Joslin ( R2 = .19, P < .005). CONCLUSION: Adults with T1D with suboptimal glycemic control significantly improved HbA1c without a negative impact on weight 1 year after transitioning from MDI to CSII.

Should We Screen for Type 2 Diabetes?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

The prevalence of diabetes in the United States is rising. Twelve percent of U.S. adults have diabetes and another 37% have impaired fasting glucose or impaired glucose tolerance. Diabetes is a major risk factor for such outcomes as cardiovascular disease, blindness, chronic kidney disease, and limb amputation. An important consideration is whether screening for abnormal glucose levels or diabetes reduces cardiovascular or all-cause morbidity and mortality. In October 2015, the U.S. Preventive Services Task Force published recommendations on screening for abnormal blood glucose and concluded that intensive lifestyle interventions have a moderate benefit in reducing progression to diabetes in patients who have abnormal blood glucose levels detected by screening. It found inadequate evidence that such screening reduces cardiovascular or all-cause mortality and no evidence of psychological or other harms from screening. The Task Force recommends glucose screening every 3 years for adults aged 40 to 70 years who are overweight or obese and do not have symptoms of diabetes. In this article, we present the case of a man who meets these criteria and explore his preferences and concerns regarding screening. Two experts then debate screening merits and benefits, the significance of abnormal blood glucose levels and diabetes as cardiovascular risk factors, and application of the guidelines to this particular patient.

IMPROVEMENTS IN METABOLIC CONTROL IN ADULTS WITH TYPE 2 DIABETES FOLLOWING REFERRAL TO A DIABETES CENTER, 2005-2010.

OBJECTIVE: We aimed to compare metabolic control in adults with diabetes in the general population to those newly referred to a diabetes center and after 1 year of specialty care. METHODS: We performed a retrospective comparison of adults with diabetes aged ≥20 years data from the National Health and Nutrition Examination Survey (NHANES, n = 1,674) and a diabetes center (n = 3,128) from 2005-2010. NHANES participants represented the civilian, non-institutionalized U.S. POPULATION: Diabetes center referrals lived primarily around eastern Massachusetts. The proportion attaining targets for glycated hemoglobin A1c (A1c), blood pressure (BP), low-density lipoprotein (LDL) cholesterol, or all 3 (ABC control) and the proportion prescribed medications to lower A1c, BP, or cholesterol were evaluated. RESULTS: Compared to the general sample, a smaller proportion of new diabetes center referrals had A1c <7% (<53 mmol/mol, 24% vs. 53%, P<.001), BP <130/80 mm Hg (38% vs. 50%, P<.001), and ABC control (5.6% vs. 17%, P<.001) but not LDL<100 mg/dL (<2.6 mmol/L, 54% vs. 53%, P = .65). After 1 year, more diabetes center referrals attained targets for A1c (40%), BP (38%), LDL (67%), and ABC control (15%) (P<.001 for all versus baseline). ABC control was not different between the general sample and diabetes center referrals at 1 year (P = .16). After 1 year, a greater percentage of diabetes center referrals compared to the general sample were prescribed medications to lower glucose (95% vs. 72%), BP (79% vs. 64%), and cholesterol (77% vs. 54%)(all P<.001). CONCLUSION: Compared to the general population, glycemic control was significantly worse for adults newly referred to the diabetes center. Within 1 year of specialty care, ABC control increased 270% in the setting of significant therapy escalation. ABBREVIATIONS: A1c = glycated hemoglobin A1c ABC = composite of A1c, blood pressure, and cholesterol ACEi = angiotensin-converting enzyme inhibitor ARB = angiotensin receptor blocker BMI = body mass index BP = blood pressure EHR = electronic health record LDL = low-density lipoprotein NCHS = National Center for Health Statistics NHANES = National Health and Nutrition Examination Survey PCP = primary care provider.

Should sulfonylureas remain an acceptable first-line add-on to metformin therapy in patients with type 2 diabetes? Yes, they continue to serve us well!

Since their introduction to clinical practice in the 1950s, sulfonylureas have been widely prescribed for use in patients with type 2 diabetes. Of all the other medications currently available for clinical use, only metformin has been used more frequently. However, several new drug classes have emerged that are reported to have equal glucose-lowering efficacy and greater safety when added to treatment of patients in whom metformin monotherapy is no longer sufficient. Moreover, current arguments also suggest that the alternative drugs may be superior to sulfonylureas with regard to the risk of cardiovascular complications. Thus, while there is universal agreement that metformin should remain the first-line pharmacologic therapy for those in whom lifestyle modification is insufficient to control hyperglycemia, there is no consensus as to which drug should be added to metformin. Therefore, given the current controversy, we provide a Point-Counterpoint on this issue. In the point narrative presented below, Dr. Abrahamson provides his argument suggesting that avoiding use of sulfonylureas as a class of medication as an add-on to metformin is not appropriate as there are many patients whose glycemic control would improve with use of these drugs with minimal risk of adverse events. In the following counterpoint narrative, Dr. Genuth suggests there is no longer a need for sulfonylureas to remain a first-line addition to metformin for those patients whose clinical characteristics are appropriate and whose health insurance and/or financial resources make an alternative drug affordable.

Barriers and facilitators to self-care communication during medical appointments in the United States for adults with type 2 diabetes.

OBJECTIVE: Diabetes self-care is challenging and requires effective patient-provider communication to achieve optimal treatment outcomes. This study explored perceptions of barriers and facilitators to diabetes self-care communication during medical appointments. DESIGN: Qualitative study using in-depth interviews with a semistructured interview guide. PARTICIPANTS: Thirty-four patients with type 2 diabetes and 19 physicians who treat type 2 diabetes. RESULTS: Physicians described some patients as reluctant to discuss their self-care behaviors primarily because of fear of being judged, guilt, and shame. Similarly, patients described reluctant communication resulting from fear of being judged and shame, particularly shame surrounding food intake and weight. Physicians and patients recommended trust, nonjudgmental acceptance, open/honest communication, and providing patients hope for living with diabetes as important factors for improving self-care communication. Further, patients stressed the clinical benefits of physicians directly addressing poor self-care behaviors while physicians described having few strategies to address these difficulties. CONCLUSIONS: Physician-patient self-care communication barriers included patients' reluctance to discuss self-care behaviors and physicians' perceptions of few options to address this reluctance. Treatment recommendations stressed the importance of establishing trusting, nonjudgmental and open patient-provider communication for optimal diabetes treatment. Medical education is needed to improve physicians' strategies for addressing self-care communication during medical appointments.

Innovation in diabetes care: improving consumption of healthy food through a "chef coaching" program: a case report.

Nutrition therapy as part of lifestyle care is recommended for people with type 2 diabetes. However, most people with diabetes do not follow this guideline. Changing eating habits involves obtaining knowledge and building practical skills such as shopping, meal preparation, and food storage. Just as fitness coaches use their specific knowledge base in fitness to enhance the effectiveness of their coaching, credentialed chefs trained as health coaches might combine their culinary expertise with coaching in order to improve clients' food choices and lifestyles. This report documents the case of a 55-year-old white male physician, single and living alone, who was recently diagnosed with type 2 diabetes and reported chronic stress, sedentary behavior, and unhealthy eating habits. He participated in a chef coaching program of 8 weekly one-on-one 30-minute coaching sessions via Skype delivered by a chef trained as a health coach. During the first five meetings, the patient's goals were primarily culinary; however, with his success in accomplishing these goals, the patient progressed and expanded his goals to include other lifestyle domains, specifically exercise and work-life balance. At the end of the program, the patient had improved both his nutritional and exercise habits, his confidence in further self-care improvement, and his health parameters such as HgA1c (8.8% to 6.7%; normal <6.5%). We conclude that chef coaching has the potential to help people with diabetes improve their practical culinary skills and implement them so that they eat better and, further, has the potential to help them improve their overall self-care. We intend to further develop chef coaching and assess its potential as we learn from its implementation.

Se recomienda un tratamiento nutricional como parte de un estilo de vida saludable para las personas con diabetes de tipo 2. No obstante, la mayoría de las personas con diabetes no siguen esta pauta. Cambiar los hábitos de alimentación implica obtener conocimientos y desarrollar habilidades prácticas, como ir de compras, preparar comidas y almacenar los alimentos. De la misma forma que los entrenadores personales usan sus conocimientos específicos del mantenimiento físico, para mejorar la efectividad de los entrenamientos, los acreditados chefs, que se han formado como entrenadores de la salud, podrían combinar su experiencia culinaria con el entrenamiento especializado en la salud, para mejorar las elecciones alimentarias y los estilos de vida de sus clientes.Este informe documenta el caso de un médico de 55 años, blanco, soltero y que vive solo, a quien se le diagnosticó recientemente diabetes de tipo 2 y que presentaba estrés crónico, comportamiento sedentario y hábitos dietéticos insanos. Participó en un programa de entrenamiento con un chef durante 8 sesiones individuales de 30 minutos por semana a través de Skype, impartido por un chef con formación específica en la salud. Durante las primeras cinco reuniones, los objetivos del paciente fueron principalmente culinarios; no obstante, al haber conseguido con éxito estos objetivos, el paciente avanzó y amplió los objetivos e incluyó otros ámbitos respecto al estilo de vida, en concreto, el equilibrio entre el ejercicio y el trabajo. Al final del programa, el paciente había mejorado los hábitos alimenticios y los hábitos de ejercicio, la confianza en sí mismo para seguir mejorando el cuidado personal y los parámetros médicos, como la HbA1c (de 8,8 % a 6,7 %; normal <6,5 %).La conclusión es que el entrenamiento con chef ayuda potencialmente a las personas con diabetes a la hora de mejorar sus habilidades culinarias y de ponerlas en práctica para comer mejor. Además, tiene potencial para ayudarles a mejorar el cuidado personal en general. Tenemos intención de desarrollar el entrenamiento con chef y valorar su potencial, al mismo tiempo que vamos aprendiendo de su implementación.