The Ambulatory Diabetes Outreach Program (ADOP): Rigorous Evaluation of a Pharmacist and Nurse-Led Care Model.

BACKGROUND: Although several systematic reviews found that ambulatory diabetes mellitus (DM) interventions involving pharmacists generally yielded better outcomes than the ones that did not, existing studies have limitations in rigor and study design. OBJECTIVE: To examine the intention-to-treat effects of the Ambulatory Diabetes Outreach Program (ADOP) on participants' A1c values and healthcare utilization over a 52-month follow-up period. DESIGN: Difference-in-differences with staggered adoption. Specifically, we employed the Callaway and Sant'Anna's "group-time average treatment effect" estimator using not-yet treated as controls adjusting for patient's age, BMI, sex, race, comorbidity, payor, and socio-economic status. PARTICIPANTS: All patients with at least one ADOP treatment encounter from July 2017 to October 2021, regardless of program completion or length of exposure to the program. INTERVENTION: ADOP, a collaborative population health program led by pharmacists and nurse specialists to provide individualized type 2 DM management and education within a large and diverse health system. MAIN MEASURES: Patients' A1c values and healthcare utilization, including inpatient admission, inpatient days, and numbers of visits to the emergency department, urgent care, and primary care in recent 6 months. KEY RESULTS: ADOP participation was associated with an overall average reduction of 1.04 percentage points (95%CI - 1.12, - 0.95) in A1c level. Similar A1c reductions were also observed in the subgroups by sex and race/ethnicity. An average of 2 months were required to reach the overall average effect, which persisted over 4 years. Compared to the respective utilization levels pre-intervention, participants also had average reductions in inpatient admissions by 32.4%, inpatient days by 81.6%, visits to the emergency department by 21.6%, and primary care by 17.9%. CONCLUSIONS: The results suggest that a collaborative model of pharmacist and nurse-led type 2 DM intervention was effective in improving A1c outcomes and reducing healthcare utilization in the long term.

Type 2 diabetes in children and adolescents: Challenges for treatment and potential solutions.

Historically perceived as a disease mainly affecting adults, the prevalence of type 2 diabetes mellitus (T2DM) among children and adolescents has been rising, mirroring the increasing rates of childhood obesity. Currently, youth-onset T2DM poses a significant public health challenge globally. Treating youth-onset T2DM poses numerous critical challenges, namely limited and inadequate therapeutic options, and difficulties with conducting therapeutic studies. As a result, current treatment guidelines are based on adult studies and expert consensus. Few prominent guidelines on the treatment of youth-onset T2DM have been published recently, i.e., by the American Diabetes Association (ADA) 2024, National Institute for Healthcare and Excellence United Kingdom (NICE UK) 2023, International Society Paediatric and Adolescents Diabetes (ISPAD) 2022, Australasian Paediatric Endocrine Group (APEG) 2020 and Diabetes Canada 2018. This review first explores the unique aspects of youth-onset T2DM. It then summarises the different treatment guidelines, discusses the different treatment modalities based on available evidence and identifies any gaps. The review also explores challenges in the treatment of youth-onset T2DM with potential solutions and discusses recent trials on the treatment of youth-onset T2DM. Continued research aims to optimise treatment, improve outcomes, and alleviate the burden of T2DM on youths.

Degree of Food Processing is Associated with Glycemic Control in African American Adults with Type 2 Diabetes: Findings from the TX STRIDE Clinical Trial.

BACKGROUND: Type 2 diabetes mellitus (T2DM) disproportionately affects African American (AA) populations. Despite the importance of diet in diabetes management, the association of diet quality and/or the degree of food processing with glycemic control in AA adults with T2DM remains unclear. OBJECTIVE: This study aimed to examine associations between diet quality scores and the degree of processing in the diet with HbA1c in AA adults with T2DM. DESIGN: This cross-sectional study used baseline data from participants in TX STRIDE (Texas Strength Through Resilience in Diabetes Education), an ongoing clinical trial. PARTICIPANTS/SETTING: Participants involved in this analysis (n=273) were AA adults with T2DM recruited through local churches in Austin, TX, and the surrounding areas from August 2020 through April 2023. MAIN OUTCOME MEASURES: Participants provided two 24-hour dietary recalls (one weekend and one weekday) and a blood sample to measure HbA1c. Healthy Eating Index-2015, Alternate Healthy Eating Index-2010, and Alternate Mediterranean Diet scores were calculated. The NOVA method was used to calculate the percentage of grams and calories that came from ultra-processed foods (UPF) and unprocessed or minimally processed foods (U/MPF). STATISTICAL ANALYSES PERFORMED: Linear regression and ANOVA models tested associations between the diet quality scores and degree of food processing with HbA1c, adjusting for demographic covariates. Models were stratified by insulin use after finding a significant interaction with UPF and U/MPF. RESULTS: Regression analyses revealed that the percentage of grams in the total diet from UPF was positively associated with HbA1c (ßadj =0.015, Padj =0.032) while U/MPF was inversely associated with HbA1c (ßadj = -0.014, Padj =0.043). There was no significant association between any diet quality score and HbA1c. CONCLUSIONS: In AA adults with T2DM, only the degree of food processing was associated with HbA1c. Future research should explore whether a causal relationship exists between food processing and HbA1c and investigate mechanisms by which UPFs may affect glycemic control.

Comparative Efficacy and Safety of Weekly GLP-1/GIP Agonists vs. Weekly Insulin in Type 2 Diabetes: A Network Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Diabetes mellitus (DM) significantly impacts global health due to its complications and the economic burden it places on healthcare systems. The rise of novel once-weekly diabetes medications with different mechanisms of action necessitates an evaluation of their relative efficacy and safety. OBJECTIVES: This study compares the efficacy and tolerability of once-weekly insulin analogs (icodec and BIF) with once-weekly GLP-1/GIP agonists (semaglutide, exenatide, tirzepatide, dulaglutide) in managing type 2 diabetes mellitus (T2DM). METHODS: We conducted a network meta-analysis (NMA) using data from randomized controlled trials (RCTs) that compared these treatments with a baseline of daily basal insulin. Primary outcomes included changes in HbA1c, body weight, and tolerability. RESULTS: The analysis integrated data from 25 RCTs, involving 18,257 patients. Tirzepatide significantly outperformed other treatments in reducing HbA1c and promoting weight loss. Weekly insulins, compared to GLP-1/GIP agonists, showed a more tolerable profile and were beneficial for certain patient demographics emphasizing weight stability. CONCLUSION: Our findings suggest that while once-weekly GLP-1/GIP agonists provide superior glycemic control and weight management, weekly insulins offer viable options for patients prioritizing fewer side effects and weight stability. This comprehensive comparison aids in refining personalized treatment strategies for T2DM management.

Modern Challenges in Type 2 Diabetes: Balancing New Medications with Multifactorial Care.

Type 2 diabetes mellitus (T2DM) is a prevalent chronic metabolic disorder characterized by insulin resistance and progressive beta cell dysfunction, presenting substantial global health and economic challenges. This review explores recent advancements in diabetes management, emphasizing novel pharmacological therapies and their physiological mechanisms. We highlight the transformative impact of Sodium-Glucose Cotransporter 2 inhibitor (SGLT2i) and Glucagon-Like Peptide 1 Receptor Agonist (GLP-1RA), which target specific physiological pathways to enhance glucose regulation and metabolic health. A key focus of this review is tirzepatide, a dual agonist of the glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptors. Tirzepatide illustrates how integrating innovative mechanisms with established physiological pathways can significantly improve glycemic control and support weight management. Additionally, we explore emerging treatments such as glimins and glucokinase activators (GKAs), which offer novel strategies for enhancing insulin secretion and reducing glucose production. We also address future perspectives in diabetes management, including the potential of retatrutide as a triple receptor agonist and evolving guidelines advocating for a comprehensive, multifactorial approach to care. This approach integrates pharmacological advancements with essential lifestyle modifications-such as dietary changes, physical activity, and smoking cessation-to optimize patient outcomes. By focusing on the physiological mechanisms of these new therapies, this review underscores their role in enhancing T2DM management and highlights the importance of personalized care plans to address the complexities of the disease. This holistic perspective aims to improve patient quality of life and long-term health outcomes.

Identification of phase angle and Triglyceride-Glucose index as biomarkers for prediction and management of diabetic foot disease.

Introduction: Approximately 25 % of diabetic patients develop diabetic foot ulcers (DFUs), significantly increasing morbidity, mortality, and healthcare costs. Effective control and prevention are crucial. Objective: This study aims to identify easily measurable parameters for predicting DFU risk by assessing the correlation between Phase Angle (PA) and the Triglyceride-Glucose (TyG) index with DFU risk. Materials and methods: A comparative case-control study was conducted at the General Hospital of Elche from March to June 2023 with 70 participants (33 with diabetes, 37 without). Cases had diabetes for over five years and a diabetic foot risk grade of 0, 1, or 2 (IWGDF 2019). Exclusion criteria included inability to walk, prior use of orthoses, and severe complications like edema or wounds. Predictive variables were PA, TyG index, body composition, and biochemical markers. Statistical analyses included Pearson/Spearman tests for correlations, Student's t-test/Mann-Whitney test for group comparisons, and ANOVA/Kruskal-Wallis tests for normally and non-normally distributed variables. Results: PAand TyG index were strongly linked to diabetic foot risk, supporting their potential as biomarkers. Significant relationships with other relevant biomarkers were also confirmed. Conclusion: PA and TyG index are valuable, easily measurable biomarkers for assessing diabetic foot risk, and can be monitored in primary care settings. Implementing these biomarkers in routine practice could enhance the management of diabetic complications, particularly in resource-limited settings, by enabling early detection and intervention, thus improving patient outcomes and reducing the burden of advanced complications.

Hemoglobin A1c Levels Are Related to Patency and Adverse Limb Events in Diabetics After Revascularization.

OBJECTIVE: Poor glycemic control in the perioperative period has been reported to be associated with early and late major adverse limb events (MALE). However, these studies were mostly from large databases or lacked long-term outcomes. We examined the long-term effects of high hemoglobin A1c (HbA1c) level on patency, MALE, limb salvage (LS) and survival after lower extremity revascularization procedures in diabetic patients. METHODS: Patients with diabetes who had revascularization for Rutherford class 3-6 ischemia between May 2002 and December 2018 were identified. Patients with HbA1c≤7% were compared to HbA1c>7% for patency, MALE, survival, LS and amputation-free survival (AFS). RESULTS: Of 706 patients, 699 had HbA1c data (775 limbs), with 311 (357 limbs) in HbA1c≤7%, and 388 (418 limbs) in HbA1c>7% groups. Patients with HbA1c>7% were younger (69.9±10.2 vs 71.7±9.5, P=0.011), had higher lipid levels, insulin use (70% vs 49%, P<0.01), ASA 4, and had lower prevalence of chronic kidney disease (CKD) (32%vs41%, P=0.023). HbA1c>7% patients were more likely to present with chronic limb-threatening ischemia (CLTI) (79% vs 72%,P=0.019) and undergo infrapopliteal interventions (49% vs 42%, P=0.005), with no difference in anatomic complexity (TASC C/D, 75% vs 77%, p=0.72) or type of revascularization (24% vs 18% Open, 66% vs 70% EV, 10% vs 12% Hybrid, p=0.236). Patency and freedom from MALE were significantly lower in patients with HbA1c>7% for infra-inguinal revascularizations, whereas AFS and overall survival were similar. In patients with CLTI, LS rates at five years were significantly lower in patients undergoing open revascularization (HbA1c>7%: 64%±6%vs HbA1c<7%:86%±5%, P=0.020), whereas it was similar after endovascular interventions (HbA1c>7%:79%±4% vs HbA1c<7%:77%±3%, p=0.631). Seventy patients with HbA1c>7% lost limbs vs 38 patients with HbA1c≤7% (P=0.007). In multivariate analysis, HbA1c was significantly associated with primary patency. HbA1c, insulin use, level of intervention, and ACEI use were associated with MALE. CONCLUSIONS: Perioperative HbA1c>7% is associated with poorer patency rates, and increased MALE especially at the infra-inguinal level revascularization in diabetics, with no significant impact on survival. Limb salvage is impacted after open, but not after endovascular revascularization.

Assessing perceptions of nursing knowledge, attitudes, and practices in diabetes management within Chinese healthcare settings.

Background: Effective management of diabetes mellitus (DM) involves comprehensive knowledge, attitudes, and practices (KAP) by nurses, which is essential for optimal patient care and aiding patients in their self-management of the condition. Method: This survey evaluates nurses' self-assessed knowledge, attitudes, and practices (KAP) related to diabetes management, focusing on their perceptions of personnel expertise and care approaches. Using a stratified sampling method, the survey was disseminated across various online platforms from January 2023 to February 2024 within China, including WeChat and Sina Weibo. We employed binary logistic regression and Chi-square tests to explore the statistical correlates of KAP related to DM. Results: A total of 4,011 nurses participated, revealing significant perceived knowledge deficiencies in specialized DM management areas, with only 34% (n = 1,360) proficient in current pharmacological treatments. Attitudinal assessments showed that 54% (n = 2,155) recognized the importance of cultural competence in dietary counseling. Practices were strong in routine glucose monitoring (96%, n = 3,851) but weaker in psychological support (68%, n = 2,736). Regression analysis indicated significant effects of experience on KAP, where nurses with 1-5 years of experience were more likely to show better knowledge (OR = 1.09; p = 0.08), and those with advanced degrees demonstrated higher competence (OR = 1.52; p = 0.028). Marital status influenced attitudes, with single nurses more likely to exhibit positive attitudes (OR = 0.49; p < 0.001), and work environment impacted knowledge, with hospital-based nurses more knowledgeable (OR = 1.15; p = 0.14). Additionally, gender differences emerged, with male nurses showing greater knowledge (OR = 1.65; p = 0.03) and better practices in diabetes care (OR = 1.47; p = 0.04). Conclusion: The study underscores the critical need for targeted educational programs and policy interventions to enhance nursing competencies in DM management. While the study provides valuable insights into nurses' perceptions of their competencies, future research should incorporate objective knowledge assessments to ensure a comprehensive understanding of their actual capabilities. Interestingly, the data also suggests a substantial opportunity to leverage technology and inter-professional collaboration to further enhance DM management efficacy among nurses, fostering an integrated care approach.

Training of Community Health Workers in Diabetes Lead to Improved Outcomes for Diabetes Screening and Management in Low- and Middle-Income Countries: Protocol for a Systematic Review.

BACKGROUND: Diabetes is a growing concern worldwide, particularly in low- and middle-income countries (LMICs). Type 2 diabetes mellitus constitutes a significant proportion of cases and is associated with debilitating microvascular complications. Type 2 diabetes mellitus is steadily increasing among the LMICs where many barriers to health care exist. Thus, task shifting to community health workers (CHWs) has been proposed as a solution to improve diabetes management in these settings. However, CHWs often lack the necessary training to manage diabetes effectively. Thus, a systematic review is required to present evidence of the highest degree for this intervention. OBJECTIVE: This study aims to establish the protocols for a systemic review. METHODS: Using the Participants Intervention Comparator Outcome Time Study Design (PICOTS) framework, this study outlines a systematic review aiming to evaluate the impact of training programs for CHWs in diabetes management in LMICs. Quantitative studies focusing on CHWs, diabetes training, focusing on diabetes management outcomes like hemoglobin A1c levels and fasting blood glucose levels, between January 2000 and December 2023 and found on databases such as PubMed, Ovid MEDLINE, Evidence Based Medicine Reviews, BASE, Google Scholar, and Web of Science will be included. We will include randomized controlled trials but will also include observational studies if we find less than 5 randomized controlled trials. An author committee consisting of 3 reviewers will be formed, where 2 reviewers will conduct the review independently while the third will resolve all disputes. The Cochrane Methods Risk of Bias Tool 2 will be used for assessing the risk of bias and the Grading of Recommendations, Assessment, Development and Evaluation approach for the meta-analysis and narrative synthesis analysis will be used. The results will be presented in a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram. RESULTS: The review will begin in May 2024 and conclude in 3 months. CONCLUSIONS: The review will synthesize existing evidence and provide insights into the effectiveness of such programs, informing future research and practice in diabetes care in LMICs. TRIAL REGISTRATION: PROSPERO CRD42022341717; https://tinyurl.com/jva2hpdr. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/57313.

Carbohydrate Content Classification Using Postprandial Heart Rate Responses from Non-Invasive Wearables.

The rising incidence of type 2 diabetes underscores the need for technological innovations aimed at enhancing diabetes management by aiding individuals in monitoring their dietary intake. This has resulted in the development of technologies capable of tracking the timing and content of an individual's meals. However, the ability to use non-invasive wearables to estimate or classify the carbohydrate content of the food an individual has just consumed remains a relatively unexplored area. This study investigates carbohydrate content classification using postprandial heart rate responses from non-invasive wearables. We designed and developed timeStampr, an iOS application for collecting timestamps essential for data labeling and establishing ground truth. We then conducted a pilot study in controlled, yet naturalistic settings. Data were collected from 23 participants using an Empatica E4 device worn on the upper arm, while each participant consumed either low-carbohydrate or carbohydrate-rich foods. Due to sensor irregularities with dark skin tones and non-compliance with the study's health criteria, we excluded data from three participants. Finally, we configured and trained a Light Gradient Boosting Machine (LGBM) model for carbohydrate content classification. Our classifiers demonstrated robust performance, with the carbohydrate content classification model consistently achieving at least 84% in accuracy, precision, recall, and AUCROC within a 60 s window. The results of this study demonstrate the potential of postprandial heart rate responses from non-invasive wearables in carbohydrate content classification.

How to Use Continuous Glucose Monitoring Efficiently in Diabetes Management: Opinions and Recommendations by German Experts on the Status and Open Questions.

Today, continuous glucose monitoring (CGM) is a standard diagnostic option for patients with diabetes, at least for those with type 1 diabetes and those with type 2 diabetes on insulin therapy, according to international guidelines. The switch from spot capillary blood glucose measurement to CGM was driven by the extensive and immediate support and facilitation of diabetes management CGM offers. In patients not using insulin, the benefits of CGM are not so well studied/obvious. In such patients, factors like well-being and biofeedback are driving CGM uptake and outcome. Apps can combine CGM data with data about physical activity and meal consumption for therapy adjustments. Personalized data management and coaching is also more feasible with CGM data. The same holds true for digitalization and telemedicine intervention ("virtual diabetes clinic"). Combining CGM data with Smart Pens ("patient decision support") helps to avoid missing insulin boluses or insulin miscalculation. Continuous glucose monitoring is a major pillar of all automated insulin delivery systems, which helps substantially to avoid acute complications and achieve more time in the glycemic target range. These options were discussed by a group of German experts to identify concrete gaps in the care structure, with a view to the necessary structural adjustments of the health care system.

Implementation of an Interprofessional Diabetes Management Clinic in the Rural Primary Care Setting.

Background: Access to a primary care provider is not guaranteed for many living in rural settings. Notably, rural populations experience a higher degree of burden from chronic diseases compared to urban-dwellers. For example, diabetes can go undiagnosed and undertreated with lack of primary care. To address these care gaps at a large, rural family medicine practice in western North Carolina, a multidisciplinary pharmacist-led diabetes clinic was developed. Objectives: This article describes the implementation, evolution, and impact of the diabetes management clinic and explores future directions for improving the experience of patients and health care providers. Practice Description and Innovation: The diabetes management clinic at Mountain Area Health Education Center (MAHEC) is a pharmacy resident-led interdisciplinary clinic incorporating nutrition and pharmacy learners to provide patient care in both telehealth and in-office settings. Since its inception in 2018, the clinic has facilitated meaningful learning opportunities for students and residents and helped patients manage their diabetes in a multifaceted approach. Evaluation Methods: A retrospective, cross-sectional study evaluated diabetes-related outcomes for 80 patients seen in the diabetes management clinic during twelve months of appointments. The primary outcome measure was change in A1c from baseline. Results: Among patients with a follow-up A1c during the study (n=64), there was a mean reduction in A1c by 0.79% from baseline. Additionally, among those with a second follow-up A1c available (n=32), there was a mean reduction from baseline in A1c of 1.42%. Conclusion: The utilization of pharmacy residents as part of an interdisciplinary diabetes management clinic can extend access to care for underserved patients. The clinic also serves as a structured teaching clinic for interdisciplinary learners, and it has contributed to positive clinical outcomes, strong interprofessional collaboration, and expansion of experiential education opportunities since its inception in 2018.

A case study on the implementation of quality and comprehensive indicators set in routine diabetes care.

INTRODUCTION: Type 2 diabetes is a major public health issue in Mexico due to its high prevalence and its projection for the coming years for this disease. Findings on multidisciplinary care related to chronic diseases have proven effective, based on measurement of patient-centered outcomes, The Center of Comprehensive Care for Patients with Diabetes (CAIPaDi) is a multidisciplinary program focused on reducing diabetes complications. This case study aims to illustrate the results of implementing health outcomes measurements and demonstrate the beneficial effects of establishing a comprehensive model of care through a patient-centered approach. METHODS: A descriptive analysis of the comprehensive care indicators of patients with type 2 diabetes treated in the CAIPaDi program between 2013 and 2023 was conducted. The results were structured according to the standard set of outcomes for diabetes proposed by the International Consortium for Health Outcomes Measurements (ICHOM). RESULTS: The baseline and prospective registration of consultations was completed for five years, complying with 25 of the 26 indicators of the ICHOM set. In diabetes control, 56.5% of patients had A1c ≤ 7%, 87.9% had BP ≤ 130/80 mmHg, 60.9% had LDL-cholesterol < 100 mg/dl, and obesity rates decreased from 42.19% to 30.6% during annual consultations. Fewer years of diagnosis before the first visit is key to overall improvement in program adherence (P = 0.02). In acute events, a hyperglycemic crisis occurred in only two cases and severe hypoglycemia episodes in 8 patients. For chronic complications, no lower limb amputations occurred. Cardiovascular outcomes occurred in < 1%. Periodontal disease was analyzed, and periodontitis decreased from 82.9% to 78.7%. Mortality reports were low, with COVID-19 being the main cause of death. Patient-reported outcomes demonstrated reductions in anxiety, depression, and diabetes distress during follow-up. CONCLUSION: Registering quality-of-care indicators is feasible in a comprehensive care program. It allows improving the medical, mental health, and lifestyle outcomes of patients with type 2 diabetes and provides relevant data for planning health programs. A quick diagnosis before program adherence is crucial for overall improvement in patients.

Need for an Artificial Intelligence-based Diabetes Care Management System in India and the United States.

Objective: Diabetes mellitus is an important chronic disease that is prevalent around the world. Different countries and diverse cultures use varying approaches to dealing with this chronic condition. Also, with the advancement of computation and automated decision-making, many tools and technologies are now available to patients suffering from this disease. In this work, the investigators attempt to analyze approaches taken towards managing this illness in India and the United States. Methods: In this work, the investigators have used available literature and data to compare the use of artificial intelligence in diabetes management. Findings: The article provides key insights to comparison of diabetes management in terms of the nature of the healthcare system, availability, electronic health records, cultural factors, data privacy, affordability, and other important variables. Interestingly, variables such as quality of electronic health records, and cultural factors are key impediments in implementing an efficiency-driven management system for dealing with this chronic disease. Conclusion: The article adds to the body of knowledge associated with the management of this disease, establishing a critical need for using artificial intelligence in diabetes care management.

The interplay of social support and education on diabetes knowledge: a focus on Korean American women.

OBJECTIVE: Although diabetes is one of the leading causes of death among Korean Americans, the levels and predictors of diabetes knowledge in this group have not been sufficiently reported. This study aimed to (1) describe the level of diabetes knowledge of Korean immigrant women in the U.S. and (2) examine whether there is an interaction effect between social support and education on diabetes knowledge. DESIGN: This study conducted a cross-sectional survey design. The sample included 227 Korean immigrant women living in the southeast region of the U.S. The fourteen items of the Diabetes Knowledge Test were used to assess the diabetes knowledge level of Korean American women. A multiple linear regression analysis was conducted to examine the interaction effect between social support and education on diabetes knowledge. RESULTS: Only 6% of the participants presented a good diabetes knowledge level, 12.5% had a poor level, and the majority (81.5%) had a moderate level. We found a significant interaction effect between social support and education on diabetes knowledge. The highest diabetes knowledge was observed when individuals with a lower education level had higher social support. CONCLUSION: Future health practices and policies may focus on increasing knowledge among Korean American women with lower education levels and lower social support. Implementing peer-led initiatives can enhance diabetes knowledge and encourage better self-care practices within the community.

Community-engaged Systems for Population Health Improvement: A Novel Approach to Improve Diabetes Outcomes in Rural Communities.

BACKGROUND: Approaches to prevent and manage diabetes at a community population level are hindered because current strategies are not aligned with the structure and function of a community system. We describe a community-driven process based on local data and rapid prototyping as an alternative approach to create diabetes prevention and care management solutions appropriate for each community. We report on the process and provide baseline data for a 3-year case study initiative to improve diabetes outcomes in two rural Nebraska communities. METHODS: We developed an iterative design process based on the assumption that decentralized decision-making using local data feedback and monitoring will lead to the innovation of local sustainable solutions. Coalitions act as community innovation hubs and meet monthly to work through a facilitated design process. Six core diabetes measures will be tracked over the course of the project using the electronic health record from community clinics as a proxy for the entire community. RESULTS: Baseline data indicate two-thirds of the population in both communities are at risk for prediabetes based on age and body mass index. However, only a fraction (35% and 12%) of those at risk have been screened. This information led both coalitions to focus on improving screening rates in their communities. DISCUSSION: In order to move a complex system towards an optimal state (e.g., improved diabetes outcomes), stakeholders must have access to continuous feedback of accurate, pertinent information in order to make informed decisions. Conventional approaches of implementing evidence-based interventions do not facilitate this process.

BMI variability and cardiovascular outcomes within clinical trial and real-world environments in type 2 diabetes: an IMI2 SOPHIA study.

BACKGROUND: BMI variability has been associated with increased cardiovascular disease risk in individuals with type 2 diabetes, however comparison between clinical studies and real-world observational evidence has been lacking. Furthermore, it is not known whether BMI variability has an effect independent of HbA1c variability. METHODS: We investigated the association between BMI variability and 3P-MACE risk in the Harmony Outcomes trial (n = 9198), and further analysed placebo arms of REWIND (n = 4440) and EMPA-REG OUTCOME (n = 2333) trials, followed by real-world data from the Tayside Bioresource (n = 6980) using Cox regression modelling. BMI variability was determined using average successive variability (ASV), with first major adverse cardiovascular event of non-fatal stroke, non-fatal myocardial infarction, and cardiovascular death (3P-MACE) as the primary outcome. RESULTS: After adjusting for cardiovascular risk factors, a + 1 SD increase in BMI variability was associated with increased 3P-MACE risk in Harmony Outcomes (HR 1.12, 95% CI 1.08-1.17, P < 0.001). The most variable quartile of participants experienced an 87% higher risk of 3P-MACE (P < 0.001) relative to the least variable. Similar associations were found in REWIND and Tayside Bioresource. Further analyses in the EMPA-REG OUTCOME trial did not replicate this association. BMI variability's impact on 3P-MACE risk was independent of HbA1c variability. CONCLUSIONS: In individuals with type 2 diabetes, increased BMI variability was found to be an independent risk factor for 3P-MACE across cardiovascular outcome trials and real-world datasets. Future research should attempt to establish a causal relationship between BMI variability and cardiovascular outcomes.

Evidence of traditional Chinese medicine for treating type 2 diabetes mellitus: from molecular mechanisms to clinical efficacy.

CONTEXT: The global prevalence of type 2 diabetes mellitus (T2DM) has increased significantly in recent decades. Despite numerous studies and systematic reviews, there is a gap in comprehensive and up-to-date evaluations in this rapidly evolving field. OBJECTIVE: This review provides a comprehensive and current overview of the efficacy of Traditional Chinese Medicine (TCM) in treating T2DM. METHODS: A systematic review was conducted using PubMed, Web of Science, Wanfang Data, CNKI, and Medline databases, with a search timeframe extending up to November 2023. The search strategy involved a combination of subject terms and free words in English, including 'Diabetes,' 'Traditional Chinese Medicine,' 'TCM,' 'Hypoglycemic Effect,' 'Clinical Trial,' and 'Randomized Controlled Trial.' The studies were rigorously screened by two investigators, with a third investigator reviewing and approving the final selection based on inclusion and exclusion criteria. RESULTS: A total of 108 relevant papers were systematically reviewed. The findings suggest that TCMs not only demonstrate clinical efficacy comparable to existing Western medications in managing hypoglycemia but also offer fewer adverse effects and a multitarget therapeutic approach. Five main biological mechanisms through which TCM treats diabetes were identified: improving glucose transport and utilization, improving glycogen metabolism, promoting GLP-1 release, protecting pancreatic islets from damage, and improving intestinal flora. CONCLUSIONS: TCM has demonstrated significant protective effects against diabetes and presents a viable option for the prevention and treatment of T2DM. These findings support the further exploration and integration of TCM into broader diabetes management strategies.

A wearable non-enzymatic sensor for continuous monitoring of glucose in human sweat.

To enhance personalized diabetes management, there is a critical need for non-invasive wearable electrochemical sensors made from flexible materials to enable continuous monitoring of sweat glucose levels. The main challenge lies in developing glucose sensors with superior electrochemical characteristics and high adaptability. Herein, we present a wearable sensor for non-enzymatic electrochemical glucose analysis. The sensor was synthesized using hydrothermal and one-pot preparation methods, incorporating gold nanoparticles (AuNPs) functionalized onto aminated multi-walled carbon nanotubes (AMWCNTs) as an efficient catalyst, and crosslinked with carboxylated styrene butadiene rubber (XSBR) and PEDOT:PSS. The sensors were then integrated onto screen-printed electrodes (SPEs) to create flexible glucose sensors (XSBR-PEDOT:PSS-AMWCNTs/AuNPs/SPE). Operating under neutral conditions, the sensor exhibits a linear range of 50 µmol/L to 600 µmol/L, with a limit of detection limit of 3.2 µmol/L (S/N = 3), enabling the detection of minute glucose concentrations. The flexible glucose sensor maintains functionality after 500 repetitions of bending at a 180° angle, without significant degradation in performance. Furthermore, the sensor exhibits exceptional stability, repeatability, and resistance to interference. Importantly, we successfully monitored changes in sweat glucose levels by applying screen-printed electrodes to human skin, with results consistent with normal physiological blood glucose fluctuations. This study details the fabrication of a wearable sensor characterized by ease of manufacture, remarkable flexibility, high sensitivity, and adaptability for non-invasive blood glucose monitoring through non-enzymatic electrochemical analysis. Thus, this streamlined fabrication process presents a novel approach for non-invasive, real-time blood glucose level monitoring.

Recent Innovations in Footwear and the Role of Smart Footwear in Healthcare-A Survey.

Smart shoes have ushered in a new era of personalised health monitoring and assistive technologies. Smart shoes leverage technologies such as Bluetooth for data collection and wireless transmission, and incorporate features such as GPS tracking, obstacle detection, and fitness tracking. As the 2010s unfolded, the smart shoe landscape diversified and advanced rapidly, driven by sensor technology enhancements and smartphones' ubiquity. Shoes have begun incorporating accelerometers, gyroscopes, and pressure sensors, significantly improving the accuracy of data collection and enabling functionalities such as gait analysis. The healthcare sector has recognised the potential of smart shoes, leading to innovations such as shoes designed to monitor diabetic foot ulcers, track rehabilitation progress, and detect falls among older people, thus expanding their application beyond fitness into medical monitoring. This article provides an overview of the current state of smart shoe technology, highlighting the integration of advanced sensors for health monitoring, energy harvesting, assistive features for the visually impaired, and deep learning for data analysis. This study discusses the potential of smart footwear in medical applications, particularly for patients with diabetes, and the ongoing research in this field. Current footwear challenges are also discussed, including complex construction, poor fit, comfort, and high cost.