Diabetic Medicine最新文献

Aims

Type 1 diabetes stigma (T1D-stigma), the negative social judgements towards people living with type 1 diabetes (T1D), is linked to poor psychological well-being and suboptimal diabetes self-management. This qualitative study explored the T1D-stigma experiences of adults living with T1D in the UK.

Methods

UK-based adults (aged ≥18 years) with T1D completed an online survey as part of a wider T1D-stigma study. Respondents who endorsed at least one item on the Type 1 diabetes stigma assessment scale (DSAS-1) were then invited to provide more information about their stigma experiences. Responses were analysed using framework analysis.

Results

The majority of respondents (96%) endorsed experiencing at least one instance of perceived or experienced stigma. A framework analysis of N = 337 participants' responses developed five themes and 19 sub-themes. The first and second themes explored the ‘Sources’ and ‘Drivers and facilitators’ of T1D-stigma. The third theme encapsulated the ‘Experiences’ of T1D-stigma, where participants described ‘unsolicited comments and advice’, ‘discrimination and rejection’ and ‘lack of understanding’. The fourth theme encompassed the ‘Impact’ of T1D-stigma, where participants described its social, emotional, and behavioural impact. The final theme explored Stigma management’ and described ‘dealing with T1D-stigma’, ‘changes over time in self, society and diabetes technology’ and ‘protective factors in T1D-stigma encounters’.

Conclusion

This study has provided the first systematic qualitative analysis of T1D-stigma in the UK. In line with other diabetes-related stigma research, T1D-stigma was broad in its manifestations and impact. Participants volunteered information about T1D-stigma management, despite not being explicitly asked about this, highlighting approaches that could inform future interventions.

Aims

To explore the association between using automated insulin delivery (AID) systems and physical activity (PA) levels among people with type 1 diabetes.

Methods

Cross-sectional study including 1156 participants from the BETTER Type 1 Diabetes registry. Inclusion criteria: type 1 diabetes; aged ≥18 years old; reported PA with a validated questionnaire. PA is defined as activities lasting at least 10 consecutive minutes. Regression models (with and without adjustment for imbalanced variables) were used to compare PA levels among treatment options, with pairwise comparisons between the AID group and each group (i.e. Pump + continuous glucose monitoring (CGM), Injections + CGM, and non-CGM group).

Results

In the AID group, 87% of participants reported performing PA during the past 7 days (primary outcome), compared to 79% in the Pump + CGM group, 77% in the Injections + CGM group and 77% in the non-CGM group (p = 0.134 without adjustment; and p = 0.316 with adjustment for sex, age, duration of diabetes, highest educational level and annual household income). Only 28% of study participants met the target of performing at least 150 min of moderate to vigorous PA per week.

Conclusions

Compared with other treatment modalities, AID users within the BETTER T1D registry tended to engage in more frequent and longer PA. However, these differences may be attributed to sociodemographic factors rather than the technologies themselves. Our study also shows a low percentage of participants meeting PA recommendations. Continued research and development on diabetes technologies, more personalized interventions and public health strategies are needed.

Aims

Drivers of inequitable health outcomes are underexplored in minoritized youth with type 1 diabetes (T1D). In this pilot qualitative study, we recruited parents and guardians (hereafter referred to as caregivers) of youth with T1D on public insurance at Stanford Medicine Children's Health. We explore the reasons caregivers cited for lower uptake of insulin pumps as compared with continuous glucose monitoring (CGM) sensors.

Methods

Caregivers (n = 21, 39 ± 8 years, youth age range 3–11 years, 67% Hispanic, 48% Spanish-speaking, 69% income <$50 K) completed focus groups or interviews which were conducted, transcribed, and analysed in English (n = 9) or Spanish (n = 7), per caregiver preference. Transcripts were analysed deductively and inductively by a four-member team that included three bilingual members.

Results

One prevailing and novel theme emerged: CGM is a necessity, but an insulin pump is negotiable, with three supporting sub-themes: (1) child preference (e.g., body real estate); (2) parental hesitancy (e.g., pump mistrust); (3) provider as gatekeeper (e.g., CGM prioritized). The second and third themes identified were insurance-related barriers and language-related barriers (e.g., English manuals only). The final theme identified was facilitators of pump use (e.g., recommendation by provider).

Conclusions

Caregivers of youth with T1D and public insurance endorse the perception that CGM is a necessity over an insulin pump. Clinicians should be aware of this perception given the overwhelming evidence supporting that automated insulin delivery systems improve diabetes outcomes. These data further outline the importance of continued advocacy by clinicians, payers, and industry for equitable access to diabetes technology for all youth with T1D.

Aim

Type 2 diabetes (T2D) in pregnancy is increasingly common and associated with suboptimal outcomes for these women and their children. We aimed to synthesize observational evidence on associations of modifiable preconception, pregnancy and postpartum risk factors with perinatal outcomes among women with pregestational T2D.

Methods

Searches were conducted in six databases (September 2023). Observational studies among women with pregestational T2D were included if they reported associations of modifiable risk factors with maternal and/or child outcomes. Screening, data extraction and quality assessments were conducted by two reviewers. Findings were synthesized through random effects meta-analysis or narrative synthesis when results were too few or heterogeneous to pool.

Results

Searches identified 15,578 results; 58 studies were included. Meta-analysis showed excessive gestational weight gain (GWG) was associated with large for gestational age (LGA) (OR 2.39, 95%CI 1.74–3.29) but not small for gestational age (SGA). Meta-analysis demonstrated no associations between preconception care or metformin use with adverse pregnancy, birth and neonatal outcomes. However, narrative synthesis showed preconception care was associated with increased use of folic acid and vitamin D, and reduced GWG. Further narrative synthesis findings showed that higher BMI was associated with multiple suboptimal pregnancy, birth and neonatal outcomes. Excessive GWG was associated with increased insulin requirements and increased likelihood of neonatal hypoglycaemia. The use of metformin/oral hypoglycaemic medications was associated with reduced GWG and fewer caesarean deliveries. There was mixed or no evidence of association for other reported exposures and outcomes.

Conclusion

Based on observational evidence, increasing access to preconception care could be beneficial to optimize maternal nutrition and weight-related outcomes, and addressing obesity and GWG has the potential to improve maternal and neonatal outcomes in pregnancies affected by T2D.

Aims

This systematic review and meta-analysis assessed the safety and efficacy of metformin in managing gestational diabetes mellitus (GDM), focusing on maternal, neonatal and long-term outcomes. While lifestyle changes are first-line treatment, pharmacological therapy is often required. Insulin, the standard, has drawbacks including weight gain, neonatal hypoglycaemia and maternal anxiety. Metformin is a promising alternative due to its insulin-sensitizing effects, but concerns remain about placental transfer and long-term effects on offspring.

Methods

A systematic search was conducted in PubMed and Embase up to 29 August 2024, including randomized controlled trials (RCTs) and follow-up studies. Primary outcomes were neonatal hypoglycaemia, birthweight and long-term metabolic outcomes. Study quality was assessed using RoB 2.0 and ROBINS-I. Data were synthesized using the IVhet model.

Results

Ten RCTs were included. Metformin was associated with a statistically significant reduction in neonatal hypoglycaemia (OR: 0.65, 95% CI: 0.46–0.92) and lower birthweight (MD: −68.96 g, 95% CI: −108.34 to −29.57). A non-significant trend towards reduced LGA risk was observed. No significant differences in prediabetes, diabetes or insulin resistance were found.

Long-term outcomes in children remain uncertain due to limited and heterogeneous follow-up data.

Conclusions

Metformin appears safe and effective in GDM management, but more data are needed on long-term outcomes.

Aims

Efforts to achieve type 2 diabetes (T2D) remission by weight loss using low-calorie diets are gaining momentum, mainly in high-income countries. The HoDiRECT Nepal project demonstrated the feasibility of a low-calorie traditional Nepali diet for diabetes remission. This qualitative substudy explored the factors affecting its implementation.

Methods

HoDiRECT participants who had completed 8 weeks of a low-calorie diet were invited to participate in one-to-one interviews at follow-up visits. The interviews were guided by a predesigned interview protocol and conducted in Nepali. The interviews were audio recorded, transcribed verbatim and analysed using a thematic framework approach.

Results

Interviews with 16 participants confirmed general acceptability of the intervention. Participants' motivation to enrol in the programme was driven by their desire to stop taking diabetes medications, achieve better diabetes control and lose weight. Understanding diabetes, its complications and the perceived value of diet influenced their decision to adhere to the programme. Adherence was facilitated by the ability to prepare food or have someone to do so, clear information about the diet and continued guidance. Participants found adherence difficult during travel and on social/cultural occasions. Healthcare professionals' involvement had a positive value, but popular beliefs, often false, about food for diabetes influenced participants' dietary behaviour.

Conclusions

Adherence to a weight-loss regimen can be enhanced if the diet is simple to prepare and if there is greater education for patients and their communities about diabetes, highlighting the effectiveness of diet as a treatment, with clear and consistent messaging about dietary practices.

Aim

Periodontitis is a chronic inflammatory oral disease characterised by the persistent activation of immune cells, which contributes to insulin resistance and, consequently, an increased risk of systemic diseases, including gestational diabetes mellitus (GDM). At the same time, the risk of periodontitis is higher in individuals with diabetes, with higher glycaemic levels being the primary contributing factor. Oral health review is also advised in diabetes care by the NICE guidelines, because of its impact on blood glucose management. However, oral health may be overlooked in GDM due to the volume of other interventions required. Furthermore, little is known about the barriers and facilitators to oral healthcare support among healthcare professionals (HCPs) working in GDM care.

To examine the barriers and facilitators to oral healthcare support among HCPs in GDM care.

Methods

The interview guide was based on the Theoretical Domains Framework (TDF), and semi-structured interviews were used for data collection. The sample consisted of UK-based HCPs with different professional backgrounds.

Results

Four barriers and three facilitators were identified. These are related to the following TDF domains: professional role and identity; beliefs about consequences; knowledge; skills; memory, attention, and decision processes; and environmental context and resources.

Conclusions

Oral health was not prioritised in GDM care. Furthermore, limited knowledge, increasing demands and time constraints, and fear of health-related information overload were barriers to oral healthcare support. Training and education to increase knowledge, perceived importance of oral health and the HCPs' role and responsibilities facilitated oral healthcare support.

Background

Inpatients with diabetes have higher early unplanned readmission (EUR) rates. Diabetes management team (DMT) review reduces EUR. While glucose-based patient selection for DMT reduces in-hospital adverse outcomes, this single criterion is a suboptimal predictor of EUR.

Aim

We developed, compared and externally validated four EUR prediction models in diabetes inpatients using primarily early admission data to facilitate timely review. Secondarily, we investigated how combining predictive and glucose data can refine patient selection for DMT review.

Methods

We constructed three traditional models (classification tree, logistic group lasso, elastic net) and a neural network model using 14 routinely available variables. Models were externally validated and performance assessed by area under the curve (AUC). We analysed the overlap between high-risk patients and those with abnormal glucose (≥1 glucose level <4 or >15 mmol/L) according to pre-specified sensitivities (25%, 50%, 75%).

Results

Group lasso, elastic net and neural network performed similarly (AUC 0.722–727 test cohort, 0.653–0.667 validation), outperforming the tree (AUC 0.663 test cohort, 0.595 validation). These models identified 9%, 21%–23% and 41%–42% of admissions as ‘high risk’ using respective sensitivities of 25%, 50% and 75%. In the group lasso, approximately half of ‘high-risk’ patients also had abnormal glucose which reduced the DMT review cohort to 4.9%, 10.8% and 19.2% for sensitivities of 25%, 50% and 75%.

Conclusion

EUR prediction models facilitate targeted, timely DMT review. Regularised regression models offer a feasible, practical approach for identifying high-risk patients in resource-limited hospital settings. Combining model-identified risk with abnormal glucose refines patient selection, optimising resource allocation.