Dhiren Patel, PharmD, Robert Busch, MD, and Diana Issacs, PharmD, discuss recent advances in diabetes technology and their impact on patient care.

Pillars of Diabetes Care Technology

A provider toolkit with clinically relevant resources related to diagnosis and management of central precocious puberty.

CPP Provider Toolkit

Our Disease State Series was born out of the idea of providing the most practical information and resources to clinicians. In this installment, we will be focusing on thyroid disorders.

Disease State Series: Thyroid Disorders

A pair of experts in the management of diabetes review the role of insulin therapy and review the approval process for biosimilars, including the FDA's approval of the first interchangeable insulin biosimilar.

Interchangeable Insulin Biosimilars: A Game Changer in Diabetes Management

A systematic review and meta-analysis of randomized controlled trials assessing the effects of vegan diets on cardiometabolic health from the European Congress on Obesity (ECO) provides a comprehensive overview of the impact of adherence to a vegan diet on body weight and glycemic control among patients with overweight weight and those with type 2 diabetes.

Leveraging data from nearly a dozen randomized trials with more than 700 adult participants, results of the study indicate adherence to a vegan diet for at least 12 weeks was associated with greater glycemic control, reductions in body weight, and reduced LDL-C, but had no effect on blood pressure, HDL-C, and triglycerides.

“This rigorous assessment of the best available evidence to date indicates with reasonable certainty that adhering to a vegan diet for at least 12 weeks may result in clinically meaningful weight loss and improve blood sugar levels, and therefore can be used in the management of overweight and type 2 diabetes”, said lead investigator Anne-Ditte Termannsen, PhD, of the Steno Diabetes Center, 

. “Vegan diets likely lead to weight loss because they are associated with a reduced calorie intake due to a lower content of fat and higher content of dietary fiber. However, more evidence is needed regarding other cardiometabolic outcomes.”

Interest in dietary science and the role of nutrition is at an all-time in recent years. With this, the popularity of plant-based diets has also grown. Spurred by an interest in further exploring the effects of these diets on cardiometabolic health, Termannsen and colleagues from the University of Copenhagen designed a systematic review and meta-analysis to estimate these effects using data from randomized clinical trials among patients with either overweight, which was defined as a BMI of 25 kg/m2 or greater, or with type 2 diabetes.

Through a systematic literature search of the MEDLINE, Embase, CINAHL, and CENTRAL database, as well as reference lists of relevant articles from inception through February 26, 2021, investigators hoped to identify all randomized controlled trials comparing the effects of vegan diets for at least 12 weeks in adult patients with the aforementioned conditions on outcome measures that included body weight, BMI, HbA1c, systolic and diastolic blood pressure, total cholesterol, LDL-C, HDL-C, and triglycerides. From their initial search, investigators identified 1012 records for potential inclusion and 11 were ultimately deemed eligible for inclusion in quantitative synthesis.

The 11 trials included had a mean duration of 19 weeks and a total population of 796 individuals, with a mean age ranging from 48-61 years. Investigators pointed out these trials considered weight loss of at least 11 pounds to be clinically meaningful.

Upon analysis, results indicated vegan diets were associated with significantly reduced body weight and BMI, with mean differences in reductions of 4.1 kg (95% CI, -5.9 to -2.4; 

<.001) and 1.38 kg/m2 (95% CI, -1.96 to -0.80; 

<.001), respectively. In contrast, the mean differences observed for HbA1c (-0.18% [95% CI, -0.29 to -0.07]; 

=.002), total cholesterol (-0.30 mmol/L [95% CI, -0.52 to -0.08]; 

=.007), and LDL-C (-0.24 mmol/L [95% CI, -0.40 to -0.07]; 

=.005) with vegan diets compared to control diets were less apparent.

Further analysis revealed reductions in body weight and BMI with vegan diets were greater when compared against coining a normal diet without dietary changes than compared with other intervention diets, with mean differences of -7.4 kg (95% CI, -10.2 to -4.7; 

<.001) and -2.78 kg/m2 (95% CI, -3.91 to -1.65; 

<.001) compared to -2.7 kg (95% CI, -4.3 to -1.2; 

 <.001) and -0.87 kg/m2 (95% CI, - 1.34 to -0.40; 

In the aforementioned statement, investigators urged caution when interpreting the results of their study. These limitations included the small sample sizes of studies, varied contents of a vegan diet, and none of the studies prescribing a control diet that exactly matched the intervention diet in all other aspects except veganism.

“The results suggest that adhering to vegan diets for at least 12 weeks may be effective in individuals with overweight or type 2 diabetes to induce a meaningful decrease in body weight and improve glycemia. Some of this effect may be contributed to differences in the macronutrient composition and energy intake in the vegan diets versus control diets,” wrote investigators.

This study, “Effects of vegan diets on cardiometabolic health: A systematic review and meta-analysis of randomized controlled trials,” was presented at ECO 2022.

Articles

Data from a study presented at the European Congress on Obesity details the effects of adherence to a vegan diet on cardiometabolic health using data obtained from randomized controlled trials assessing the effects of vegan diets as an intervention. 

Vegan Diets Can Improve HbA1c, Body Weight in Overweight or Type 2 Diabetes

Patrick Campbell is the assistant managing editor of Endocrinology Network, as well as its sister publication Practical Cardiology. Prior to joining these brands, he led coverage of cardiology and diabetes with HCPLive. Before joining parent company MJH Life Sciences in 2019, he spent time as a beat reporter with the Pocono Record in Stroudsburg, PA, and Star News Group in Manasquan, NJ. He also touts experience in multimedia, having spent time as a freelance multimedia specialist with NJ Advance Media and multimedia coordinator at the Pocono Record.  Follow him on Twitter @RealPatCampbell or reach him via email at PCampbell@mjhlifesciences.com.

Reducing sedentary time by just an hour per day among patients with metabolic syndrome could reduce improve glycemic control and other markers of cardiometabolic health, according to results from a recent trial.

A trial assessing the effects of a low-intensity intervention aimed at reducing sedentary by 1 hour per day, results of the study demonstrate reducing sedentary time and increasing light-intensity physical activity was associated with improvements in several cardiometabolic biomarkers in adults with metabolic syndrome, including fasting insulin levels, HbA1c, and liver alanine aminotransferase.

“It is an encouraging thought that health benefits can be achieved by reducing the time spent sitting and increasing the amount of even light-intensity physical activity. For many, this may be an easier starting point than increasing actual exercise,” said lead investigator Taru Garthwaite, MSc

 a doctoral candidate at the University of Turku in Finland, 

Although it is common knowledge among providers and laypersons that decreasing sedentary is associated with improved health outcomes, the magnitude of benefit is the subject of debate depending on the patient population in question. With this in mind, the current study was conducted by Garthwaite and colleagues from the Turku PET Centre and the UKK Institute in Finland to assess the impact of a low-intensity intervention aimed at limiting sedentary by an hour per day and replacing it with standing time or light-intensity physical among patients with metabolic syndrome.

A parallel-group randomized controlled trial, the study was conducted between April 2017 and November 2019, with eligible patients recruited through newspaper advertisements and leaflets distributed in the local community. investigators sought to enroll a population of sedentary and inactive working-aged adults with metabolic syndrome. Specific inclusion criteria required patients to be 40-65 years of age, have less than 120 minutes per week of self-reported moderate to vigorous physical activity, accelerometer-measured sitting time of 10 hours or more per day, a baseline BMI of 25-40 kg/m2, a blood pressure greater than 160/100 mmHg, and fulfillment of at least 3 prespecified metabolic syndrome criteria.

The aim of the intervention was to reduce sedentary behavior by 1 hour per day compared to the reported sedentary time during the baseline screening. those randomized to the intervention received guidance in the form of 1-hour tailored personal counseling sessions to sit less by increasing standing and light-intensity physical activity, without intentionally adding exercise or moderate-to-vigorous physical activity.

A total of 263 patients volunteered to participate in the trial. Of these 155 were screened and 64 were ultimately selected for inclusion. Of the 64 chosen to participate, 63 completed the trial, with 1 participant dropping out due to personal reasons. The mean age of the final study cohort was 58 (SD, 7) years, 58% were women, 41% of participants were overweight and 59% were considered obese. Baseline data suggested participants spent a mean of 10.04 (SD, 1.01) hours per day engaging in sedentary behavior, a mean of 1.79 (SD, 0.59) hours per day standing, a mean of 1.74 (SD, 0.44) h/ day in light-intensity physical activity, and 0.97 (SD, 0.32) hours per day in moderate-to-vigorous physical activity, took a mean of 5149 (SD, 1825) steps per day, and experienced a mean of 29 (SD, 8) breaks in sedentary behavior daily. Of the 64 patients selected for inclusion, 33 were randomized to the intervention and 31 were randomized to the control arm of the study, with these patients receiving instruction to maintain usual lifestyle habits.

At the end of the trial, results suggested those in the intervention arm experienced a reduction in sedentary behavior of 50 (95% CI, 24 to 73) minutes per day, with this being driven by an increase in light-intensity and moderate-to-vigorous physical activity of 19 (95% CI, 8 to 30) and 24 (95% CI, 14 to 34) minutes per day, respectively. Investigators pointed out standing times increased among those in the intervention arm by 6 (95% CI, -11 to 23) minutes per day, but this difference failed to reach statistical significance. Investigators also noted baseline activity levels were maintained among those in the control arm throughout the duration of the trial.

Additionally, results of the investigators’ analyses indicated randomization to the intervention arm was associated with significant improvements in fating insulin (83.4 [68.7, 101.2] vs 102.0 [95% CI, 83.3 to 125.0] pmol/l), HOMA-IR (3.2 [95% CI, 2.6 to 3.9] vs 4.0 [95% CI, 3.2 to 4.9]), HbA1c (37 [95% CI, 36 to 38] vs. 38 [95% CI, 37 to 39] mmol/mol), and liver enzyme alanine aminotransferase (28 [95% CI, 24 to 33] vs. 33 [95% CI, 28 to 38] U/l) when compared to randomization to the trial’s control arm.

“To our knowledge, this is the first study to measure sedentary behavior and physical activity with accelerometers continuously throughout the 3-month intervention, and to investigate the health effects of SB reduction in sedentary and inactive, middle-aged adults with metabolic syndrome,” wrote investigators.

Effects of reduced sedentary time on cardiometabolic health in adults with metabolic syndrome: A three-month randomized controlled trial

Journal of Science and Medicine in Sport.

A 3-month trial found reducing sedentary time by just an hour per day was enough to produce statistically significant changes in biomarkers for cardiovascular risk among patients with metabolic syndrome. 

Reducing Sedentary Time By An Hour Per Day Can Provide Health Benefits in Metabolic Syndrome

A bionic pancreas may no longer be science fiction and could soon become a reality for patients with type 1 diabetes, according to the results of a trial presented at the 15th International Conference on Advanced Technologies and Treatments for Diabetes (ATTD).

The Insulin-Only Bionic Pancreas Pivotal Trial (IO BPPT), a pivotal trial assessing the safety and efficacy of Beta Bionics Incorporated’s iLet Bionic Pancreas, results of the study demonstrated use of the investigational device was associated with significant reductions in HbA1c and improved time in range compared with standard care in patients with type 1 diabetes.

“Compared to what was a very challenging standard of care where 31% of participants used a hybrid closed loop system, and therefore you would predict might not have much potential for improvement in their glucose control, the bionic pancreas reduced A1c by a clinically significant margin of 0.5% consistently. We think this is important because the FDA considers something more than 0.4% to be clinically significant.” said study presenter Stephen Russell, MD, PhD, associate professor of medicine at Harvard Medical School, during his presentation at ATTD 2022. “It did that overall, in all subgroups, and reduced the variation in A1c.”

An investigator-initiated, multicenter, randomized controlled trial funded, in part, by a grant from the National Institutes of Health to Boston University, IO BPPT was led by investigators at the Jaeb Center for Health Research and conducted in 16 medical centers across the US. Launched with the intent of assessing the safety and efficacy of iLet Bionic Pancreas’s insulin dosing configuration compared to standard care, which included both bumps therapy and multiple daily injections (MDI), the trial randomized 440 patients with type 1 diabetes aged 6 years or older to the iLet Bionic Pancreas or standard care for 13 weeks to assess impact on glycemic control.

Produced by Beta Bionics, the iLet Bionic Pancreas is billed as a pocket-sized, wearable device designed to autonomously dose insulin. The device is designed to be worn like an insulin pump, but only requires users to enter their body weight to initialize therapy and would then begin to automatically titrate and infuse insulin without requiring the user to count carbohydrates, set insulin-to-carbohydrate ratios, set insulin basal rates, set correction factors, or determine bolus insulin for meals or corrections.

When enrolling patients in the trial, investigators had a goal to create a more representative study population than seen in previous type 1 diabetes trials. With this in mind, investigators sought to enroll a population where 33% or more were using MDI,33% or more were using an insulin pump, 20% or more had an HbA1c of less than 7%, 33% had an HbA1c greater than 8%, and with an overall population where 15% or more were of minority race/ethnicity. investigators noted there was no upper limit for HbA1c in the trial’s enrollment criteria and any FDA-approved PLGS or hybrid closed loop system were allowed.

Of the 440 patients included in the trial, 275 were adult patients aged 18 years or older. These patients were randomized in a 2:1:2 ratio to bionic pancreas with insulin aspart or insulin lispro, standard care, or bionic pancreas with fast-acting insulin aspart. The remaining 165 patients included in the study were children aged 6 to less than 18 years. These patients were randomized in a 2:1 ratio to the bionic pancreas with insulin aspart of insulin lispro or standard care.

The primary analyses combined results from adults and children using the bionic pancreas with insulin aspart or insulin lispro against standard care. Investigators also conducted prespecified secondary analysis assessing bionic pancreas with insulin aspart or insulin lispro against standard care in children and adults separately as well as in adults with bionic pancreas and fast-acting insulin aspart against standard of care in adult patients.

Upon analysis, results indicated use of the bionic pancreas was associated with a 0.5% reduction in HbA1c at the end of the 13-week study period compared to standard care. In a subgroup analysis of patients with an HbA1c greater than 7% at baseline, the reduction observed with bionic pancreas versus standard of care increased to 0.7%. Additionally, when assessing time in range, results suggested use of the iLet Bionic Pancreas was associated with a mean increase in time in range per day of 2.6 hours compared with standard of care. In a secondary analysis, the mean increase in time in range per day was 2.4 hours among children with type 1 diabetes.

Safety analyses demonstrated use of the bionic pancreas was not associated with any significant increases in mean time spent with CGM values below 54 mg/dL during the study period compared to standard of care. During his presentation, Russell noted severe hypoglycemia events occurred in both arms of the study and none of the events observed in the bionic pancreas arm were due to device malfunction.

“The results of this trial confirm that the iLet Bionic Pancreas may serve a population of people who are otherwise unable to reach glycemic goals with currently available diabetes technology,” said Jeanne Jacoby, FNP, CDCES, Director of Medical Affairs, Beta Bionics, in a 

. “As a medical professional and a person with diabetes, I look forward to us being able to offer a solution that may change the lives of this underserved population.”

This study, “Results of the Insulin-only Bionic Pancreas Pivotal Trial,” was presented at ATTD 2022.

Data from a pivotal trial presented at ATTD 2022 demonstrate the use of the iLet Bionic Pancreas was associated with significant improvements in HbA1c and TIR among a diverse study population of adults and children with type 1 diabetes compared with standard care. 

iLet Bionic Pancreas Shows Promise in Pivotal Trial

The rapid integration of continuous glucose monitoring technologies has brought forth a wave of innovation within these technologies. Among the most recent additions to the equation has been smartphone applications to optimize the use of CGM technologies in patients with diabetes.

As the market for CGM devices becomes more and more competitive, manufacturers have sought to one-up each other by providing users with cutting-edge technologies and features, such as smartphonehave applications, with their CGM. Now, a study presented at the 15th International Conference on Advanced Technologies and Treatments for Diabetes (ATTD) is offering insight into what features within a diabetes smartphone application were associated with improvements in glycemic control and what ones do not provide benefit.

“The aim of the project presented in the poster was to explore the effects of specific features in apps for people with type 2 diabetes on glycemic control, though diabetes application have the potential to support glycemic control in type 2 diabetes, there's a lack of evidence regarding to the effect of the individual features of the apps in regards to glycemic control,” said study presenter Julie Egmose, MSc, of Aalborg University, during her presentation at ATTD 2022.

Although companies have focused on making their CGM devices and product offerings the most appealing in the marketplace, Egmose and colleagues from Aalborg University designed the present study to fill current gaps in knowledge related to what features might provide the most benefit in terms of improving glycemic control. With this in mind, investigators designed their study as a review data from the PubMed, EMBASE, and CINAHL databases.

From a systematic search of literature in these databases, investigators identified 437 total records for potential inclusion in their study. After exclusion of duplicates and application of inclusion criteria, a total of 13 full-text articles were assessed for eligibility and 7 were ultimately included in the investigators’ analysis. Inclusion criteria for the study required studies to enroll patients with type 2 diabetes, assess features in diabetes mellitus management apps, and assess blood sugar as an outcome of interest. Additionally, these studies were required to have been published in English, Danish, Swedish, or Norwegian. Articles were excluded if results were not divided according to type of diabetes and if the features in the apps were not divided into the results.

From the 7 studies identified for inclusion, a total of 5 app features were identified. These included feedback mechanisms, a glucose-monitoring and feedback system, gamification, biofeedback-assisted relaxation, and diabetes education. Of note, multiple feedback mechanisms were assessed, including an insulin titration algorithm with immediate feedback mechanism and feedback from health professionals.

Upon analysis, results of the investigators’ analyses suggested only 3 of the features assessed were associated with significant improvements in glycemic c control. These features were the monitoring and feedback-system, gamification, and diabetes education.

“Overall, it seems that diabetes app should contain an educational feature gamification, and a feature for sharing data with healthcare professionals to improve glycemic control. However, more evidence is needed to determine the effect of individual features in diabetes apps,” Egmose added, during the latter portions of her presentation at ATTD 2022.

This study, “Which Diabetes App Features Improve Glycemic Control in Type 2 Diabetes? A Scoping Revie,” was presented at ATTD 2022.

A review of data presented at ATTD 2022 dissects what features within smartphone applications created to improve diabetes management actually contribute to improved glycemic control. 

Study Details Diabetes App Features Associated with Improving Glycemic Control

A new analysis of national prescription data from 2015-2020 details the sharp increase in prescribing of SGLT2 inhibtiors and GLP-1 RAs, with results suggesting the total number of annual prescriptions for SGLT2 inhibitors doubling and the annual number of GLP-1 RA prescriptions tripling from 2015-2020.

An analysis of data from the IQVIA National Prescription Audit from January 2015-December 2020, results suggest the increase in prescriptions was most apparent among cardiologists, who saw a 12-fold increase in monthly prescriptions for SGLT2 inhibitors and a 4-fold increase for GLP-1 RAs during the study period, with endocrinologists prescribing the most SGLT2 inhibitors and GLP-1 RAs per capita.

“Our study demonstrates that while prescriptions from cardiologists for SGLT2i and GLP‐1RA medications have increased many‐fold since 2015, they continue to account for a very small share of the use of these therapies. Most prescriptions were provided by PCPs/internists, while endocrinologists accounted for the most prescriptions per provider,” wrote investigators.

Conducted by Michael J. Blaha, MD, MPH, and a team of colleagues from Johns Hopkins Bloomberg School of Public Health, the current study was launched with the intent of describing contemporary trends in SGLT2 inhibitor and GLP-1 RA use among cardiologists compared against clinicians in other specialties. With this in mind, investigators designed their study as a descriptive analysis of serial, cross-sectional data from the IQVIA National Prescription Audit, which captures approximately 90% of retail prescription dispensing in the US, to estimate monthly trends in prescription from 2005-2020. For the purpose of analysis, investigators also used the American Medical Association’s Physician Masterfile to assess the average annual SGLT2 inhibitor and GLP-1 RA prescriptions dispensed per physician during the study period.

From 2015-2020, a total of 63.2 million SGLT2 inhibitors and 63.4 million GLP-1 RA medication were dispensed in the US. Initial analysis indicated annual prescriptions doubled for SGLT2 inhibitors and tripled for GLP-1 RAs from 2015 to 2020, with the average annual growth rate of 15.6% for SGLT2 inhibitors and 25.2% for GLP-1 RAs during the 6-year study period. Further analysis demonstrated the monthly prescriptions dispensed for SGLT2 inhibitors among cardiologists increased 12-fold, with 2228 dispensed in January 2015 compared to 25,815 in December 2020. For GLP-1 RAs, the monthly dispensed prescription increased 4-fold from 1927 dispensed in January 2015 to 6981 in December 2020.

When assessing rates of increases relative to other specialties, results indicate cardiologists outpaced the overall increase for SLGT2 inhibitors, with a 532% increase seen among cardiologists compared to 101% increase overall, but lagged for overall increase for GLP-1 RAs, with a 160% increase seen among cardiologists compared to a 207% increase overall.

Despite these increases in prescription, investigators pointed out cardiologists represented a small proportion of national monthly totals, with cardiologists accounting for 0.5% of SGLT2 inhibitor prescriptions in January 2015 and 1.9% in December 2020. For GLP-1 RAs, the proportion of prescriptions from cardiologists declined during the study period from 0.5% in January 2015 to 0.4% in December 2020.

Other key points from the study can be found below:

PCPs/Internists prescribe more SGLT2 inhibitors and GLP-1 RAs than any other specialty, accounting for 57% and 52% of SGLT2 inhibitor and GLP-1 RA prescriptions, respectively, in 2020.

Endocrinologists led in terms of prescription per physician, with rates of 272 prescriptions per endocrinologist for SGLT2 inhibitors and 405 prescriptions per endocrinologist for GLP-1 RAs.

Canagliflozin controlled the greatest share of SGLT2 inhibitor prescriptions at the beginning of the study period, but was surpassed by empagliflozin in 2017. From 2017 onward, empagliflozin controlled the greatest share of SGLT2 inhibitor prescriptions.

Following the release of DAPA-HF results at ESC 2019, a decrease in empagliflozin’s share of SGLT2 inhibitor prescriptions was observed, with the share decreasing by 18% from September 2019 to December 2020. During that same period, dapagliflozin’s share increased by 23%.

Share of GLP-1 RA prescriptions shifted during the study period as well, with weekly GLP-1 RAs representing 76% of the GLP-1 RAs prescriptions from cardiologists in January 2015 to 19% in December 2020.

Among both cardiologists and noncardiologists, the most dispensed GLP‐1 RAs in 2020 were dulaglutide (39% of cardiology GLP‐1RAs and 45% of noncardiology GLP‐1RAs) followed by semaglutide (37% of cardiology GLP‐1 RAs and 28% of noncardiology GLP‐1RAs), which are both weekly injections.

In their discussion, investigators describe their stance on cardiologists' underprescription of these agents despite the marked improvements in prescriptions rates observed in recent years.

“In light of prior estimates showing that 40% to 70% of patients with T2D and CVD see a cardiologist each year,that an individual with T2D and CVD is equally as likely to encounter a PCP and 4 times less likely to encounter an endocrinologist as they are a cardiologist in a given year,and that one‐third of the patients that cardiologists manage have diabetes,our results demonstrating a limited role of cardiologists in disseminating SGLT2i and GLP‐1RA therapies present an opportunity to optimize access to these cardiometabolic therapies,” wrote investigators.

This study, “National Trends in Use of Sodium‐Glucose Cotransporter‐2 Inhibitors and Glucagon‐like Peptide‐1 Receptor Agonists by Cardiologists and Other Specialties, 2015 to 2020,” was published in the 

Journal of the American Heart Association.

New data suggests the number of prescriptions for SGLT2 inhibitors in the US has doubled since 2015 with prescriptions for GLP-1 receptor agonists tripling during the same time period. 

SGLT2 Inhibitor, GLP-1 Receptor Agonist Prescribing Increased Sharply Since 2015

New research from a team in Germany suggests a pair of common herpesviruses could be contributing to impaired glucose metabolism and risk of developing 

An analysis of the health impact of 7 herpesviruses on the incidence of prediabetes, results of the study provide evidence of associations of herpes simplex virus (HSV) 2 and cytomegalovirus (CMV) serostatus with incidence of diabetes and prediabetes, which investigators suggest indicates these herpesviruses may contribute to development of impaired glucose metabolism.

“Our study suggested that while prediabetes incidence was primarily explained by age, BMI, cholesterol and fasting glucose, both HSV2 and CMV added additional complementary risk information, despite high viral prevalence and co-occurrence,” wrote investigators.

Citing cross-sectional and population-based studies providing data in support of an association between herpesvirus and risk of type 2 diabetes, Tim Woelfle and colleagues from Ludwig-Maximilians University and Helmholtz Munich sought to provide clinicians with insight into the relationship between different herpesviruses and incidence of prediabetes. With this in mind, investigators designed their study as an analysis of the KORA cohort to assess incidence of prediabetes using antibody measurements for HSV 1, HSV 2, varicella-zoster virus, Epstein-Barr virus, CMV, human herpesvirus (HHV) 6, and HHV7. A population-based health research platform in the south of Germany, the KORA F4 study and FF4 study provided investigators with information related to more than 5000 individuals.

For the purpose of analysis, regression models were used to estimate associations between serostatus of each herpesvirus and prediabetes incidence after 7 years of follow-up, with adjustment for sex, age, BMI, education, smoking, physical activity, parental diabetes, hypertension, lipid levels, insulin resistance, and fasting glucose.

Of the 3077 and 2279 participants originally included in the F4 and FF4 studies, investigators identified 1967 individuals who had undergone extensive phenotyping, including viral multiplex serology for human herpesviruses, and met additional inclusion criteria for the study. Of these, 1257 had normal glucose tolerance at baseline and meta criterion for being at risk of prediabetes. This cohort had a median age of 54 (range 32-81) at baseline, 49.2% were men, and the mean follow-up duration was 6.5 years. During the follow-up period, 364 patients developed prediabetes and 17 developed type 2 diabetes. Among the study cohort, Epstein-Barr virus was the most prevalent herpesvirus at F4, with a reported prevalence of98%. This was followed by HSV1 (88%), HHV7 (85%), VZV (79%), CMV (46%), HHV6 (39%) and HSV2 (11%) , which had prevalence rates of 88%, 85%, 79%, 46%, 39%, and 11%, respectively.

Results of the investigators’ analyses suggest HSV2 and CMV were associated with prediabetes coincidence among the study cohort, with these associations being independent of sex, age, BMI, smoking, education, physical activity, parental diabetes, hypertension, lipid levels, insulin resistance, and fasting glucose. Results of the analyses indicated those who were seropositive for HSV2 had increased odds of developing prediabetes during the 6.5 years between F4 and FF4 (OR, 1.66 [95% CI, 1.13-2.43]) in unadjusted models, but this was slightly attenuated in adjusted models (OR, 1.59 [95% CI, 1.01-2.48]). Similarly, those who were seropositive for CMV had an increased incidence of prediabetes (OR, 1.47 [95% CI, 1.15-1.87]), which was attenuated slightly when adjusted for potential confounders (OR, 1.31 [95% CI, 1.00-1.78]).

“These results highlight the link between viruses and (pre)diabetes, and the need for more research evaluating public health viral prevention strategies, possibly including the development of effective vaccines against herpesviruses,” investigators wrote.

Health impact of seven herpesviruses on (pre)diabetes incidence and HbA1c: results from the KORA cohort

An analysis of data from the KORA study suggests HSV 2 and CMV seropositivity were independently associated with increased odds of developing prediabetes.

Herpesviruses Linked to Increased Risk of Prediabetes, Impaired Glucose Control

A recent analysis of data from nearly 4000 patients in the US provides insight into the association of food insecurity in young adulthood with risk of diabetes later in life.

Conducted by investigators from Washington State University (WSU), data from the study suggest food insecurity was associated with increases in BMI as well as increased incidence of obesity and diabetes from young to middle adulthood in unadjusted and adjusted models.

“When we look at the data 10 years later, we do see this separation in prevalence of diabetes: those that experienced risk of food insecurity at young adulthood are more likely to have diabetes in middle adulthood,” said Cassandra Nguyen, PhD, the study’s lead author and an assistant professor with WSU’s Institute for Research and Education to Advance Community Health, in 

Citing reliance on cross-sectional studies and self-reported data among previous studies, Nguyen and a team of colleagues designed the current study as an analysis of data from the 4th and 5th waves of the National Longitudinal Study of Adolescent to Adult Health, with the intent of assessing the association of risk of food insecurity with BMI, obesity, and diabetes, with adjustment for sociodemographic features. A nationally representative cohort study conducted by the Carolina Population Center at the University of North Carolina–Chapel Hill, the study provided investigators with data related to more than 20,000 adolescent patients enrolled during the 1994-1995 academic school year.

Limiting their study to those with data from waves 4 and 5 of the study, which occurred in 2008-2009 and 2016-2018 when cohort members were 24–32 and 32–42 years old, respectively, investigators identified a cohort of 3992 individuals with no missing data related to risk of food insecurity, body weight, diabetes, and sociodemographic characteristics for inclusion in their study. Overall, 4655 patients had participated in both wave 4 and wave 5, but 663 patients were considered ineligible for inclusion based on missing data.

Results of the investigators’ analyses suggested risk of food insecurity at wave 4 was significantly associated with respondents’ sex (

=.02). Initial analysis indicated the prevalence of obesity at both wave 4 (

=.004) was higher among participants who were at risk of food insecurity at wave 4 in comparison to those not at risk of food insecurity. Additionally, the prevalence of diabetes at wave 4 was not significantly altered by risk of food insecurity at wave 4 (

=.21) but was more prevalent among participants during wave 5 who had reported risk of food insecurity at wave 4 (

In models adjusting for Further analysis revealed risk of food insecurity was no longer significantly associated with obesity among non-Hispanic White respondents (

 >.05), and interaction terms between risk of food insecurity and assessment wave were not significant in any models (

 >.05) in models adjusting for sociodemographic characteristics.

“In the current study, risk of food insecurity assessed at 1 time point in young adulthood was associated with BMI and obesity at young adulthood and middle adulthood but did not relate to change over time. This aligns with prior research that reports food insecurity is associated with higher BMI,” investigators wrote.

Risk of Food Insecurity in Young Adulthood and Longitudinal Changes in Cardiometabolic Health: Evidence from the National Longitudinal Study of Adolescent to Adult Health,

An analysis of data from more than 3500 individuals followed for more than 20 years provides insight into the impact of food insecurity on risk of cardiometabolic conditions, including obesity and type 2 diabetes.

Food Insecurity in Young Adulthood Linked to Obesity, Diabetes Risk Later in Life

A flawed “one-size-fits-all” approach to 

 may be contributing to increased prevalence among minority patients, according to results of a recent study.

A cross-sectional analysis of data from the National Health and Nutrition Examination Survey (NHANES) from 2011-2018, results of the study suggest tailoring the BMI threshold for diabetes screening according to racial and ethnic background could reduce disparities in diabetes diagnosis, with investigators recommending lowering the threshold for screening to 18.5 kg/m2 or greater in Black and Hispanic Ameri can and to 20 kg/m2 or greater among Asian Americans.

“The simplicity of a single screening threshold for all Americans is alluring, but it is deeply inequitable,” said senior investigator Dhruv Kazi, MD, MSc, MS, associate director of the Smith Center and associate professor of medicine at Harvard Medical School, 

. “Our findings suggest that Asian, Hispanic, and Black Americans may need to get screened at lower BMI or younger ages than white Americans. If the current thresholds are universally applied, without accounting for differential risk in racial/ethnic groups, clinicians may underdiagnose diabetes in Asian, Hispanic, and Black Americans.”

Despite an enhanced emphasis in recent guidelines and initiatives, racial disparities in diagnosis and treatment of diabetes continue to be among the most prominent issues in disease management on a population level. Citing previous research indicating racial/ethnic minority patients were less aware their diagnosis and more likely to die of diabetes, Kazi and a team of colleagues from Beth Israel Deaconess Medical Center (BIDMC) sought to assess whether a more tailored approach to screening might improve diagnosis rates using data from NHANES cycles occurring between 2011 and 2018.

The specific intent of the investigators’ efforts was to determine the equivalent BMI thresholds for diabetes screening among racial/ethnic minority Americans that would be expected to produce similar tradeoffs of screening-related benefits and harms to the implementation of the 2021 US Preventive Services Task Force recommendations, which recommends screening for diabetes among adults aged 40-70 years with 25 kg/m2 or greater and the starting age was later amended to begin at 35 years.

For the purpose of analysis, logistic regression was used to estimate diabetes prevalence at various BMIs for White, Asian, Black, and Hispanic Americans. For each group, the equivalent BMI threshold was defined as the BMI which the prevalence of diabetes in 35-year-old persons in that group is equal to that in 35-year-old White adults at a BMI of 25 kg/m2. Investigators pointed out ranges were estimated to account for uncertainty in prevalence estimates for White and minority populations.

Results of the investigators' analyses found the prevalence of diabetes among adults aged 35 years with a BMI of 25 kg/m2 was significantly higher among Asian Americans (3.8% [95% CI, 2.8-5.1]), Black Americans (3.5% [95% CI, 2.7-4.7]), and Hispanic Americans (3.0% [95% CI, 2.1-4.2%]) than among White Americans (1.4% [955 CI, 1.0-2.0]). When compared to a BMI threshold of 25 kg/m2 among White Americans, the equivalent BMI thresholds for diabetes prevalence were 20 kg/m2 (range, <18.5-23 kg/m2) for Asian Americans, less than 18.5 kg/m2 (range, <18.5-23 kg/m2) for Black Americans, and 18.5 kg/m2 (range, <18.5-24 kg/m2) for Hispanic Americans.

“Delayed diagnosis and inadequate treatment of diabetes can produce catastrophic consequences, jeopardizing one’s heart, kidney, eyes, and limbs. But it doesn’t affect all of us equally – there are striking disparities that are largely the legacy of structural racism,” added lead investigator Rahul Aggarwal, MD, internal medicine resident at BIDMC, in the aforementioned statement. “Fixing the health disparities for Americans with diabetes will require a range of strategic investments in health care and efforts to reduce structural inequities. Making screening more equitable is a place to start, as it ensures that individuals with diabetes can receive preventive care and treatment in a timely manner and avert the most catastrophic consequences of diabetes.”

Diabetes Screening by Race and Ethnicity in the United States: Equivalent Body Mass Index and Age Thresholds,

A cross-sectional study of NHANES data suggests lowering BMI thresholds for diabetes screening among racial/ethnic minority patients could improve diabetes diagnosis and lower risk of adverse outcomes.

Tailored BMI Thresholds for Screening Could Improve Diabetes Diagnoses in Minority Patients

A man in his mid-30’s with a medical history significant for obesity and diabetes on an insulin pump presents to the hospital with 4 days of gradually worsening right foot pain and swelling. He denies any fever but has had intermittent chills and also feels a bit of generalized weakness. He denies any other complaints.

Vital signs are normal except for a pulse of 118 and a BP of 104/51 mmHg. Physical exam is otherwise normal except for a red swollen foot.

: normal except for glucose 431, bicarb 19

Our latest endocrine case report features a man in his mid-30’s with a medical history significant for obesity and diabetes on an insulin pump presenting to the hospital with 4 days of gradually worsening right foot pain and swelling. Can you determine the correct diagnosis?

Endocrine Case Report: Foot Infection

Natalie Bellini, DNP, FNP-BC, is a nurse practitioner specializing in diabetes management with the R&B Medical Group based out of Niagara Falls, NY. 

In this special edition episode of Diabetes Dialogue: Therapeutics, Technology, & Real-World Perspectives, hosts Diana Isaacs, BCPS, BC-ADM, BCACP, CDCES, FADCES, FCCP, and Natalie Bellini, DNP, FNP-BC, recap their experiences from the 15th International Conference on Advanced Technologies and Treatments for Diabetes (ATTD). 

Topics of discussion for the episode include favorite sessions from the conference and clinical pearls they took away from their experience, including the latest updates in the world of diabetes smartphone apps, smart insulin pens, and CGM systems. Also included in the episode is a reaction to Eli Lilly and Company’s announcement of topline data from the SURMOUNT-1 trial in late April.

Diabetes Dialogue: Therapeutics, Technology, and Real-World Perspectives is available in an audio-only format on 

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In this special edition ATTD Recap episode of Diabetes Dialogue: Therapeutics, Technology, & Real-World Perspectives, hosts Drs. Diana Isaacs and Natalie Bellini provide insight from ATTD 2022, including the latest updates in the world of diabetes smartphone apps, smart insulin pens, and CGM systems. 