The Relationship Between Adverse Childhood Experiences and Diabetes in Central Michigan Adults

Objective: Adverse childhood experiences (ACEs) predispose individuals to poor health outcomes as adults. Although a dose-response relationship between the number of ACEs and certain chronic illnesses has been shown, the impact of ACEs on diabetes is not thoroughly understood. We investigated the prevalence of ACEs in patients with diabetes and the potential relationship to the severity of diabetes.Methods: Patients with diabetes (both type 1 and type 2) or obesity were surveyed from the Endocrinology & Diabetes Center at McLaren Central Michigan in Mount Pleasant, Michigan. A validated, standard ACE questionnaire was administered to quantify the number of adverse childhood events that patients have experienced. A retrospective chart analysis was then conducted, addressing the relationship of ACEs with the severity of disease in the diabetes group and the obesity group. The number of ACEs was correlated with disease comorbidities, complications, and measurable quantities, such as body mass index (BMI) and hemoglobin A1c (HbA1c).Results: ACE scores in both diabetes and obesity groups were shown to have a greater prevalence compared to the general ACE average in Michigan. ACE scores also positively correlated to BMI and HbA1c in the diabetes group. Those with higher ACE scores in the diabetes group were also more likely to have depression and anxiety.Conclusion:ACE screening may lead to a greater understanding of the severity of and progression of diabetes. Ultimately, these results could provide support to potential interventional studies leading to the altered management of diabetes in patients with ACEs, or preventative intervention to children with ACEs.Abbreviations: ACE = adverse childhood experiences; BMI = body mass index; HbA1c = hemoglobin A1c; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus     

Impact of Switching Youth With Diabetes to Insulin Degludec in Clinical Practice

Objective: Many youth with diabetes struggle to meet glycemic targets. The new ultralong duration of action of insulin degludec (iDeg) holds potential to ameliorate missed doses of basal insulin and improve glycemic control in youth with diabetes.Methods: A retrospective chart review was undertaken of youth age 13 to <24 years in our practice with type 1 diabetes (T1D) or type 2 diabetes (T2D) who had been switched from glargine or detemir to iDeg to evaluate the impact of this transition on glycemic control.Results: Glycated hemoglobin A1c (HbA1c) in youth with T1D (n = 82) remained stable during 6 months of treatment with iDeg (10.1 ± 2.11% &lsqb;87 ± 23 mmol/mol] at start of iDeg compared to 10.1 ± 2.12% &lsqb;87 ± 23 mmol/mol] at 6 months of treatment), whereas in youth with T2D (n = 16), HbA1c significantly declined from 10.6 ± 2.3% (92 ± 25 mmol/mol) to 8.3 ± 2.2% (67 ± 24 mmol/mol) (P = .0024).Conclusion: In youth switched to iDeg, which in our practice is commonly due to ineffectiveness of the patient's current regimen, the outcome differences we saw may be due to preserved beta-cell function in youth with T2D. It remains to be seen whether there are benefits of transition to iDeg in youth with T1D beyond glycemic outcomes, such as reduction in ketosis and episodes of diabetic ketoacidosis.Abbreviations: DKA = diabetic ketoacidosis; DPV = Diabetes-Patienten-Verlaufsdokumentation (German/Austrian Prospective Diabetes Follow-Up Registry); HbA1c = glycated hemoglobin A1c; iDeg = insulin degludec; T1D = type 1 diabetes; T2D = type 2 diabetes     

Increased Bone Turnover in Type 2 Diabetes Patients Randomized to Bariatric Surgery Versus Medical Therapy at 5 Years

Objective: The aim of our study was to determine the 5-year outcomes of bariatric surgery versus intensive medical therapy on bone turnover in patients with type 2 diabetes mellitus (T2DM) from the STAMPEDE trial.Methods: This was an ancillary investigation of a 5-year randomized control trial at a single tertiary care center involving 95 patients aged 48.5 ± 8 years with obesity (body mass index &lsqb;BMI], 36.5 ± 3.6 kg/m²) and uncontrolled T2DM (glycated hemoglobin 9.3 ± 1.6% &lsqb;78 mmol/mol]). Patients were randomized to intensive medical therapy (IMT; n = 25), Roux-en-Y gastric bypass (RYGB; n = 37), or sleeve gastrectomy (SG; n = 33) for diabetes treatment. Bone formation marker osteocalcin (OC), bone resorption marker serum C-telopeptide of type 1 collagen (CTX), and intact parathyroid hormone (PTH) were assessed at baseline and 5 years postintervention. Analysis with key clinical parameters and outcomes (i.e., age, menopausal status, gender, weight loss) was performed.Results: Percent change in CTX at 5 years increased in both surgical groups, by 137 ± 108% in RYGB (P<.001) and 61.1 ± 90% in SG (P<.001) compared to 29.8 ± 93% in IMT (P = .12). OC also increased from baseline in the surgical cohorts, by 138 ± 19% in RYGB (P<.001) and 71 ± 69% in SG (P<.001) compared to 43.8 ± 121.1% in IMT (P = .83). Increases in both CTX and OC correlated linearly with increases in PTH levels in RYGB patients (P<.001). Increase in CTX correlated with decreased BMI in SG patients (P = .039).Conclusion: In patients with T2DM, bone turnover remains chronically elevated at 5 years following RYGB, and to a lesser extent in SG patients.Abbreviations: BMI = body mass index; BTM = bone turnover marker; CTX = C-telopeptide of type 1 collagen; HbA1c = glycated hemoglobin; IMT = intensive medical therapy; OC = osteocalcin; PPI = proton-pump inhibitor; PTH = parathyroid hormone; RYGB = Roux-en-Y gastric bypass; SG = sleeve gastrectomy; T2DM = type 2 diabetes mellitus; TZD = thiazolidinedione     

Quality of Care Provided to Patients with Diabetes Mellitus in Puerto Rico: Managed Care Versus Fee-for-Service Experience

ObjectiveTo evaluate and compare the quality of diabetes care in a large managed care system and fee-for-service payment system in Puerto Rico.MethodsThis retrospective cross-sectional study assessed the adherence to standards of diabetes care in 1,687,202 subjects—226,210 from a fee-for-service population and 1,460,992 from a managed care group. Patients with diabetes mellitus were identified from insurance claims reports. Type of health-care provider, service location, number of visits, and laboratory utilization were also assessed.ResultsFrom the analysis, we identified 90,616 patients with diabetes (5.4% of the overall study group). Of these, 66,587 (73.5%) were found to have at least one encounter with a physician in a medical visit. Of the 66,586 patients with diabetes who visited a physician, only 4% were treated by an endocrinologist. General laboratory utilization was 34% for the entire population of patients with diabetes studied. In the group of patients with documented laboratory tests, 93% had a documented fasting blood glucose test; in contrast, hemoglobin A1c testing was performed in only 9% of the patients. The fee-for-service group had a higher rate of visits to medical specialists and general laboratory utilization, whereas the managed care group had a higher rate of hospital admissions and emergency department visits.ConclusionThe quality of diabetes management and the subsequent outcomes are related to patient and healthcare provider adherence to standards of care. In this analysis, we found that patients and physicians are responsible for low compliance with recognized standards of diabetes care in Puerto Rico. The lack of adequate management will lead to increased mortality, development and severity of chronic complications, and increased emergency department utilization. Therefore, health-care providers and payers should find ways to achieve more effective promotion of adherence to accepted standards of care for patients with diabetes. (Endocr Pract. 2005;11:376-381)     

Differences in Achieving Hba1C Goals Among Patients Seen by Endocrinologists and Primary Care Providers

Objective: This study evaluated whether there is a difference in the proportion of patients with type 2 diabetes who achieve a hemoglobin A1c (HbA1c) <7% within one year following treatment by an endocrinologist or primary care physician (PCP).Methods: We conducted a retrospective, propensity-matched study of patients with type 2 diabetes that were not optimally controlled and seen within our health system from 2007–2016. We assessed differences in short term health outcomes for patients following an endocrinologist visit compared to a PCP visit.Results: Patients seen by endocrinologists obtained HbA1c control at a faster rate (hazard ratio = 1.226; 95% confidence interval = 1.01 to 1.488) than those seen by a PCP. Furthermore, 34.5% and 29.5% of those treated by endocrinologists and PCPs, respectively, obtained HbA1c control by one year. Endocrinologists were more likely to prescribe a new medication class within 90 days than PCPs (14.1% versus 10.3%, respectively, P = .043). There was no difference in the risk of hospitalization between groups; 24.4% and 24.1% of those treated by endocrinologists and PCPs, respectively, were hospitalized within one year.Conclusion: Patients treated by endocrinology specialists were more likely to achieve a target HbA1c of <7% (53 mmol/mol) than those treated by PCPs in our health-care system. The performance difference may be partially explained by a higher rate of adding new classes of diabetes medications to the patient's pharmacologic regimens within 90 days by endocrinologists compared with PCPs. The long-term impact of these differences is unknown but has the potential to have an unfavorable impact on the health of the population.Abbreviations: ACP = American College of Physicians; CI = confidence interval; DUHS = Duke University Health System; HbA1c = hemoglobin A1c; HR = hazard ratio; PCP = primary care physician; SMD = standard mean difference     

Cheiroarthropathy: A Common Disorder in Patients in the T1D Exchange

Objective: Diabetic cheiroarthropathy is a long-term complication of diabetes that causes significant morbidity and can impair functional abilities. It has not been well studied in individuals with type 1 diabetes (T1D). The T1D Exchange registry provided an opportunity to assess the frequency of cheiroarthropathy and related characteristics.Methods: An internet-based survey was sent to 6,199 registry participants ≥18 years old, with 1,911 (31%) responding (62% female, 90% non-Hispanic White, mean age 40 years, median diabetes duration 20 years, mean glycated hemoglobin &lsqb;HbA1c] 7.7% &lsqb;61 mmol/mol]).Results: A total of 586 (31%) adults reported a diagnosis of ≥1 upper extremity disorder: 293 (15%) reported frozen shoulder, 293 (15%) trigger finger, 261 (14%) carpal tunnel, and 92 (5%) Dupuytren contracture, with 281 (15%) reporting ≥2 disorders. Those with upper extremity joint disorders were more likely older (P<.001) and had longer duration of diabetes (P<.001) than those without. HbA1c levels at the time of survey completion were 7.6% in participants with cheiroarthropathy versus 7.8% (62 mmol/mol) in participants without cheiroarthropathy.Conclusion: Cheiroarthropathy is common in adults with T1D. Additional research is needed to understand the pathogenesis and risk factors for this disorder. Standards of care for early recognition and treatment of diabetic cheiroarthropathy are also needed, particularly for adults with long-term diabetes. Improved awareness of cheiroarthropathy signs and symptoms of is needed so that patients can be identified and seek treatment before the condition causes disability.Abbreviations: BMI = body mass index; CGM = continuous glucose monitor; DCCT/EDIC = Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications; HbA1C = glycated hemoglobin; T1D = type 1 diabetes; T2D = type 2 diabetes     

The Association of Gestational Weight Gain and Adverse Pregnancy Outcomes in Women with Gestational Diabetes Mellitus

Objective: To explore the association of excessive gestational weight gain (GWG) defined by the Institute of Medicine (IOM) targets and adverse perinatal outcomes in gestational diabetes mellitus (GDM) pregnancies, and whether a modified target might be related to a lower rate of adverse perinatal outcomes for GDM.Methods: This retrospective cohort study involved 1,138 women of normal glucose tolerance (NGT) and 1,200 women with GDM. Based on the IOM target, pregnancies were classified to appropriate GWG (aGWG), inadequate GWG, and excessive GWG (eGWG). Modified GWG targets included: upper limit of IOM target minus 1 kg (IOM-1) or 2 kg (IOM-2), both upper and lower targets minus 1 kg (IOM-1-1) or 2 kg (IOM-2-2).Results: The proportions of women achieving eGWG were 26.3% in NGT and 31.2% in GDM (P = .036); in comparison, for aGWG NGT, the risks of large for gestational age (LGA) were significantly higher in eGWG NGT (adjusted odds ratio &lsqb;OR] 1.47; 95% confidence interval &lsqb;CI] 1.02 to 2.13), aGWG GDM (adjusted OR 1.42; 95% CI 1.03 to 1.95), and eGWG GDM (adjusted OR 2.70; 95% CI 1.92 to 3.70). GDM pregnancies gaining aGWG based on the modified GWG targets (IOM-2, IOM-1-1, and IOM-2-2) had a lower prevalence of LGA and macrosomia delivery than that for similar pregnancies using the original IOM target (all P<.05).Conclusion: For aGWG GDM according to the IOM target, adhering to a more stringent weight control was associated with decreased adverse outcomes. A tighter IOM target might help to reduce the prevalence of adverse pregnancy outcomes.Abbreviations: aGWG = appropriate gestational weight gain; BG = blood glucose; BMI = body mass index; CI = confidence interval; eGWG = excessive gestational weight gain; GDM = gestational diabetes mellitus; GW = gestational weeks; GWG = gestational weight gain; HbA1c = hemoglobin A1c; iGWG = inadequate gestational weight gain; IOM = Institute of Medicine; LGA = large for gestational age; NGT = normal glucose tolerance; NICU = neonatal intensive care unit; OGTT = oral glucose tolerance test; OR = odds ratio; PARp = partial population attributable risks; SGA = small for gestational age     

Intermittent Intensive Insulin Therapy for Type 2 Diabetes: Effects on Hypoglycemia,Weight Gain,and Quality of Life Over 2 Years

Objective: In early type 2 diabetes (T2DM), the administration of short-term intensive insulin therapy (IIT) can induce glycemic remission for a year thereafter, but this effect ultimately wanes. In this context, intermittently repeating short-term IIT could provide a strategy for maintaining the otherwise transient benefits of this intervention. However, the viability of this strategy would be contingent upon not inducing undesirable effects of insulin therapy such as excessive hypoglycemia and fat deposition. We thus sought to evaluate the effect of administering short-term IIT every 3 months on hypoglycemia, weight gain, and quality of life in early T2DM.Methods: In this 2-year pilot trial, 24 adults with T2DM of 2.0 ± 1.7 years duration and hemoglobin A1c of 6.4 (46 mmol/mol) ± 0.1% were randomized to 3 weeks of IIT (glargine, lispro) followed by either (1), repeat IIT for up to 2 weeks every 3 months or (2), daily metformin. IIT was titrated to target near-normoglycemia (premeal glucose 4 to 6 mmol/L; 2-hour postmeal <8 mmol/L). Participants were assessed every 3 months, with quality of life (QOL) evaluated annually.Results: The rate of hypoglycemia (<3.5 mmol/L) was low in the metformin and intermittent IIT arms (0.37 versus 0.95 events per patient-year; P = .28). There were no differences between the groups in changes over time in overall, central, or hepatic fat deposition (as reflected by weight &lsqb;P = .10], waist-to-hip ratio &lsqb;P = .58], and alanine aminotransferase &lsqb;P = .64], respectively). Moreover, there were no differences between the groups in QOL at 1- and 2-years.Conclusion: Intermittent short-term IIT may be safely administered in early T2DM without excessive adverse impact on hypoglycemic risk, anthropometry, or QOL.Abbreviations: ALT = alanine aminotransferase; HbA1c = hemoglobin A1c; IIT = intensive insulin therapy; ISSI-2 = insulin secretion-sensitivity index-2; OGTT = oral glucose tolerance test; QOL = quality of life; SF-36 = medical outcomes study 36-item short-form health survey; T2DM = type 2 diabetes     

Open Access to Diabetes Center from the Emergency Department Reduces Hospitalizations in the Susequent Year

Objective: Patients who present to the emergency department (ED) for diabetes without hyperglycemic crisis are at risk of unnecessary hospitalizations and poor outcomes. To address this, the ED Diabetes Rapid-referral Program (EDRP) was designed to provide ED staff with direct booking into the diabetes center. The objective of this study was to determine the effects of the EDRP on hospitalization rate, ED utilization rate, glycemic control, and expenditures.Methods: We conducted a single-center analysis of the EDRP cohort (n = 420) and compared 1-year outcomes to historic controls (n = 791). We also compared EDRP patients who arrived (ARR) to those who did not show (NS). The primary outcome was hospitalization rate over 1 year. Secondary outcomes included ED recidivism rate, hemoglobin A1c (HbA1c), and healthcare expenditures.Results: Compared with controls, the EDRP cohort was less likely to be hospitalized (27.1% vs. 41.5%, P<.001) or return to the ED (52.2% vs. 62.3%, P = .001) at the end of 1 year. Total hospitalizations were also lower in the EDRP (157 ± 19 vs. 267 ± 18 per 1,000 persons per year, P<.001). The EDRP cohort had a greater reduction in HbA1c (-2.66 vs. -2.01%, P<.001), which was more pronounced when ARR patients were compared with NS (-2.71% vs. -1.37%, P<.05). The mean per patient institutional healthcare expenditures were lower by $5,461 compared with controls.Conclusion: Eliminating barriers to scheduling diabetes-focused ambulatory care for ED patients was associated with significant reductions in hospitalization rate, ED recidivism rate, HbA1c, and healthcare expenditures in the subsequent year.Abbreviations:ARR = arrivedED = emergency departmentEDRP = emergency department diabetes rapid-referral ProgramHbA1c = hemoglobin A1cNS = no show     

Efficacy of Control-IQ Technology in a General Endocrine Clinic

ObjectiveRecent advances in technology have allowed for the expanded use of hybrid closed-loop insulin pump therapy and automated insulin delivery systems for the management of diabetes mellitus. We assessed the outcomes of introducing Tandem t:slim X2 with the Control-IQ technology in a general endocrine clinic.MethodsData from 66 adults with type 1 (n = 61) and type 2 (n = 5) diabetes mellitus were aggregated for analysis. Patients were either transitioned from traditional insulin pump therapy or multiple daily injection therapy to Tandem t:slim X2 with the Control-IQ technology from January 2020 to June 2021. The assessed clinical end points included changes in time below range, time above range, and time in target range. Changes in hemoglobin A1C before and after Control-IQ technology implementation were noted. The primary outcome was a change in time in target range with the Control-IQ technology.ResultsThere was a significant increase in time in target range when comparing pre- and post–Control-IQ technology (49.5% vs 63.3%, P < .0003) values. There was a reduction in time above range (46.8% vs 34.9%, P < .0013), a decrease in time below range (4.0% vs 1.7%, P = .017), and a decrease in hemoglobin A1C after transitioning to the Control-IQ technology (7.7% [61 mmol/mol] vs 7.1% [54 mmol/mol], P < .017). The patient dropout rate was low (7%).ConclusionThe Control-IQ technology system was effective in reducing hyperglycemia while increasing time in target range and decreasing hypoglycemia. This technology is a useful and effective addition to the growing number of automated insulin delivery systems. The clinical outcomes mirror the results found in the key adult pivotal trials.     

Outcomes Associated With Insulin Therapy Disruption After Hospital Discharge Among Patients with Type 2 Diabetes Mellitus who Had Used Insulin Before and During Hospitalization

ObjectiveTo evaluate outcomes associated with insulin therapy disruption after hospital discharge in patients with type 2 diabetes mellitus who had used insulin before and during hospitalization.MethodsIn this observational, retrospective analysis of medical records obtained from a coordinated health system in the United States, patients with type 2 diabetes mellitus who had used insulin 30 days before and during hospitalization were included. Clinical and cost outcomes were compared between patients who continued insulin therapy and those who had disrupted insulin therapy after hospital discharge.ResultsIn total, 2160 records were analyzed (851 patients with continued insulin therapy and 1309 patients with disrupted insulin therapy). Mean baseline glycated hemoglobin A_1c levels were 8.56% and 7.73% in patients who continued insulin therapy and patients who disrupted insulin therapy, respectively (P <.001), suggesting that patients who discontinued insulin therapy had better glycemic control at baseline. Continued insulin therapy was associated with an expected greater reduction in glycated hemoglobin A_1c (P <.001); similar hypoglycemia rates; lower risks of all-cause hospital readmission, diabetesrelated readmission, and all-cause emergency department visits; and improved survival. Continued insulin therapy was associated with $3432 lower total medical service costs than disrupted therapy over the 6-month postdischarge period.ConclusionEnsuring adherence to insulin therapy in patients who require insulin therapy after hospitalization should be a priority for postdischarge patient care programs. However, the clinical implications of this study are limited by the fact that it could not be determined whether all patients required insulin therapy after hospital discharge. (Endocr Pract. 2012;18:651-659)     

Trends in the Care and Outcomes of Medicare Beneficiaries with Type 2 Diabetes, 2002–2011

Objective: To summarize characteristics of Medicare beneficiaries with type 2 diabetes and to describe changing trends in care and outcomes.Methods: We conducted a retrospective cohort study of a nationally representative 5% sample of fee-for-service Medicare beneficiaries 65 years and older with prevalent type 2 diabetes, between January 1, 2002, and December 31, 2011. The main outcome measures were diabetes-related screening tests, mortality, hospital admissions, dialysis, and lower extremity amputation.Results: The average age of Medicare beneficiaries with diabetes was 76.5 years, 56% were women, and 83% were white. Screening practices in beneficiaries with diabetes improved from 2002 to 2011, with rising rates of foot exams, renal screening, hemoglobin A1c tests, and lipid profile tests. The prevalence of nephropathy and neuropathy increased. Although inpatient admissions declined from 2002 to 2011, diabetes-related emergency department visits increased. Amputation and end-stage renal disease remained static, while 1-year mortality declined over the study period.Conclusion: In this medically complex group of patients with high comorbidity, we observed improvements in screening practices and room for further improvement. Although the mortality rate decreased, other outcomes did not improve consistently. Health care resource has changed over time, with decreased hospital admissions and increased emergency department visits.Abbreviations:CCW = Chronic Conditions Data WarehouseESRD = end-stage renal diseaseHbA1c = hemoglobin A1cHEDIS = Healthcare Effectiveness Data and Information SetICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification     

The Synergy to Enable Glycemic Control Following Emergency Department Discharge Program for Adults with Type 2 Diabetes: Step-Diabetes

Objective: To evaluate a diabetes (DM) care delivery model among hyperglycemic adults with type 2 DM being discharged from the emergency department (ED) to home. The primary hypothesis was that a focused education and medication management intervention would lead to a greater short-term improvement in glycemic control compared to controls.Methods: A 4-week, randomized controlled trial provided antihyperglycemic medications management using an evidence-based algorithm plus survival skills diabetes self-management education (DSME) for ED patients with blood glucose (BG) levels ≥200 mg/dL. The intervention was delivered by endocrinologist-supervised certified diabetes educators. Controls received usual ED care.Results: Among 101 participants (96% Black, 54% female, 62.3% Medicaid and/or Medicare insurance), 77% completed the week 4 visit. Glycated hemoglobin A1C (A1C) went from 11.8 ± 2.4 to 10.5 ± 1.9% (P<.001) and 11.5 ± 2.0 to 11.1 ± 2.1% in the intervention and control groups, respectively (P = .012). At 4 weeks, the difference in A1C reduction between groups was 0.9% (P = .01). Mean BG decreased for both groups (P<.001), with a higher percentage of intervention patients (65%) reaching a BG <180 mg/dL compared to 29% of controls (P = .002). Hypoglycemia rates did not differ by group, and no severe hypoglycemia was reported. Medication adherence (Modified Morisky Score©) improved from low to medium (P<.001) among intervention patients and did not improve among controls.Conclusions: This study provides evidence that a focused diabetes care delivery intervention can be initiated in the ED among adults with type 2 diabetes and hyperglycemia and safely and effectively completed in the ambulatory setting. Improvement in short-term glycemic outcomes and medication adherence were observed.Abbreviations: A1C = glycated hemoglobin A1C BG = blood glucose BMI = body mass index CDE = certified diabetes educator CI = confidence interval DM = diabetes mellitus DSME = diabetes self-management education ED = emergency departmentMMAS-8 = Modified Morisky Medication Scale PCP = primary care provider POC = point of care SQ = subcutaneous     

Chromium Effects on Glucose Tolerance and Insulin Sensitivity in Persons at Risk for Diabetes Mellitus

ObjectiveTo investigate the effects of daily chromium picolinate supplementation on serum measures of glucose tolerance and insulin sensitivity in patients at high risk for type 2 diabetes mellitus.MethodsWe conducted a randomized, double-blind, placebo-controlled, modified cross-over clinical trial with 6-month sequences of intervention and placebo followed by a 6-month postintervention assessment. Adult patients with impaired fasting glucose, impaired glucose tolerance, or metabolic syndrome were enrolled. Participants received 6-month sequences of chromium picolinate or placebo at 1 of 2 dosages (500 or 1000 mcg daily). Primary outcome measures were change in fasting plasma glucose, 2-hour plasma glucose during oral glucose tolerance testing, fasting and 2-hour insulin, and homeostasis model assessment of insulin resistance (HOMA-IR). Secondary outcomes included anthropometric measures, blood pressure, endothelial function, hemoglobin A_1c, lipids, and urinary microalbumin.ResultsFifty-nine participants were enrolled. No changes were seen in glucose level, insulin level, or HOMA-IR (all P > .05) after 6 months of chromium at either dosage level (500 mcg or 1000 mcg daily) when compared with placebo. None of the secondary outcomes improved with either chromium dosage compared with placebo (P > .05).ConclusionsChromium supplementation does not appear to ameliorate insulin resistance or impaired glucose metabolism in patients at risk for type 2 diabetes and thus is unlikely to attenuate diabetes risk. (Endocr Pract. 2011;17:16-25)     

Ethnic disparity in hemoglobin A1c levels among normoglycemic offspring of parents with type 2 diabetes mellitus

ObjectiveTo investigate the racial/ethnic disparities in hemoglobin A_1c levels among nondiabetic persons with similar parental history of type 2 diabetes mellitus.MethodsWe studied a community-based sample of adult offspring of parents with type 2 diabetes mellitus. Measurements included anthropometry, hematology assessments, serial fasting plasma glucose, oral glucose tolerance testing, plasma insulin, hemoglobin A_1c, insulin sensitivity, and b-cell function, using a homeostasis model assessment.ResultsThe study included 302 participants (135 white, 167 black). Compared with white participants, black participants had lower fasting plasma glucose levels (91.9 ± 0.51 mg/dL vs 93.6 ± 0.50 mg/dL, P = .015), lower area under the curve of plasma glucose during oral glucose tolerance testing (P = <.001), higher body mass index (31.1 ± 0.61 kg/m² vs 28.5 ± 0.57 kg/m², P = <.001), and similar insulin sensitivity and b-cell function. Hemoglobin A_1c was higher in black participants than in white participants (5.68 ± 0.033% vs 5.45 ± 0.028%, P <.001). The absolute black-white difference in hemoglobin A_1c level of approximately 0.22% persisted after adjusting for age, hemoglobin, hematocrit, body mass index, waist circumference, fasting plasma glucose, glucose area under the curve, and other covariates.ConclusionsAmong healthy offspring of parents with type 2 diabetes mellitus in this study, African American participants had higher hemoglobin A_1c levels than white participants after adjusting for age, adiposity, blood glucose, and known variables. Thus, plasma glucose level is more valid than hemoglobin A_1c for diagnosing prediabetes or diabetes in black persons. (Endocr Pract. 2012; 18:356-362)     

Greater Low-Density Lipoprotein Cholesterol Variability Increases the Risk of Cardiovascular Events in Patients with Type 2 Diabetes Mellitus

Objective: Variability in lipid levels has been associated with poor cardiovascular outcomes in patients with coronary artery disease. The aim of this study was to investigate whether low-density lipoprotein cholesterol (LDLC) variability can be used to predict cardiovascular events in patients with type 2 diabetes mellitus (DM).Methods: A total of 5,354 patients with type 2 DM were enrolled in this study. Cardiovascular events including peripheral arterial disease, coronary artery disease, stroke, and cardiovascular death were defined as the study endpoints, and standard deviations of lipid levels were used to define intra-individual lipid variability.Results: Univariate Cox proportional hazards analysis showed that LDL-C standard deviation (hazard ratio &lsqb;HR] = 1.016; 95% confidence interval &lsqb;CI] = 1.006 to 1.022; P<.001) was associated with a higher risk of cardiovascular events. Multivariate Cox proportional hazards analysis showed that an increase in LDL-C standard deviation significantly increased the risk of cardiovascular events (HR = 1.063; 95% CI = 1.025 to 1.102; P = .01). Kaplan-Meier analysis of cardiovascular event-free survival showed that the patients in tertiles 2 and 3 of the standard deviation of LDL-C had worse cardiovascular event-free survival compared to those in tertile 1.Conclusion: Variability in LDL-C could predict cardiovascular events in the patients with type 2 DM in this study.Abbreviations: CAD = coronary artery disease; CI = confidence interval; CVD = cardiovascular disease; DM = diabetes mellitus; eGFR = estimated glomerular filtration rate; HbA1c = glycosylated hemoglobin; HDL-C = high-density lipoprotein cholesterol; HR = hazard ratio; KMUHRD = Kaohsiung Medical University Hospital Research Database; LDL-C = low-density lipoprotein cholesterol; SD = standard deviation; UACR = urine albumin to creatinine ratio     

An Individualized Inpatient Diabetes Education and Hospital Transition Program for Poorly Controlled Hospitalized Patients with Diabetes

ObjectiveTo evaluate predictors of outcomes associated with an inpatient diabetes education and discharge support program for hospitalized patients with poorly controlled diabetes (glycated hemoglobin [HbA1c]>9%).MethodsPatients participated in individualized diabetes education conducted by a certified diabetes educator (CDE) that included an exploration of barriers and goal setting during hospitalization with telephone follow-up and communication with primary providers at discharge. Predictors of HbA1c reduction, successful follow-up, and readmission were analyzed.ResultsThere were 82 subjects, and 48% were insulin naïve. Patients with type 2 diabetes (T2D, n = 58) had a significant decrease in HbAlc at follow-up (-2.8%, P < .0001), while those with type 1 diabetes (T1D, n = 19) did not (+ 0.02%, P = .96). However, after adjustment for other factors, only increasing age, higher baseline HbA1c, earlier education, and initiation of basal insulin were significant predictors of reduction in HbA1c. Higher area level income and empowerment and earlier education were significant predictors of outpatient follow-up within 30 days. While 28% were admitted for severe hyperglycemia, only 1 patient was readmitted with severe hyperglycemia. Successful phone contact was 77% and 57% with and without the support of non-CDE assistants respectively, but all outcomes were similar.ConclusionThe study suggests that an individualized inpatient diabetes education and transition program is associated with a significant reduction in HbA1c that is dependent on baseline HbA1c, older age, initiation of insulin, and earlier enrollment. Additional interventions are needed to ensure better continuity of care. (Endocr Pract. 2014;20:1265-1273)     

Upstroke Time Per Cardiac Cycle is Associated with Cardiovascular Prognosis in Type 2 Diabetes

Objective: Upstroke time per cardiac cycle (UTCC) in the lower extremities has been found to be predictive of cardiovascular mortality in the general population. Therefore, the purpose of the study was to test the associations between increasing UTCC and outcomes in patients with type 2 diabetes.Methods: A total of 452 patients with type 2 diabetes (age, 67.5 ± 8.6 years; male, 54%) registered in a share-care program participated in the study at an outpatient clinic in Taipei Veterans General Hospital across a mean of 5.8 years. Primary outcomes were all-cause mortality hospitalization for coronary artery disease, stroke, revascularization, amputation, and diabetic foot syndrome. Secondary end-point outcome was all-cause mortality.Results: Increment of UTCC associations with primary and secondary outcomes were undertaken prior to baseline characteristic adjustments. A UTCC of 20.1% exhibited the greatest area under curve (AUC), sensitivity, and specificity balance to predict composite events in receiver operating curves (AUC, 0.63 &lsqb;P = .001]; sensitivity, 67.7%; specificity, 54.9%). Sixty-four composite events and 17 deaths were identified from medical records. UTCC ≥20.1% was associated with the occurrence of composite events and an increased risk of mortality. For composite events, an adjusted hazard ratio (HR) of 2.45 and 95% confidence interval (CI) of 1.38 to 4.35 (P = .002) were calculated. For all-cause mortality, an adjusted HR of 1.91 and 95% CI of 0.33 to 10.99 (P = .467) were calculated.Conclusion: Increasing UTCC was associated with cardiovascular outcomes in patients with type 2 diabetes. Therefore, UTCC is advocated as a noninvasive screening tool for ambulatory patients with type 2 diabetes.Abbreviations: CAD = coronary artery disease; CI = confidence interval; eGFR = estimated glomerular filtration rate; HR = hazard ratio; PAD = peripheral artery disease; UTCC = upstroke time per cardiac cycle     

American Association Of Clinical Endocrinologists And American College Of Endocrinology Guidelines For Management Of Dyslipidemia And Prevention Of Cardiovascular Disease - Executive Summary

Objective: The development of these guidelines is mandated by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs).Methods: Each Recommendation is based on a diligent review of the clinical evidence with transparent incorporation of subjective factors.Results: The Executive Summary of this document contains 87 Recommendations of which 45 are Grade A (51.7%), 18 are Grade B (20.7%), 15 are Grade C (17.2%), and 9 (10.3%) are Grade D. These detailed, evidence-based recommendations allow for nuance-based clinical decision making that addresses multiple aspects of real-world medical care. The evidence base presented in the subsequent Appendix provides relevant supporting information for Executive Summary Recommendations. This update contains 695 citations of which 202 (29.1 %) are evidence level (EL) 1 (strong), 137 (19.7%) are EL 2 (intermediate), 119 (17.1%) are EL 3 (weak), and 237 (34.1%) are EL 4 (no clinical evidence).Conclusion: This CPG is a practical tool that endocrinologists, other healthcare professionals, regulatory bodies and health-related organizations can use to reduce the risks and consequences of dyslipidemia. It provides guidance on screening, risk assessment, and treatment recommendations for a range of patients with various lipid disorders. These recommendations emphasize the importance of treating low-density lipoprotein cholesterol (LDL-C) in some individuals to lower goals than previously recommended and support the measurement of coronary artery calcium scores and inflammatory markers to help stratify risk. Special consideration is given to patients with diabetes, familial hypercholesterolemia, women, and pediatric patients with dyslipidemia. Both clinical and cost-effectiveness data are provided to support treatment decisions.AbbreviationsA1C = hemoglobin A1CACE = American College of EndocrinologyACS = acute coronary syndromeAHA = American Heart AssociationASCVD = atherosclerotic cardiovascular diseaseATP = Adult Treatment Panelapo = apolipoproteinBEL = best evidence levelCKD = chronic kidney diseaseCPG = clinical practice guidelinesCVA = cerebrovascular accidentEL = evidence levelFH = familial hypercholesterolemiaHDL-C = high-density lipoprotein cholesterolHeFH = heterozygous familial hypercholesterolemiaHIV = human immunodeficiency virusHoFH = homozygous familial hypercholesterolemiahsCRP = high-sensitivity C-reactive proteinLDL-C = low-density lipoprotein cholesterolLp-PLA₂ = lipoprotein-associated phospholipase A₂MESA = Multi-Ethnic Study of AtherosclerosisMetS = metabolic syndromeMI = myocardial infarctionNCEP = National Cholesterol Education ProgramPCOS = polycystic ovary syndromePCSK9 = proprotein convertase subtilisin/kexin type 9T1DM = type 1 diabetes mellitusT2DM = type 2 diabetes mellitusTG = triglyceridesVLDL-C = very low-density lipoprotein cholesterol