Search

Purpose: To analyze and compare metabolic, lifestyle and mental health parameters in relatives and people-with-T2DM (PDM) with and without support.Patients and Methods: We included 160 patients with < 5 years of diagnosis of T2DM, without disabling complications, and non-smokers, attending a multidisciplinary program for diabetes control, and their accompanying relatives. If the patients or relatives abandoned the program, we contacted them and asked to take laboratory tests and answer surveys regarding anxiety, depression, and perception of their family support. Variables distribution was assessed with the Kolmogorov–Smirnov test. We used ANOVA or Kruskal Wallis Tests, according to variable distribution. Frequencies and percentages are used for categorical values and analyzed with a chi-square test. We separated the participants in four groups: relatives with and without support and PDM with and without support.Results: We included 160 participants, age 51± 10, and 54.3% women. Total cholesterol (188± 36 vs 204± 43 vs 170± 34 vs 181± 35 mg/dL, p=0.001), LDL-cholesterol (113± 35 vs 125± 27 vs 101 ± 30 vs 109± 29, p=0.008), and non-HDL cholesterol (143± 32 vs 154 ± 30 vs 129± 33 vs 135± 35 mg/dL, p=0.010) were higher in the group without support. Although patients without family support had lower values, they did not achieve metabolic goals. Weight (75± 17 vs 77± 19 vs 74.2± 10.5 vs 90.2± 17.3 kg) and body mass index (28.9± 4.8 vs 30.1± 4.7 vs 27.4± 3.3 vs 33± 4.3 kg/m2) were higher in PDM without family support (p< 0.001 for both).Conclusion: Support in PDM and their families is important in metabolic control. However, raising awareness among family members to screen for diabetes and changes in lifestyle are points to improve. Including the evaluation of social and family support will allow a more complete assessment to identify barriers to achieving goals. [ABSTRACT FROM AUTHOR]

aime-Casas,3 Aida Jiménez-Corona,2,4 David Rivera-De La Parra,1,2 Enrique Octavio Graue-Hernández,2 Sergio Hernández-Jiménez1 On behalf of the Group of Study CAIPaDi1Centro de Atención Integral del Paciente con Diabetes (CAIPaDi) Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; 2Instituto de Oftalmología Fundación Conde de Valenciana IAP, Mexico City, Mexico; 3Escuela de Medicina, Universidad Panamericana, Mexico City, Mexico; 4Dirección General de Epidemiología, Secretaría de Salud, Mexico City, MexicoCorrespondence: Liliana Pérez-Peralta, Centro de Atención Integral del Paciente con Diabetes, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga No. 15. Colonia Sección XVI, Tlalpan, Mexico City, 14080, Mexico, Tel +52 55 54870900 (5045), Email [email protected] Purpose: To evaluate the risk factors associated with diabetic macular edema (DME) in patients with a recent type 2 diabetes mellitus (T2DM) diagnosis.Patients and Methods: We conducted a case-control study at a third-level hospital in Mexico City. We enrolled patients ≥ 18 years old, with T2DM less than five years of diagnosis, without disabling complications, and non-smokers. The control group was patients with diabetic retinopathy and without macular edema (DR-DME). Cases were patients with DR+DME. We measured fasting glucose, creatinine, lipid profile, urinary albumin/creatinine ratio (ACR), and HbA1c. An ophthalmological examination consisted of visual acuity measurement, digital three-field fundus photography with an automatic non-mydriatic camera, slit lamp, and Optical coherence tomography (OCT) examination.Results: 183 and 61 patients with DR-DME and DR+DME, respectively, were included in the analysis. The prevalence of mild DR was higher in the DR-DME group, but the frequencies of moderate and severe retinopathy were higher in the DR+DME group. Patients in the DR-DME group had better vision than those in the DR+DME group. Logistic regression analysis revealed that age (OR, 1.07), HbA1c (OR, 1.19), and Albumin-to-Creatinine Ratio (ACR) > 30 mg/g (OR, 3.37) were associated with an increased possibility of DME compared to DR-DME.Conclusion: Our study provides insights into the association between risk factors and DME. We found a statistically strong association between HbA1c levels, age, and ACR. Patients with poor metabolic control should undergo an extensive medical examination to screen for DME, which may be related to the chronicity of DM and renal damage. [ABSTRACT FROM AUTHOR]

Introduction: Anxiety disorders (AXD) are among the most prevalent mental health conditions in patients with type 2 diabetes (T2D). Previous data have established an association of other psychiatric conditions with poor metabolic control and increased odds of diabetes-related complications. Nonetheless, follow-up information about the effects of AXD on the metabolic control of patients with TD2 is still limited. Objective: Evaluate the effects of AXD on the metabolic parameters of patients with T2D over 12 months of follow-up in a multidisciplinary comprehensive care model. Methods: Prospective study of T2D subjects enrolled in a comprehensive care program with follow-up at 3 and 12 months of treatment. Patients were assessed using the Mini-International Neuropsychiatric Interview and the Hospital Anxiety and Depression Scale (HADS). We registered clinical and metabolic characteristics from each visit. Metabolic parameters over time were analyzed with a mixed model of repeated measures using AXD and time as interaction variables. Results: Our sample included 2703 patients at baseline, and 1161 (43%) subjects continued the follow-up at 12 months. The AXD group had more females, lower age, and fewer years of formal education compared with subjects without AXD at baseline, 3 and 12 months. Patients with AXD also reported higher mean fasting glucose at three months, and higher HbA1c at three and 12 months. Our MMRM for HbA1c reported significant differences over time in subjects with and without AXD. The differences in means between groups increased from 0.17% at three months to 0.31% at 12 months. The variables from the HADS anxiety score, sex, age, years of diagnosis, and insulin treatment were also associated with HbA1c parameters over time. Conclusion: Patients with AXD had the worst glycemic control at 3 and 12 months of follow-up. HbA1c differences in patients with AXD compared with non-AXD subjects increases over time in association with anxiety symptoms. [ABSTRACT FROM AUTHOR]

Diabetic retinopathies are important disabling conditions. Micro-RNAs (miRNAs) are regulators of gene expression and diseases can change their expression. Our aim was to analyze the expression of miRNAs in serum and vitreous samples from patients with diabetic retinopathies. The following groups and number of individuals were included: proliferative diabetic retinopathy (PDR) (n = 16), diabetic macular edema (DME) (n = 17), and idiopathic epiretinal membrane (IEM) as non-diabetic controls (n = 23). The initial miRNA expression was explored using TaqMan low-density arrays (TLDAs) with subsequent validation through a quantitative polymerase chain reaction (qPCR). Target genes were identified through bioinformatic tools for enrichment analysis. The TLDAs revealed the following miRNAs with differential expression in terms of PDR vs. IEM: miR-320a-3p, miR-92a-3p, and miR-375-3p in the serum, with miR-541-5p and miR-223-5p in the vitreous samples. DME vs IEM: miR-486-5p, miR-145-5p, miR-197-3p, and miR-125b-5p in the serum, and miR-212-3p in vitreous samples. PDR vs. DME: miR-486-5p, miR-100-5p, miR-328-3p, miR-660-5p, and miR-145 in the serum and none in the vitreous samples. Validation was confirmed only for miR-145, miR-92a, and miR-375 in the serum. The relevant enriched pathways for these three validated miRNAs, miR-145, miR-92a, and miR-375 were the vascular endothelial growth factor and its receptor, hepatocyte growth factor receptor, epidermal growth factor, focal adhesion, and phosphoinositide 3-kinase. Our results support the involvement of miRNAs in the pathophysiology of diabetic retinopathies and reinforce their potential as biomarkers or therapeutic resources. [ABSTRACT FROM AUTHOR]

Purpose: To describe the metabolic status and clinical characteristics associated with NPPD in patients with less than five years of T2D diagnosis and explore the role of age in the presentation of psychiatric comorbidities. Patients and Methods: This was a cross-sectional study of subjects who attended a comprehensive care program. Patients were assessed using the Mini-International Neuropsychiatric Interview, and clinical and metabolic characteristics were registered. Multivariate logistic regression analyses were conducted to identify risk and protective factors for psychiatric disorders. We performed an analysis to further explore age's influence on our results. Results: We included 1953 patients, and 40.1% had any psychiatric disorder. Younger age, female sex, and personal psychiatric history were associated with NPPD. The use of insulin was reported as a protective factor for eating disorders. Body mass index was associated with any psychiatric disorders and eating disorders. The analysis of age reported that patients younger than 45 years had the worst metabolic parameters and increased odds for NPPD, while patients older than 65 years had the best metabolic measures and decreased odds for psychiatric comorbidity. Conclusion: NPPD were frequent comorbidities in our sample; younger age, female sex, and personal psychiatric history were the most important factors associated with psychiatric comorbidities. Younger subjects experience a higher risk for psychiatric disorders and worst metabolic control. [ABSTRACT FROM AUTHOR]

We compared the completeness of data captured by physicians in a diabetes outpatient clinic using a general electronic health record system versus one that was specifically geared to diabetes. Use of a diabetes-oriented data system was found to allow for greater capture of crucial variables required for diabetes care than a general electronic record and was well accepted by health care providers. [ABSTRACT FROM AUTHOR]

Background: Nutritional diagnosis involves identifying a nutritional problem, its cause, and the signs that indicate it to guide appropriate treatment. Few studies report on the most prevalent nutritional diagnoses in people living with type 2 diabetes (T2D)., Objective: To define nutritional diagnoses across different domains and their association with metabolic, anthropometric, and dietary parameters in individuals with T2D., Methods: A personalized nutritional intervention was conducted using the Nutrition Care Process (NCP) model, which encompasses assessment, diagnosis, intervention, and evaluation, utilizing standardized terminology from the Nutrition Care Process Terminology (NCPT). Two dietitians, trained and standardized in applying the NCP and NCPT, performed patient assessments and established the diagnoses. Patients over 18 years old with a diagnosis of T2D for less than 5 years were included., Results: Data from 2,050 patients were analyzed, of whom 55.3% were women, and 44.7% were men, with a median age of 57 and 54 years, respectively. The most prevalent nutritional diagnosis was excessive energy and carbohydrate intake. Diagnoses were distributed across domains: Intake (55.9%), Behavioral/Environmental (32.7%), Clinical (10.2%), and 1.2% without nutritional diagnosis. Significant intergroup differences were observed in anthropometric variables such as BMI, waist circumference, and body fat percentage ( p  < 0.05). HbA1c and glucose levels were significantly higher in the Intake and Behavioral groups ( p  < 0.001). Albumin/creatinine ratio (ACR) was higher in the ingestion group ( p  = 0.007). Caloric and carbohydrate intake were higher in the ingestion group, while protein and fat intake were higher in the clinical and behavioral groups ( p  < 0.001)., Conclusion: Nutritional diagnoses in the intake domain, followed by behavioral/ environmental and clinical domains, are highly prevalent in people with T2D and are associated with worse metabolic control, higher BMI, and increased energy and carbohydrate intake. Timely identification of issues in these domains can support targeted nutritional therapy to improve disease management and promote a healthy lifestyle., Clinical Trial Registration: https://clinicaltrials.gov/study/NCT02836808?term=caipadi&rank=2, Identifier (NCT02836808)., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Landa-Anell, Del Razo-Olvera, Bodnar, Cordova-Isidro, Lagunas-Valdepeña, Arias-Marroquín, García-Ulloa, Melgarejo-Hernández and Hernández-Jiménez.)

Introduction: The burden of multimorbidity is recognised increasingly in low- and middle-income countries (LMICs), creating a strong emphasis on the need for effective evidence-based interventions. Core outcome sets (COS) appropriate for the study of multimorbidity in LMICs do not presently exist. These are required to standardise reporting and contribute to a consistent and cohesive evidence-base to inform policy and practice. We describe the development of two COS for intervention trials aimed at preventing and treating multimorbidity in adults in LMICs., Methods: To generate a comprehensive list of relevant prevention and treatment outcomes, we conducted a systematic review and qualitative interviews with people with multimorbidity and their caregivers living in LMICs. We then used a modified two-round Delphi process to identify outcomes most important to four stakeholder groups (people with multimorbidity/caregivers, multimorbidity researchers, healthcare professionals and policymakers) with representation from 33 countries. Consensus meetings were used to reach agreement on the two final COS., Registration: https://www.comet-initiative.org/Studies/Details/1580., Results: The systematic review and qualitative interviews identified 24 outcomes for prevention and 49 for treatment of multimorbidity. An additional 12 prevention and 6 treatment outcomes were added from Delphi round 1. Delphi round 2 surveys were completed by 95 of 132 round 1 participants (72.0%) for prevention and 95 of 133 (71.4%) participants for treatment outcomes. Consensus meetings agreed four outcomes for the prevention COS: (1) adverse events, (2) development of new comorbidity, (3) health risk behaviour and (4) quality of life; and four for the treatment COS: (1) adherence to treatment, (2) adverse events, (3) out-of-pocket expenditure and (4) quality of life., Conclusion: Following established guidelines, we developed two COS for trials of interventions for multimorbidity prevention and treatment, specific to adults in LMIC contexts. We recommend their inclusion in future trials to meaningfully advance the field of multimorbidity research in LMICs., Prospero Registration Number: CRD42020197293., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Diabetes and poor glycemic control are significant predictors of severity and death in the COVID-19 disease. The perception of this risk in individuals with type 2 diabetes (T2D) could modify coping styles, leading to behaviors associated with better self-care and metabolic control. Theoretically, active coping is associated with better glycemic control in patients with T2D. Nonetheless, information during extreme risk like the COVID-19 pandemic is still limited. Our objective was to evaluate the association between coping styles and risk perception in the COVID-19 pandemic and the change in metabolic parameters. This is a prospective study that included individuals with T2D treated in a tertiary care center during the COVID-19 outbreak who returned to follow-up one year later. We assessed coping styles and risk perception with the Extreme Risk Coping Scale and the risk perception questionnaire. Clinical characteristics and metabolic parameters were registered in both visits. Groups were compared using Kruskal Wallis tests, and changes in metabolic parameters were assessed with Wilcoxon rank sum tests. Our sample included 177 participants at baseline, and 118 concluded the study. Passive coping was more frequent in women. Low-risk perception was associated with higher age, lower psychiatric comorbidities, and lower frequency of psychiatric treatment compared with other risk perception groups. Patients with active coping plus high-risk perception did not have a change in metabolic parameters at follow-up, whereas patients with other coping styles and lower risk perception had an increase in total cholesterol, LDL-cholesterol, and triglycerides. There were no differences by coping group or by risk perception in glycemic control., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Alcántara-Garcés et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Diabetic peripheral neuropathy (DPN) causes morbidity and affects the quality of life. Before diabetes diagnosis, neuropathic damage may be present. Sudoscan provides accurate measurement of the sudomotor function. This study aimed to assess the abnormalities detected by Sudoscan, offered estimates of DPN prevalence, and investigated the relationship between metabolic and clinical parameters. Additionally, we evaluated the diagnostic accuracy of the Sudoscan compared with monofilament and tuning fork tests for detecting DPN., Research Design and Methods: Cross-sectional descriptive study including patients with type 2 diabetes for <5 years since diagnosis. We investigated the presence of DPN using a 128 Hz tuning fork test, the 10 g monofilament, and the sudomotor dysfunction in feet using Sudoscan. We compared patients with and without alterations in the Sudoscan. A logistic regression model analyzed variables independently associated with sudomotor dysfunction., Results: From 2013 to 2020, 2243 patients were included, 55.1% women, age 51.8 years, and 17.1% with normal weight. Monofilament tests and/or tuning fork examination were abnormal in 29% (95% CI 0.23% to 0.27%) and 619 patients (27.6%, 0.25% to 0.29%) had sudomotor alterations. In logistic regression analysis, age (β=1.01, 0.005-1.02), diastolic blood pressure (β=0.98, 0.96-0.99), heart rate (β=1.01, 1.00-1.02), glucose (β=1.00, 1.00-1.03), albuminuria (β=1.001, 1.000-1.001), beta-blockers=1.98, 1.21-3.24) and fibrate use=0.61, 0.43-0.87) were associated with sudomotor dysfunction. The AUC (area under the curve) for Sudoscan was 0.495 (0.469-0.522), with sensitivity and specificity of 24% and 71%, respectively., Conclusion: The Sudoscan identified an important proportion of patients with dysfunction, allowing prompt intervention to decrease the risk for complications., Trial Registration Number: NCT02836808., Competing Interests: Competing interests: CAA-S is part of the Editorial Board of BMJ Open Diabetes Research and Care., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background and Aims: Type 2 diabetes mellitus is one of the major public health concerns. The current lifestyle and advances in technology resulted in the development of a virtual mode of professional healthcare, which is an effective alternative method of management of patients. This study aimed to assess the feasibility of implementation of a virtual comprehensive care programme during the COVID-19 pandemic, patients' acceptance and the changes in self-care behaviours, metabolic parameters and emotional factors., Methods: The programme employed in this study included nine health interventions in 1 day. Due to the COVID-19 pandemic, the mode of interventions, including questionnaires, patient evaluations and a satisfaction survey, was modified to the virtual form in 2020. This study assessed the changes in self-care behaviours, metabolic parameters and emotional factors and compared the data pertaining to patients who received virtual healthcare in 2020 with those who received face-to-face modality of medical care in 2019., Results: During June to November 2020, 130 patients received healthcare by means of the virtual modality. The change in modality of healthcare was feasible and 75% of the patients displayed good acceptance of the same. The evaluation of self-care behaviours included self-monitoring blood glucose (SMBG) levels, foot care and regular exercise. The duration of exercise decreased from 120 to 0 min/week ( p  < 0.001). However, there was no change in metabolic parameters. Regarding the mental health parameters, we observed an increase in the proportion of patients with anxiety (21.5% versus 11.1%), depressive symptoms (10.8% versus 4.3%), diabetes distress (18.5% versus 11.1%) and prescription of psychotropic drugs (32.8% versus 18.2%) ( p  < 0.05) in virtual versus face-to-face, respectively., Conclusion: The virtual comprehensive care programme for the management of patients with diabetes is a feasible approach that allows healthcare professionals to provide an adequate care during the COVID-19 pandemic., Competing Interests: Conflict of interest statement: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (© The Author(s), 2021.)

Introduction: To assess the cost-effectiveness of a multidisciplinary and comprehensive innovative diabetes care program (CAIPaDi) versus usual treatment in public health institutions., Research Design and Methods: Using a cost-effectiveness analysis, we compared the CAIPaDi program versus usual treatment given in Mexican public health institutions. The analysis was based on the IQVIA Core Diabetes Model, a validated simulation model used to estimate long-term clinical outcomes. Data were prospectively obtained from the CAIPaDi program and from public databases and published papers. Health outcomes were expressed in terms of life-years gained and quality-adjusted life years (QALYs). Health and economic outcomes were estimated from a public perspective and discounted at 5% per year over a 20-year horizon. Costs are reported in US dollars (US$) of 2019. A probabilistic sensitivity analysis was performed using life-years gained and QALYs., Results: The CAIPaDi costs on average US$559 (95% CI: -$879 to -$239) less than the usual treatment (95% CI: -$879 to -$239) and produced a difference in mean life-years gained (0.48, 95% CI: 0.45 to 0.52) and mean QALYs (1.43, 95% CI: 1.40 to 1.46). The cost-effectiveness ratio resulted in a saving per life-year gained of -US$1155 (95% CI: -$1962 to -$460). Mean differences in QALYs resulted in a saving per QALY of -US$735 (95% CI: -$1193 to -$305). Probabilistic sensitivity analysis proved the results are robust on both life-years gained and QALYs., Conclusions: CAIPaDi has a better cost-effectiveness ratio than the usual therapy in Mexican public health institutions., Competing Interests: Competing interests: CAA-S is an editorial board member for the BMJ Open Diabetes Research & Care Journal. There are no other potential conflicts of interest relevant to this article., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Lipid control is essential in type 2 diabetes mellitus (T2DM). The aim of this study is to investigate factors associated with lipid therapy adherence and achievement of goals in real-life setting among patients with recently diagnosed T2DM., Research Design and Methods: This is a longitudinal analysis in a center of comprehensive care for patients with diabetes. We include patients with T2DM, <5 years of diagnosis, without disabling complications (eg, amputation, myocardial infarct, stroke, proliferative retinopathy, glomerular filtration rate <60 mL/min/m 2 ) and completed 2-year follow-up. The comprehensive diabetes care model includes 9 interventions in 4 initial visits and annual evaluations. Endocrinologists follow the clinic's guideline and adapt therapy to reach risk-based treatment goal. The main outcome measures were the proportion of patients meeting low-density lipoprotein cholesterol (c-LDL) (<100 mg/dL) and triglycerides (<150 mg/dL) and proportion of patients taking statin, fibrate or combination at baseline, 3 months and annual evaluations., Results: We included 288 consecutive patients (54±9 years, 53.8% women), time since T2DM diagnosis 1 (0-5) year. Baseline, 10.8% patients were receiving statin therapy (46.5% moderate-intensity therapy and 4.6% high-intensity therapy), 8.3% fibrates and 4.2% combined treatment. The proportion of patients with combined treatment increased to 41.6% at 3 months, decreased to 20.8% at 1 year and increased to 38.9% at 2 years of evaluation. Patients receiving treatment met LDL and triglycerides goals at 3 months (17% vs 59.7%, relative ratio (RR)=0.89, 95% CI 0.71 to 1.12), at 1 year (17% vs 26.7%, RR=0.62, 95% CI 0.41 to 0.95) and at 2 years (17% vs 29.9%, RR=0.63, 95% CI 0.43 to 0.93). Main reasons for medication suspension: patient considered treatment was not important (37.5%) and other physician suspended treatment (31.3%)., Conclusion: 88.2% of patients with T2DM required lipid-lowering drugs. Education for patients and physicians is critical to achieve and maintain diabetes goals., Trial Registration Number: NCT02836808., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Previous reports in European populations demonstrated the existence of five data-driven adult-onset diabetes subgroups. Here, we use self-normalizing neural networks (SNNN) to improve reproducibility of these data-driven diabetes subgroups in Mexican cohorts to extend its application to more diverse settings., Research Design and Methods: We trained SNNN and compared it with k-means clustering to classify diabetes subgroups in a multiethnic and representative population-based National Health and Nutrition Examination Survey (NHANES) datasets with all available measures (training sample: NHANES-III, n=1132; validation sample: NHANES 1999-2006, n=626). SNNN models were then applied to four Mexican cohorts (SIGMA-UIEM, n=1521; Metabolic Syndrome cohort, n=6144; ENSANUT 2016, n=614 and CAIPaDi, n=1608) to characterize diabetes subgroups in Mexicans according to treatment response, risk for chronic complications and risk factors for the incidence of each subgroup., Results: SNNN yielded four reproducible clinical profiles (obesity related, insulin deficient, insulin resistant, age related) in NHANES and Mexican cohorts even without C-peptide measurements. We observed in a population-based survey a high prevalence of the insulin-deficient form (41.25%, 95% CI 41.02% to 41.48%), followed by obesity-related (33.60%, 95% CI 33.40% to 33.79%), age-related (14.72%, 95% CI 14.63% to 14.82%) and severe insulin-resistant groups. A significant association was found between the SLC16A11 diabetes risk variant and the obesity-related subgroup (OR 1.42, 95% CI 1.10 to 1.83, p=0.008). Among incident cases, we observed a greater incidence of mild obesity-related diabetes (n=149, 45.0%). In a diabetes outpatient clinic cohort, we observed increased 1-year risk (HR 1.59, 95% CI 1.01 to 2.51) and 2-year risk (HR 1.94, 95% CI 1.13 to 3.31) for incident retinopathy in the insulin-deficient group and decreased 2-year diabetic retinopathy risk for the obesity-related subgroup (HR 0.49, 95% CI 0.27 to 0.89)., Conclusions: Diabetes subgroup phenotypes are reproducible using SNNN; our algorithm is available as web-based tool. Application of these models allowed for better characterization of diabetes subgroups and risk factors in Mexicans that could have clinical applications., Competing Interests: Competing interests: JPB-L, AV-V and NEA-V are enrolled at the PECEM program of the Faculty of Medicine at UNAM. JPB-L and AV-V are supported by CONACyT., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background : Mobile health (mHealth) has been hailed as a potential gamechanger for non-communicable disease (NCD) management, especially in low- and middle-income countries (LMIC). Individual studies illustrate barriers to implementation and scale-up, but an overview of implementation issues for NCD mHealth interventions in LMIC is lacking. This paper explores implementation issues from two perspectives: information in published papers and field-based knowledge by people working in this field. Methods : Through a scoping review publications on mHealth interventions for NCDs in LMIC were identified and assessed with the WHO mHealth Evidence Reporting and Assessment (mERA) tool. A two-stage web-based survey on implementation barriers was performed within a NCD research network and through two online platforms on mHealth targeting researchers and implementors. Results : 16 studies were included in the scoping review. Short Message Service (SMS) messaging was the main implementation tool. Most studies focused on patient-centered outcomes. Most studies did not report on process measures and on contextual conditions influencing implementation decisions. Few publications reported on implementation barriers. The websurvey included twelve projects and the responses revealed additional information, especially on practical barriers related to the patients' characteristics, low demand, technical requirements, integration with health services and with the wider context. Many interventions used low-cost software and devices with limited capacity that not allowed linkage with routine data or patient records, which incurred fragmented delivery and increased workload. Conclusion : Text messaging is a dominant mHealth tool for patient-directed of quality improvement interventions in LMIC. Publications report little on implementation barriers, while a questionnaire among implementors reveals significant barriers and strategies to address them. This information is relevant for decisions on scale-up of mHealth in the domain of NCD. Further knowledge should be gathered on implementation issues, and the conditions that allow universal coverage., Competing Interests: No competing interests were disclosed., (Copyright: © 2020 van Olmen J et al.)

Background : Mobile health (mHealth) has been hailed as a potential gamechanger for non-communicable disease (NCD) management, especially in low- and middle-income countries (LMICs). Individual studies illustrate barriers to implementation and scale-up, but an overview of implementation issues for NCD mHealth interventions in LMICs is lacking. This paper explores implementation issues from two perspectives: information in published papers and field-based knowledge by people working in this field. Methods : Through a scoping review publications on mHealth interventions for NCDs in LMICs were identified and assessed with the WHO mHealth Evidence Reporting and Assessment (mERA) tool. A two-stage web-based survey on implementation barriers was performed within a NCD research network and through two online platforms on mHealth targeting researchers and implementors. Results : 18 studies were included in the scoping review. Short Message Service (SMS) messaging was the main implementation tool. Most studies focused on patient-centered outcomes. Most studies do not report on process measures and on contextual conditions influencing implementation decisions. Few publications reported on implementation barriers. The websurvey included twelve projects and the responses revealed additional information, especially on practical barriers related to the patients' characteristics, low demand, technical requirements, integration with health services and with the wider context. Many interventions used low-cost software and devices with limited capacity that not allowing linkage with routine data or patient records, which incurred fragmented delivery and increased workload. Conclusion : Text messaging is a dominant mHealth tool for patient-directed of quality improvement interventions in LMICs. Publications report little on implementation barriers, while a questionnaire among implementors reveals significant barriers and strategies to address them. This information is relevant for decisions on scale-up of mHealth in the domain of NCD. Further knowledge should be gathered on implementation issues, and the conditions that allow universal coverage., Competing Interests: No competing interests were disclosed., (Copyright: © 2020 van Olmen J et al.)

Context: Patients with a body mass index (BMI) ≥35 kg/m2 have lower benefits with intensive treatments and metabolic control goals are more difficult to reach., Objective: Evaluate the effect of a comprehensive care program in patients with a BMI ≥35 kg/m2., Design: Prospective cohort study., Setting: Comprehensive Care Center in a National Institute of Health., Patients: Patients with type 2 diabetes, ≤5 years of diagnosis, without disabling complications, nonsmokers, and a BMI <45 kg/m2., Interventions: Exercise and nutritional interventions are modified for patients with a higher BMI to achieve metabolic control., Main Outcome Measures: Main outcome is achievement of treatment goals defined as HbA1c <7%, low-density lipoprotein cholesterol (LDL-c) <100 mg/dL, and blood pressure <130/80 mm Hg. Secondary measures were the percentage of patients achieving three metabolic goals., Results: A total of 587 patients with annual evaluation were included. Mean age was 55.3 ± 9.5 years, 56.6% women, time since diagnosis of 1 year (0 to 5). BMI <35 kg/m2 group included 521 patients and BMI ≥35 kg/m2 group included 66 patients. In the BMI ≥35 kg/m2 group, we observed a greater decrease in weight and fat mass at 3 months compared with <35 kg/m2 group, but the HbA1c, LDL-c, or blood pressure goals were similar at 3 months and 1 year between groups., Conclusions: Comprehensive interventions are equally effective in patients with recently diagnosed type 2 diabetes with BMI ≥35 kg/m2 compared with patients with a lower BMI., (Copyright © 2019 Endocrine Society.)