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BACKGROUND: Patients on extracorporeal life support (ECLS), either for respiratory or cardiac support, are at high risk of malnutrition; guidelines on nutrition in critical care have not incorporated solid evidence regarding these settings. The aim of this narrative review is to gather the available evidence in the existing literature and transpose general principles to the ECLS population.METHODS: A literature review of observational and interventional studies on nutrition during ECLS, and evaluation of nutrition guidelines in this perspective.RESULTS: Nutrition is paramount for improving outcomes in ECLS, as well as in critically ill patients. The caloric needs during ECLS can vary according to the severity of the clinical state, sedation, paralysis, and temperature stability. Precise evaluation of energy expenditure by indirect calorimetry is difficult because ECLS is a system dedicated to removing carbon dioxide; however, modified equations composed of carbon dioxide values taken from the membrane lung are available. Guidelines suggest starting early enteral nutrition (EN) with a hypocaloric (70%-80% of the needs) strategy, also in acute states such as septic or cardiogenic shock. Moreover, EN, despite previous concerns, is feasible in prone position, an increasingly adopted strategy during mechanical ventilation. The catabolic state is maximal in these patients, causing a protein and muscular reduction. Therefore, adequate protein delivery should be guaranteed by administering a high protein intake of up to 2 g/kg/day.CONCLUSIONS: Studies on nutrition tailored to ECLS patients are warranted. Early hypocaloric EN with high protein intake, tailored on indirect calorimetry, may be the most appropriate option.

Subcutaneous insulin resistance syndrome caused by obesity, induration at the injection site, skin temperature and other factors is common clinically, whereas resistance events caused by edema are relatively rare. This article introduced a case of a woman with type 2 diabetes mellitus with heart failure edema. Her blood glucose control was significantly associated with the level of edema. Excluding other factors, it can be concluded that edema might lead to subcutaneous insulin resistance syndrome, even if the edema at the injection site is not obvious., This article introduced a case of a woman with type 2 diabetes mellitus with heart failure edema. Her blood glucose control was significantly associated with the level of edema. Excluding other factors, it can be concluded that edema might lead to insulin subcutaneous malabsorption, even if the edema at the injection site is not obvious.

Aims/Introduction To prevent diabetic complications, strict glucose control and frequent monitoring of blood glucose levels with invasive methods are necessary. We considered the monitoring of tear glucose levels might be a possible method for non‐invasive glucose monitoring. To develop tear glucose monitoring for clinical application, we investigated the precise correlation between the blood and tear glucose concentrations. Materials and Methods A total of 10 participants and 20 participants with diabetes were admitted, and blood and tear samples were collected. Before statistical analysis, we eliminated tear samples contaminated with blood. We observed the daily blood and tear glucose dynamics, and carried out a random intercept model analysis to examine the association between the blood and tear glucose concentrations. Results Tear occult blood tests showed that the tear glucose concentrations and their variation increased in both participants with and without diabetes as contamination of blood increased. In both participants with and without diabetes, fluctuations of the plasma glucose concentrations were observed depending on the timing of collection of the samples, and the dynamics of the tear glucose concentrations paralleled those of the plasma glucose concentrations. The random intercept model analysis showed a significant association between the plasma and tear glucose concentrations in participants with diabetes (P, It is important to eliminate the tear samples contaminated with blood. Tear glucose monitoring might be a reliable and non‐invasive substitute method for monitoring the blood glucose concentrations for diabetes patients, irrespective of glycated hemoglobin levels and the timing of sample collection.

Optimal blood glucose control warrants both early intensive therapy and individualization strategies in patients with diabetes mellitus.

Background We undertook this study to evaluate the association between hyperglycemia and outcomes in patients with coronavirus disease 2019 (COVID‐19) admitted to the intensive care unit (ICU). Methods We conducted a multicenter retrospective study involving all adults with COVID‐19 admitted to the ICU between March and May 2020. Patients were divided into normoglycemic (average blood glucose, Highlights Hyperglycemia has been reported in almost half of the patients infected with coronavirus disease 2019.In critically ill patients, hyperglycemia is associated with increased morbidity and mortality, irrespective of preexisting diabetes.In our study, patients with blood glucose ≥140 mg/dL and admitted to the intensive care unit were found to have the worst outcomes in terms of mortality, mechanical ventilation need, and intensive care unit length of stay.Further studies are needed to clarify if outcomes significantly improve with tighter glucose targets.

With an increasing prevalence of diabetes worldwide, effective dietary strategies for blood glucose control are crucial. As carbohydrates make up approximately 50% of the diet, it is neither practical nor advisable to avoid them altogether. Most of the carbohydrate in the diet is derived from starch, found in potatoes, pasta, rice and bread. These foods are often processed in some way before consumption, yet little is known about the effects processing, such as chilling and reheating, has on the glycaemic response, particularly when the food is consumed in the context of a mixed meal. This article introduces the SPUD project, a BBSRC DRINC‐funded initiative. Taking the potato as the model carbohydrate, this project will investigate, via in vitro and in vivo studies, the effects of domestic food processing techniques on the glycaemic response. A final study, utilising intrinsically labelled potato and a dual stable isotope methodology, will model glucose flux data to determine the underlying mechanisms of action.

AIM To examine the associations between continuous overlapping net glycaemic action (CONGA), percentage time in hyperglycaemia (%HG) or normoglycaemia (%NG) and peripheral nerve structure and function in type 1 diabetes. METHODS Twenty-seven participants with type 1 diabetes underwent continuous glucose monitoring followed by corneal confocal microscopy and nerve excitability assessments. CONGA, %HG (> 10.0 mmol/l) and %NG (3.9-10.0 mmol/l) were correlated against corneal nerve fibre length and density in the central cornea and inferior whorl region, corneal microneuromas, and a nerve excitability score while controlling for age, sex, diabetes duration and HbA1c . RESULTS An increase in CONGA [median 2.5 (2.0-3.1) mmol/l] or %HG (mean 46 ± 18%) was associated with a worse nerve excitability score (r = -0.433, P = 0.036 and r = -0.670, P = 0.0012, respectively). By contrast, greater %NG (51 ± 17%) correlated with better nerve excitability scores (r = 0.672, P = 0.0011). Logistic regression revealed that increasing %HG increased the likelihood of abnormal nerve function [odds ratio (OR) 1.11, 95% confidence interval (CI) 1.01-1.23; P = 0.037). An increase in CONGA and %HG were associated with worsening nerve conduction measures, whereas longer %NG correlated with improved nerve conduction variables. CONGA and %HG were associated with inferior whorl corneal nerve fibre length (r = 0.483, P = 0.034 and r = 0.591, P = 0.021, respectively) and number of microneuromas (r = 0.433, P = 0.047 and r = 0.516, P = 0.020, respectively). CONCLUSIONS Short-term measures of glucose control are associated with impaired nerve function and alterations in corneal nerve morphology.

Aims To compare closed-loop (CL) and open-loop (OL) systems for glycaemic control in patients with type 1 diabetes (T1D) exposed to real-life challenging situations (gastronomic dinners or sustained physical exercise). Methods Thirty-eight adult patients with T1D were included in a three-armed randomized pilot trial (Diabeloop WP6.2 trial) comparing glucose control using a CL system with use of an OL device during two crossover 72-hour periods in one of the three following situations: large (gastronomic) dinners; sustained and repeated bouts of physical exercise (with uncontrolled food intake); or control (rest conditions). Outcomes included time in spent in the glucose ranges of 4.4-7.8 mmol/L and 3.9-10.0 mmol/L, and time in hypo- and hyperglycaemia. Results Time spent overnight in the tight range of 4.4 to 7.8 mmol/L was longer with CL (mean values: 63.2% vs 40.9% with OL; P ≤ .0001). Time spent during the day in the range of 3.9 to 10.0 mmol/L was also longer with CL (79.4% vs 64.1% with OL; P ≤ .0001). Participants using the CL system spent less time during the day with hyperglycaemic excursions (glucose >10.0 mmol/L) compared to those using an OL system (17.9% vs 31.9%; P ≤ .0001), and the proportions of time spent during the day with hyperglycaemic excursions of those using the CL system in the gastronomic dinner and physical exercise subgroups were of similar magnitude to those in the control subgroup (18.1 ± 6.3%, 17.2 ± 8.1% and 18.4 ± 12.5%, respectively). Finally, times spent in hypoglycaemia were short and not significantly different among the groups. Conclusions The Diabeloop CL system is superior to OL devices in reducing hyperglycaemic excursions in patients with T1D exposed to gastronomic dinners, or exposed to physical exercise followed by uncontrolled food and carbohydrate intake.

AIM Transition from paediatric to adult care is a critical step in life of emerging adults with type 1 diabetes. We assessed, according to indicators established by panel of experts, clinical, socio-demographic and psychosocial factors in young adults with type 1 diabetes throughout structured transition to investigate the associations, if any, with HbA1c value at time of transition. METHODS The "Verona Diabetes Transition Project" started in January 2009: a structured transition program, shared between paediatric and adult clinic, was organised with a multi-disciplinary team. All young adults underwent a semi-structured interview by a psychologist, before transition. Minimum age for transition was 18 years. RESULTS 222 (M/F = 113/109) young adults moved to adult care from January 2009 to March 2020. The mean time between the last paediatric visit and the first adult visit ranged from 13.6 ± 6.1 months at the beginning of the project to 3.6 ± 11.5 months over the following years. At first adult clinic attendance, women showed higher HbA1c values (70 ± 11 mmol/mol vs. 65 ± 7 mmol/mol or 8.57% ± 1.51% vs. 8.14% ± 0.98%, p = 0.01), higher frequency of disorders of eating behaviours (15.6% vs. 0%, p

Eating chocolate in the morning or in the evening/at night, may differentially affect energy balance and impact body weight due to changes in energy intake, substrate oxidation, microbiota (composition/function), and circadian-related variables. In a randomized controlled trial, postmenopausal females (n = 19) had 100 g of chocolate in the morning (MC), in the evening/at night (EC), or no chocolate (N) for 2 weeks and ate any other food ad libitum. Our results show that 14 days of chocolate intake did not increase body weight. Chocolate consumption decreased hunger and desire for sweets (P < .005), and reduced ad libitum energy intake by ~300 kcal/day during MC and ~150 kcal/day during EC (P = .01), but did not fully compensate for the extra energy contribution of chocolate (542 kcal/day). EC increased physical activity by +6.9%, heat dissipation after meals +1.3%, and carbohydrate oxidation by +35.3% (P < .05). MC reduced fasting glucose (4.4%) and waist circumference (−1.7%) and increased lipid oxidation (+25.6%). Principal component analyses showed that both timings of chocolate intake resulted in differential microbiota profiles and function (P < .05). Heat map of wrist temperature and sleep records showed that EC induced more regular timing of sleep episodes with lower variability of sleep onset among days than MC (60 min vs 78 min; P = .028). In conclusion, having chocolate in the morning or in the evening/night results in differential effects on hunger and appetite, substrate oxidation, fasting glucose, microbiota (composition and function), and sleep and temperature rhythms. Results highlight that the “when” we eat is a relevant factor to consider in energy balance and metabolism., Ministerio de Ciencia e Innovación (MICINN). Grant Numbers: SAF2017-84135-R, RTI2018-097982-B-I00; HHS | NIH | National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Grant Number: R01DK105072; Fundación Séneca. Grant Number: 20795/PI/18

As wearable healthcare monitoring systems advance, there is immense potential for biological sensing to enhance the management of type 1 diabetes (T1D). The aim of this work is to describe the ongoing development of biomarker analytes in the context of T1D. Technological advances in transdermal biosensing offer remarkable opportunities to move from research laboratories to clinical point‐of‐care applications. In this review, a range of analytes, including glucose, insulin, glucagon, cortisol, lactate, epinephrine, and alcohol, as well as ketones such as beta‐hydroxybutyrate, will be evaluated to determine the current status and research direction of those analytes specifically relevant to T1D management, using both in‐vitro and on‐body detection. Understanding state‐of‐the‐art developments in biosensing technologies will aid in bridging the gap from bench‐to‐clinic T1D analyte measurement advancement.

Type 1 diabetes mellitus (T1DM) remains one of the most challenging long‐term conditions to manage. Despite robust evidence to demonstrate that near normoglycaemia minimizes, but does not completely eliminate, the risk of complications, its achievement has proved almost impossible in a real‐world setting. HbA1c to date has been used as the gold standard marker of glucose control and has been shown to reflect directly the risk of diabetes complications. However, it has been recognized that HbA1c is a crude marker of glucose control. Continuous glucose monitoring (CGM) provides the ability to measure and observe inter‐ and intraday glycaemic variability (GV), a more meaningful measure of glycaemic control, more relevant to daily living for those with T1DM. This paper reviews the relationship between GV and hypoglycaemia, and micro‐ and macrovascular complications. It also explores the impact on GV of CGM, insulin pumps, closed‐loop technologies, and newer insulins and adjunctive therapies. Looking to the future, there is an argument that GV should become a key determinant of therapeutic success. Further studies are required to investigate the pathological and psychological benefits of reducing GV.

BACKGROUND Parenteral nutrition (PN) is a complicated therapy in which having specially trained clinicians can provide benefit, but it can be difficult to provide this level of expertise to all patients requiring PN. Creation of a virtual nutrition support team (NST) model allows patients across multiple hospitals to receive care from NST clinicians using remote conferencing technology on a daily basis. This study reviewed retrospective data from before and after implementation of the virtual model to assess quality indicators. METHODS The NST was developed including a team of dietitians and pharmacists with a physician medical director. Practice guidelines were developed to provide consistent methods for ordering and monitoring patients receiving PN. Patient charts in both the preintervention and postintervention groups were reviewed for indication for PN, duration of therapy, blood glucose levels, and demographic data. RESULTS A greater proportion of patients in the postintervention period had appropriate orders (97.2%) compared with patients in the preintervention period (58.9%) (P

Type 1 diabetes (T1D) is a specific form of diabetes wherein the immune system destroys insulin‐producing β cells until complete inability to secrete insulin. Patients with T1D require ins...

AIM: The use of sodium glucose co-transporter 2 (SGLT2) inhibitors in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) has been limited, primarily because glycemic efficacy is dependent on kidney function. We performed a systematic review and meta-analysis to assess the efficacy and safety of SGLT2 inhibitors in patients with T2DM and CKD, defined as estimated glomerular filtration rate (eGFR) MATERIALS AND METHODS: We searched MEDLINE, EMBASE and the Cochrane Library to August 7, 2018, as well as the websites of the United States, European, and Japanese regulatory authorities to July 27, 2018 for data from randomized controlled trials of SGLT2 inhibitors that included reporting of effects on biomarkers, cardiovascular, renal, or safety outcomes in individuals with T2DM and CKD. Random effects models and inverse variance weighting were used to calculate relative risks with 95% confidence intervals.RESULTS: Data were obtained from 27 studies with up to 7,363 participants contributing. In patients with T2DM and CKD, SGLT2 inhibitors lowered glycated hemoglobin (-0.29%, 95% CI -0.39 to -0.19), as well as blood pressure, body weight, and albuminuria. SGLT2 inhibition reduced the risk of cardiovascular death, nonfatal myocardial infarction or nonfatal stroke (RR 0.81, 95% CI 0.70-0.94) and heart failure (RR 0.61, 95% CI 0.48-0.78), without a clear effect on all-cause mortality (HR 0.86, 95% CI 0.73-1.01). These agents also attenuated the annual decline in eGFR slope (placebo-subtracted difference of 1.35 mL/1.73m2 /year, 95% CI 0.78-1.93) and reduced the risk of the composite renal outcome (HR 0.71, 95% CI 0.53-0.95). There was no evidence of additional risks with SGLT2 inhibition in CKD beyond those already known for the class, although heterogeneity was observed across individual agents for some safety outcomes.CONCLUSION: Currently available data suggest that despite only modest reductions in glycated hemoglobin, SGLT2 inhibitors reduce the risk of cardiovascular and renal outcomes in patients with T2DM and CKD, without clear evidence of additional safety concerns. This article is protected by copyright. All rights reserved.

OBJECTIVE There is limited information on factors influencing cognitive decline in rural settings from low- and middle-income countries. Using the Atahualpa Project cohort, we aimed to assess the burden of cognitive decline in older adults living in a rural Ecuadorian village. METHODS The study included Atahualpa residents aged greater than or equal to 60 years who had a follow-up Montreal Cognitive Assessment (MoCA) repeated at least 1 year after baseline. MoCA decline was assessed by multivariable longitudinal linear models, adjusted for demographics, days between MoCA tests, cardiovascular risk factors, and neuroimaging signatures of structural brain damage. RESULTS We included 252 individuals who contributed 923.7 person-years of follow-up (mean: 3.7 ± 0.7 years). The mean baseline MoCA was 19.5 ± 4.5 points, and the follow-up MoCA was 18.1 ± 4.9 points (P = 0.001). Overall, 154 individuals (61%) had lower MoCA scores at follow-up. The best fitted longitudinal linear model showed a decline of follow-up MoCA from baseline (β: 0.14; 95% CI, 0.0-0.21; P

Understanding how automated insulin delivery (AID) algorithm features impact glucose control under full closed loop delivery represents a critical step toward reducing patient burden by eliminating the need for carbohydrate entries at mealtimes. Here, we use a pig model of diabetes to compare AndroidAPS and Loop open‐source AID systems without meal announcements. Overall time‐in‐range (70–180 mg/dl) for AndroidAPS was 58% ± 5%, while time‐in‐range for Loop was 35% ± 5%. The effect of the algorithms on time‐in‐range differed between meals and overnight. During the overnight monitoring period, pigs had an average time‐in‐range of 90% ± 7% when on AndroidAPS compared to 22% ± 8% on Loop. Time‐in‐hypoglycemia also differed significantly during the lunch meal, whereby pigs running AndroidAPS spent an average of 1.4% (+0.4/−0.8)% in hypoglycemia compared to 10% (+3/−6)% for those using Loop. As algorithm design for closed loop systems continues to develop, the strategies employed in the OpenAPS algorithm (known as oref1) as implemented in AndroidAPS for unannounced meals may result in a better overall control for full closed loop systems., SHORT ABSTRACT: Understanding how algorithm features impact glucose control after unannounced meals is a critical step toward full closed loop insulin delivery and reduced patient burden. For unannounced meals in a full closed loop system, and with faster insulin pharmacokinetics inherent to pigs, time‐in‐range was greater with open‐source algorithm AndroidAPS than Loop in pigs with diabetes.

AIMS Continuous glucose monitoring system (CGMS) technologies may alert unaware hypoglycaemia or near hypoglycaemia events. However, costs are a significant concern in general CGMS use. This study describes the real-world effects of both clinical outcomes and associated costs in a major Health Maintenance Organization, 1 year following preauthorization of CGMS for each patient. METHODS Cohort study. Type 1 diabetes patients who were preauthorized CGMS were identified, and their medical records during the year before preauthorization were compared to the following year. Data were collected for glucose control, medical services utilization and related costs. RESULTS We identified 524 eligible patients, 57% males. Adherence to CGMS use was improved by age. The proportion of patients reaching HbA1c

Since the start of the COVID‐19 pandemic, the vulnerability of people with diabetes has been recognised with a greater risk of morbidity and mortality compared to the general population. The outcomes associated with diabetes may be a consequence of an impaired immune response, presence of composite comorbidities or the multi‐organ infectivity of SARS‐CoV‐2 affecting the pancreas. Emerging evidence suggests that both acute and chronic hyperglycaemia can exacerbate the clinical consequences of COVID‐19. Thus, the role of health care professionals in the observation and management of glucose control is increasingly recognised in people with diabetes in both the acute and chronic setting. In this review, we highlight the key biological implications of SARS‐CoV‐2 infection in people with diabetes, the clinical outcomes of COVID‐19 in people with diabetes and management principles with respect to glucose control including our local experiences. Copyright © 2021 John Wiley & Sons.

Objective To examine the combined association between metformin use and physical activity on HbA1c in adults with type 2 diabetes. Research Design and Methods Adults with type 2 diabetes from NHANES continuous survey (1999‐2018, n = 6447) were classified as active and inactive based on self‐reported engagement in moderate‐to‐vigorous or vigorous physical activity (MVPA or VigPA) and metformin use over the last month. Results There was a significant negative main effect of metformin usage on HbA1c levels, independent of whether individuals engaged in modest levels of MVPA or VigPA. Moreover, there was a higher prevalence of metformin users with a HbA1c .05). Conclusions There appears to be independent benefits of metformin and regular physical activity on glucose control, but the impact of these two treatments are not necessarily additive. Based on this analyses, the benefit of physical activity on HbA1c levels in type 2 diabetes is likely more apparent in those not taking metformin, as compared to those who are., There appears to be independent benefits of metformin and regular physical activity on glucose control, but the impact of these two treatments are not necessarily additive. Based on these analyses, the benefit of physical activity on HbA1c levels in type 2 diabetes is likely more apparent in those not taking metformin, as compared to those who are.

Fully automated closed‐loop insulin delivery may offer a novel way to manage diabetes in hospital. However, postprandial glycaemic control remains challenging. We aimed to assess the effect of nutritional intake on postprandial glucose control in hospitalized patients with type 2 diabetes receiving fully closed‐loop insulin therapy. The effects of different meal types and macronutrient composition on sensor glucose time‐in‐target (TIT, 3.9‐10.0 mmol/L) and mean sensor glucose were assessed with hierarchical linear models using a Bayesian estimation approach. TIT was lower and the mean sensor glucose slightly higher, after breakfast compared with lunch and dinner, whereas the insulin dose was higher. Across meals, when carbohydrates were replaced by fat, or to a lesser extent by protein, postprandial glucose control improved. For breakfast, a 3.9% improvement in TIT was observed when 10% of the energy from carbohydrates was replaced by fat. Improvements were slightly lower during lunch and dinner (3.2% and 3.4%) or when carbohydrates were replaced by protein (2.2 and 2.7%, respectively). We suggest that reducing carbohydrate at the expense of fat or protein, could further improve glucose control during fully closed‐loop insulin therapy in hospital., Diabetes, Obesity and Metabolism, 23 (1), ISSN:1462-8902, ISSN:1463-1326

AIMS To build a tool to assess the management of inpatients with diabetes mellitus and to investigate its relationship, if any, with clinical outcomes. MATERIALS AND METHODS A total of 678 patients from different settings, Internal Medicine (IMU, n = 255), General Surgery (GSU, n = 230) and Intensive Care (ICU, n = 193) Units, were enrolled. A work-flow of clinical care of diabetes was created according to guidelines. The workflow was divided into five different domains: (a) initial assessment; (b) glucose monitoring; (c) medical therapy; (d) consultancies; (e) discharge. Each domain was assessed by a performance score (PS), computed as the sum of the scores achieved in a set of indicators of clinical appropriateness, management and patient empowerment. Appropriate glucose goals were included as intermediate phenotypes. Clinical outcomes included: hypoglycaemia, survival rate and clinical conditions at discharge. RESULTS The total PS and those of initial assessment and glucose monitoring were significantly lower in GSU with respect to IMU and ICU (P

This study proposes Grasshopper Optimization Algorithm (GOA) based type 1 diabetes mellitus system utilizing the nonlinear Bergman minimal model with proportional integral derivative (PID) controller. GOA is the optimization algorithm, which is utilized for selecting the optimized tuning parameters of the PID controller also solves the nonlinear system parameter identification problem. The novelty of the proposed study is to stabilize the glucose level in blood for type 1 diabetic patients by infusion of insulin in reduced time with optimal quantity. Without any intervention to the normal activities of patients, the supply of insulin injection and glucose monitoring is performed automatically for type 1 diabetic patients using this controller. In between the measured variable and set point, the difference is calculated by the PID controller to evaluate an error values. In realistic patient oriented conditions, the control performance evaluation, control optimization, and advanced patient modelling should be highly concentrated during the research/analysis on blood glucose control. Evaluation is performed to analyze control performances and implementation is done on Simulink/MATLAB environment. The performance analysis of the type 1 diabetes mellitus system with GOA technique is also discussed and to improve the control performance, to optimize the controller parameters. The simulation results have proved the substantial improvement in the performance of proposed algorithm with the better results achieved than the other conventional controllers such as PSO-PID and EHO-PID.

Introduction We modeled associations between glycated hemoglobin (HbA1c) levels (8%) and cognitive and physical function among adults 80+ years of age with diabetes and determined whether associations differ by frailty, multimorbidity, and disability. Methods A total of 316, adults with diabetes, 80+ years of age, were from the Adult Changes in Thought Study. The Cognitive Abilities Screening Instrument Item Response Theory (CASI‐IRT) measured cognition. Short performance‐based physical function (sPPF) and gait speed measured physical function. Glycosylated hemoglobin (HbA1c) levels were from clinical measurements. Analyses estimated associations between average HbA1c levels (8%) and functional outcomes using linear regressions estimated with generalized estimating equations. Results sPPF scores did not differ significantly by HbA1c levels. Gait speed did, but only for non‐frail individuals; those with HbA1c >8% were slower (‐0.10 m/s [95% CI, −0.16 to −0.04]) compared to those with HbA1c 7% to 8%. The association between HbA1c and CASI‐IRT varied with age (interaction P = 0.04). At age 80, for example, relative to people with HbA1c levels of 7% to 8%, CASI‐IRT scores were, on average, 0.18 points lower (95% CI, −0.35 to −0.02) for people with HbA1c 8%. At older ages, these estimated differences were attenuated. Estimated associations were not modified by multimorbidity or disability. Discussion Moderate HbA1c levels of 7% to 8% were associated with better cognition in early but not late octogenarians with diabetes. Furthermore, HbA1c >8% was associated with slower gait speed among those without frailty. These results add to an evidence base for determining glucose targets for very old adults with diabetes.

Background: Exercise training improves cardiometabolic outcomes in ‘mean terms’, but little information is available in children about the impact of the frequency/week and the wide inter-individual variability to exercise training reported in adults. Objectives: We compared the effects of resistance training (RT) and high-intensity interval training (HIT), and ‘high’ and ‘low’ frequency of training/week, for their effectiveness in decreasing insulin resistance (IR) levels in schoolchildren. A second aim was to decscribe and compare the prevalence of non-responders (NRs) between the different frequencies of training protocol. Methods: Fifty-three schoolchildren with IR were randomly assigned into four groups: RT at high frequency (three times/week), HIT at high frequency, RT at a low frequency (two times/week) and HIT at low frequency. The intervention lasted 6 weeks. Blood samples and body composition, blood pressure and performance measurements were taken before and after the intervention. Results: The prevalence of NRs was similar between the RTHF and HITHF (25.0% vs. 25.0%, P > 0.05) and RTLF and HITLF groups (20.0% vs. 46.6%, P = 0.174) for decreasing homeostasis model assessment of IR. However, significant differences in the prevalence of NRs were detected between RTHF and HITHF groups in fasting glucose (FGL) (18.7% vs. 58.3%, P less than 0.031). Conclusions: Both RT and HIT improves the glucose control parameters in schoolchildren over 6 weeks, but only HIT is independent of a high or low frequency of training/week. The prevalence of NRs is similar for decreasing homeostasis model assessment of IR comparing each exercise mode in high vs. low frequency/week. However, both high- and low-frequency RT and HIT results in differences in the prevalence of NRs for FGL and other cardiometabolic and performance outcomes. © 2018 World Obesity Federation

Background Control of blood glucose levels is needed not only to alleviate symptoms of hypoglycaemia and hyperglycaemia, but also to prevent or delay diabetes-related complications. Advice for glucose control is usually provided to patients by members of the health care team. However, many diabetes apps claim to enhance self-management of blood glucose by providing decision support to patients when an out-of-range blood glucose level is recorded. In this study, we investigated the appropriateness of action prompts provided by diabetes apps for hypoglycaemia and hyperglycaemia against evidence-based guidelines. Methods We used methods previously reported to identify and select diabetes apps, which were downloaded and assessed against the American Diabetes Association (ADA) guidelines. Screenshots of action prompts corresponding to low or high out-of-range blood glucose values were subjected to content analysis. Results Of 371 diabetes self-management apps evaluated, only 217 and 216 apps alerted patients about hypoglycaemia and hyperglycaemia, respectively. Of these, 20.7% (45/217) and 15.3% (33/216) also provided action prompts. We found 5.1% of apps (hypoglycaemia: 11/217; hyperglycaemia: 11/216) provided prompts that were either too general to be helpful or not aligned with ADA guidelines. Overall, only 17.9% (39/217) and 14.8% (32/216) provided appropriate action prompts for hypoglycaemia and hyperglycaemia, respectively. Conclusion Less than one fifth of apps provided evidence-based steps to guide patients through hypoglycaemia and hyperglycaemia. The majority of apps failed to provide just-in-time diabetes self-management education to prevent frequent or severe episodes of hypoglycaemia and hyperglycaemia. Our findings emphasize the need for better design and quality assurance of diabetes apps.

Glucocorticoids (steroids) are widely used across many medical specialities for their anti-inflammatory and immunosuppressive properties. However, one of their major side effects is the development of hyperglycaemia. It is well recognized that high glucose levels in people with diabetes in hospital are associated with harm and increased lengths of hospital stay. The use of glucocorticoid (steroid) treatment in people with pre-existing diabetes will undoubtedly result in worsening glucose control, and this may be termed 'steroid-induced hyperglycaemia', and will warrant temporary additional, and more active, glycaemic management. A rise in glucose may occur in people without a known diagnosis of diabetes, and this may be termed 'steroid-induced diabetes'. There is a lack of evidence to guide how people with hyperglycaemia should be managed, and much of the guidance given here is a consensus based on best practice collated from around the United Kingdom. Where evidence is available, this is referenced. These guidelines on the management of people with diabetes treated with steroids has been adapted specifically for Diabetic Medicine. The full version of the guidelines can be found on line at: www.diabetes.org.uk/joint-british-diabetes-society or https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group.

Since 2005, more than 40 new medicines for the treatment of type 2 diabetes have been introduced on the market. These consist of 15 new active substances establishing three new classes of non-insulin products, and several new or modified insulin products and combinations. The approval of these products in Europe is regulated via the centralized procedure at the European Medicines Agency. Demonstration of benefit with regard to improved glucose control remains the principal outcome required from confirmatory studies to demonstrate efficacy. For the majority of these new medicines approved since 2005, cardiovascular outcome trials have now been completed, and have invariably supported the cardiovascular safety of these products. In some of these trials additional important benefits have been observed, for instance, a reduction in major adverse cardiovascular events and improvement of renal outcome. The existing regulatory framework and the continuous adaption of regulatory requirements to emerging developments will continue to guide the approval of new products in the future.

The prevalence of diabetes is increasing markedly worldwide, especially in China. Hemoglobin A1c is an indicator of mean blood glucose concentrations and plays an important role in the assessment of glucose control and cardiovascular risk. In 2010, the American Diabetes Association included HbA1c ≥6.5% into the revised criteria for the diagnosis of diabetes. However, the debate as to whether HbA1c should be used to diagnose diabetes is far from being settled and there are still unanswered questions regarding the cut-off value of HbA1c for diabetes diagnosis in different populations and ethnicities. This review briefly introduces the history of HbA1c from discovery to diabetes diagnosis, key steps towards using HbA1c to diagnose diabetes, such as standardization of HbA1c measurements and controversies regarding HbA1c cut-off points, and the performance of HbA1c compared with glucose measurements in the diagnosis of diabetes.