RESEARCH ROUNDUP

Here are a few of the highlights from the past 18 months of research into diabetes globally.

THE IMPORTANCE OF TIME IN RANGE

A 2019 Canadian study points out that increased use of CGMs has given people with diabetes and their carers a new range of ways to measure diabetes control. One of these ways is time in range (TIR).

TIR graphs on your CGM capture the proportion of time your glucose levels are within a target range. (The target range is usually 3.9 to 10.0 mmol/L).

For people with diabetes who use CGMs, TIR is now a common discussion point at appointments with healthcare professionals. Evidence is emerging that TIR can predict risks of complications and that lower TIR is tied to greater risk.

Standardised TIR targets are being developed. The study suggests that, for most people with type 1 or type 2 diabetes, a TIR greater than 70% is a recommended target. However, the study also makes the point that it’s still important to consider what blood glucose levels are when they are out of range. In particular, it discusses the importance of including the amount and severity of time below range (TBR) in any discussions.

The study recommends a target of less than 4% of time below 3.9 mmol/L , and less than 1% of time below <3.0 mmol/L. However, there should be “less stringent targets for older or high-risk individuals and for those under 25 years of age … glycaemic targets should be individualised.”

https://doi.org/10.1007/s00125-019-05027-0

RELAPSE AFTER BARIATRIC SURGERY – NO FAILURE

A 2020 study published by the American Diabetes Association followed 736 people with type 2 diabetes who underwent Roux-en-Y gastric bypass or sleeve gastrectomy. Of 736 patients, 425 (58%) experienced diabetes remission in the first year after surgery. These 425 patients were then followed for several more years to document any late relapses of diabetes.

It was found that 136 (32%) patients did experience late relapse of type 2, but, despite this, they maintained significant improvements in their blood sugar control and other indicators, such as their lipid profiles.

The study concluded that, while late relapse of type 2 diabetes after bariatric surgery is a real phenomenon, it should not be thought of as a failure, as the trajectory of the disease is still generally changed for the better.

https://care.diabetesjournals.org/ content/43/3/534.abstract

THE PSYCHOLOGY OF TECHNOLOGY

A study released by Diabetes UK in January this year reviews existing research into users’ feelings about, and behaviours with, three types of technology: insulin pumps, CGMs, and – newest of all – the automated insulin delivery systems that blend those technologies to “close the loop”.

Points made by the study include:

• Users of pumps and CGMs often report lower levels of diabetes distress or depression. This also holds true for automated insulin delivery systems, but as they are so new that evidence is still limited.

• In one study of CGM users, most users reported increased feelings of safety, control, and confidence in their diabetes management, but not all. Some found CGM output intrusive, and others reported frustration because of technical failures and difficulty trusting the device.

• Some users, rather than finding the increased information provided by CGMs empowering, find it overwhelming.

• Some users of CGMs, particularly teenagers, may find the shareability of CGM data is associated with unwanted interference and attention to their diabetes. The study notes: “This reduction to being nothing more than a glycaemic control number and a signal of brokenness or disability, rather than the recognition of the person's self, can have detrimental impacts on selfidentity, personality and selfconfidence. These psychosocial hurdles are far from understood and may again exclude significant segments of people with diabetes from living the lives they want rather than the lives they are boxed into.”

• For some people, disliking wearing a device on their body is a barrier to use of any technologies. There are a number of reasons: it may feel restrictive, it may be associated with negative body image or there may be a sense of being stigmatised by making diabetes visible in this way.

• Research into the hopes and fears associated with the new technology of automated insulin delivery shows that potential users have similar feelings to those that were expressed in the early days of pumps and CGMs. Potential users hope the technology will lead to reduced burden, greater flexibility, and greater spontaneity, as well as improved glycaemic control, but they worry about over-reliance on the device, the ability to trust and control the device, and how visible their condition will be.

• There is a need for more healthcare professionals to understand all these technologies in order to be able to help people with diabetes build the skills to use them.

The review concludes that, over the past 25 years, there have been amazing advances in diabetes management technology available, and psychosocial research into users’ experiences with this technology urgently needs to keep up.

https://doi.org/10.1111/dme.14234

MANAGING TYPE 1 WHILE BREASTFEEDING

A Danish study released this year has reviewed research relating to management of type 1 diabetes during breastfeeding.

It points out that breastfeeding is a potentially stressful and demanding period in life for those with type 1 diabetes, with many things to think about, including “a decline in insulin requirements immediately after delivery, maintenance of an adequate diet with sufficient carbohydrate intake”, as well as frequent monitoring of blood sugar while looking after a new baby.

The researchers found that the issues surrounding managing diabetes while breastfeeding are significantly under-researched: “In particular, there is a gap in our knowledge regarding glycemic patterns in the first 2-week period after delivery where hypoglycemia may be most prevalent.”

The researchers recommend that, in the future, studies be carried out to further understand appropriate insulin-dose adjustment during breastfeeding and, for those using insulin pump therapy, expected insulin pump settings during breastfeeding. It specifies, “The use of newer insulin pumps with an automated system that suspends basal insulin administration when low glucose is predicted needs to be explored in future studies … There is also a need for further studies on the required amount of daily carbohydrate intake to meet the energy demand and request for weight loss while avoiding hypoglycemia and ketoacidosis during breastfeeding.”

https://link.springer.com/article/10.1007/ s11892-020-01315-x

HAS COVID-19 IMPACTED TYPE 1 DIAGNOSES?

Recently, a study by the DPV initiative, a German-Austrian diabetes research organisation, sought to find out whether Covid-19 had impacted diagnoses of type 1 diabetes in young people.

Psychological stress is believed to increase the risk of type 1 diabetes. For example, there were reports of more type 1 diagnoses after catastrophes such as the 1986 Chernobyl incident and the Los Angeles earthquake in 1994.

The DPV researchers theorised that the stress of the social changes brought about by Covid-19 could have increased the risk of type 1 diabetes. They also wanted to know if contracting Covid-19 could trigger type 1, the same way some other viruses are believed to.

On the other hand, the researchers wondered if Covid-19 lockdowns and social distancing might have reduced new diagnoses – by reducing the incidence of the common viral infections that are associated with triggering type 1 diabetes.

The researchers looked at the recorded numbers of new type 1 diabetes patients in Germany who were between six months and 18 years, and found that the numbers were similar to what had been expected during this period without the added impact of Covid-19.

They concluded: “It remains unclear whether elevated stress levels and reduced infection rates outweigh each other regarding effects on the onset of type 1 diabetes in children and adolescents or whether they have no measurable impact on incidence. However, there may be a delay between immunologic factors or infections and the onset of type 1 diabetes. It is therefore crucial to conduct longterm follow-up studies.”

https://care.diabetesjournals.org/content/ diacare/early/2020/08/21/dc20-1633.full.pdf

BASAL INSULIN FOR TYPE 2: PATIENT-LED VS PHYSICIAN-LED

European researchers reviewed six studies to compare the effectiveness and safety of patientled versus physician-led titration of basal insulin in patients with uncontrolled type 2 diabetes.

They found that patient-led titration was associated with a statistically significant higher basal insulin dose, leading to benefits on HbA1c, despite a higher risk of hypoglycemia and a slight increase in body weight.

They concluded that patient-led titration of basal insulin “was not inferior to physician-led titration in patients with uncontrolled type 2 diabetes. Therefore, diabetes self-management education and support programs on basal insulin should be widely adopted in clinical practice and patients provided with tools to self-adjust their dose when necessary.”

http://dx.doi.org/10.1136/bmjdrc-2020-001477