Feature Papers in Diabetology 2023

The principal purpose of this study is to determine the prevalence of peripheral arterial disease (PAD), as well as the principal associated risk factors, in patients registered in the IDON-PAD database. PAD is a condition characterized by the narrowing or blockage of arteries in the body’s extremities due to plaque buildup, leading to reduced blood flow and tissue ischemia. While PAD primarily affects the lower extremities, it can lead to symptoms such as intermittent claudication and, in severe cases, ulcers and amputations. Risk factors for PAD are numerous and cumulative, including smoking, age over 50, type 2 diabetes mellitus, and hypertension. The prevalence of PAD increases with age, with rates ranging from 2.5% in those over 50 to 60% in those over 85, varying by ethnicity and study population. Diabetic patients face a higher risk of PAD-related complications and have lower success rates with revascularization procedures. The diagnosis of PAD traditionally relied on physical examination and symptoms, but the Ankle–Brachial Index is now a standard diagnostic tool due to its non-invasive nature and reliability. In Mexico, the prevalence of PAD is estimated at 10%, with significant risk factors being the duration of diabetes, hypertension, hypertriglyceridemia, and smoking. Notably, 70% of PAD cases are asymptomatic, emphasizing the importance of proactive screening. This study aimed to determine the prevalence of PAD and associated risk factors in diabetic patients aged 40 and above. The prevalence was found to be 11.2%, with high-risk waist circumference, elevated triglycerides, positive Edinburgh questionnaire, and weak pulses as significant predictors. The detection and management of PAD in diabetic patients require a comprehensive approach, including lifestyle modifications and regular screenings. Prevention strategies should focus on controlling risk factors, including obesity, hypertension, and dyslipidemia. In conclusion, PAD is a prevalent yet underdiagnosed condition in diabetic patients, necessitating proactive screening and comprehensive management to mitigate associated risks and improve patient outcomes. The principal limitation of this study is that, as it uses a cross-sectional methodology and is not an experimental study, although we can establish the prevalence of PAD as well as the associated risk factors, we cannot define causality or determine the hazard ratio for each of these factors. Special thanks to Dr. Leobardo Sauque Reyna and all participants for their contribution to this research. Full article

Diabetic foot is a common complication of diabetes that affects quality and prognosis of life for patients and often requires hospitalization. Infection, alone or in association with ischemia, is the main cause of hospital admission and impacts prognosis. The aim of this study is to analyze the costs of diabetic foot lesions and assess factors that influence the economic impact, focusing on infection. We included all people with diabetes with a first visit for diabetic foot during 2018 in our diabetic foot center. Database interrogation identified 422 patients. Diabetic foot treatment required hospitalization for 242 patients (58%), while 180 (42%) were treated in outpatient services. Healing time was different between the two groups: it was 136 ± 124 days (mean ± SD) for outpatients and 194 ± 190 days for patients that require hospitalization (p < 0.001). Costs: Treatment of 422 patients for diabetic foot globally costs 2063 million EUR and the mean cost for patients is 4888 EUR, with hospital stay having a high impact on this, accounting for 88% of the costs. Infection impacts hospitalization duration and ischemia impacts healing time. Ischemia and infection prolonged hospitalization duration and costs. Our work underlines that hospital treatment costs have a high impact on total costs. Full article

(1) Background: It has been previously shown that sourdough bread, compared to commercial yeast bread, elicits a lower postprandial glycemic and insulinemic response in patients with impaired glucose tolerance (IGT). Aims: Our aim was to evaluate the following aspects in persons with type 2 diabetes (T2DM): (1) glucose variations induced by three different doughs: X = bread prepared with functional alkaline biocrystal water, Y = sourdough-leavened bread, and W = bakery yeast bread; (2) the utility of flash glucose monitoring (FGM) to measure GL. (2) Methods: Twelve T2DM following diets (six males, diabetes duration 10.9 ± 1.3 years with no complications, Hba1c < 7.0%), after 12 h of fasting, consumed 180 g of the study breads leavened/matured for 48 (X), 8 (Y), and 4 h (W) at room temperature with 200 mL of water, in a random order, in single-blind conditions, on three different days. All patients had FGM running for the entire period of the experiments. Insulin was determined by capillary blood obtained for the basal and peak glucose concentrations. (3) Results: The peak glucose and peak insulin concentrations were significantly (p < 0.05) higher for W versus both X and Y, without significant differences between X and Y. The area under the curve of glucose variations for over 240 min was significantly higher in W than X (p < 0.01) and Y (p < 0.05), without significant differences between X and Y. (4) Conclusions: (1) Bread prepared with biocrystal water has the same lower GL of sourdough bread compared to bakery yeast bread, and it is easier to manage its leavening/maturation period; (2) FGM is a reliable method for determining rapid glucose changes in response to a carbohydrate meal in persons with type 2 diabetes. Full article

Background: The number of people with type 2 diabetes is increasing daily, and therefore, effective therapy is needed to successfully regulate glycemia and reduce the risk of associated complications. Recently, an oral formulation of the glucagon-like peptide-1 receptor agonist (GLP-1 RA) semaglutide has become available. Therefore, the aim of our study was to compare the effectiveness of the new oral formulation and the existing injectable formulation of semaglutide in terms of glycemic and body weight control in a real-world setting. Patients and methods: This was a single-center retrospective observational study conducted at the Rijeka Clinical Hospital Centre. A total of 106 patients with inadequately controlled type 2 diabetes (HbA1c ≥ 7%) on different oral or basal insulin supported oral therapy were enrolled in the study, and data from electronic medical records were retrospectively collected and analyzed from May 2021 to November 2022. All subjects were GLP-1 RA-naive and consequently prescribed 0.5 or 1.0 mg of once weekly injectable semaglutide (IS) or 7 mg or 14 mg of once daily oral semaglutide (OS) for at least 6 months. Glycated hemoglobin (HbA1c), body weight, and body mass index (BMI) were assessed prior to semaglutide administration and after a 6-month follow-up period. The primary endpoint was the change from baseline in HbA1c, and secondary endpoints were the change in body weight and the proportion of participants with a reduction in body weight of ≥5% and ≥10%, respectively, 6 months after the initiation of semaglutide treatment. Results: At the 6-month follow-up, no significant difference was observed between the two formulations in terms of HbA1c reduction (IS −1.1% vs. OS −1.4%, p = 0.126) and weight loss (IS −6.50 kg vs. OS −5.90 kg, p = 0.714). Exactly the same proportion of participants in both groups achieved a weight loss of ≥5% (56.7%, n = 30). A weight loss ≥ 10% was observed in 20.7% (n = 11) of participants administered IS and 15.1% (n = 8) of participants administered OS, respectively (p = 0.454). Conclusion: In a real-world setting, oral semaglutide as an add-on therapy to ongoing antihyperglycemic treatment in patients with inadequately controlled type 2 diabetes who had not previously received GLP-1 RA demonstrated a similar effectiveness as injectable semaglutide in terms of glycemic control and weight loss after 6 months of treatment. Full article

Background: Diabetes is the primary contributor to cardiovascular disease risk, and when combined with obesity, it further underscores the significance of cardiovascular risk assessment. Methods: A retrospective study of 64 patients with type 2 diabetes (T2D) and obesity on once-weekly subcutaneous semaglutide stratified by cardiovascular risk categories determined using the SCORE2/SCORE2-OP, SCORE2-Diabetes, and ASCVD score calculations. We compare the differences between groups (ASCVD: low + borderline + intermediate versus high-risk group; SCORE2/SCORE2-OP: low + moderate versus high + very high-risk group and SCORE2-Diabetes: low + moderate versus high + very high-risk group) in terms of change from baseline in body mass index (BMI) and HbA1c and weight loss outcomes. Results: Patients in the high-risk group, according to ASCVD risk score, had statistically better results in weight loss ≥ 3%, ≥5%, and ≥10% compared to ASCVD low + borderline + intermediate and without difference regarding HbA1c. According to SCORE2/SCORE2-OP, the high + very high-risk group had statistically better HbA1c and weight loss results but only for ≥5% versus the low + moderate risk group. Based on the score SCORE2-Diabetes, the high + very high-risk group had statistically significant better results in lowering HbA1c and weight loss but only for ≥5% versus the low + moderate risk group. Conclusions: To the best of our knowledge, this study represents the initial investigation linking glycemic control and weight reduction outcomes in individuals with T2D and obesity treated with once-weekly semaglutide stratified by cardiovascular risk categories determined using the SCORE2/SCORE2-OP, SCORE2-Diabetes and ASCVD score calculations. Full article

Hospitalizations for diabetes and dementia can impose a significant health and economic toll on older adults in the United States. This study sought to examine differences in hospitalization characteristics and outcomes associated with diabetes and dementia, separately and together, using 2019–2021 discharge record data from the California Department of Health Care Access and Information. The sampled group were residents of Los Angeles County who were aged 50+ at the time of the study. The multivariable linear regression analysis showed that compared to those with no diabetes or dementia, patients with diabetes alone exhibited the highest total charges, while those with comorbid diabetes and dementia exhibited lower charges (p < 0.05). The multinomial logistic regression found that patients with comorbid diabetes and dementia had the highest odds of having a length of stay of 7+ days (Adjusted Odds Ratio = 1.49; 95% Confidence Interval (CI) = 1.44–1.53). A matched case–control analysis revealed that comorbid diabetes and dementia were associated with significantly lower odds of hypertensive disease than diabetes alone (Matched Odds Ratio = 0.81; 95% CI = 0.67–0.97). Collectively, these results highlight the complex factors that may influence the variable hospitalization outcomes that are common occurrences in these three distinct disease profiles. Study findings suggest a need to consider these complexities when developing policies or strategies to improve hospitalization outcomes for these conditions. Full article

This study was conducted to determine the barriers to the utilization of diabetic retinopathy (DR) screening in Papua New Guinea (PNG). A list of patients booked for DR screening at Madang Provincial Hospital Eye Clinic (MPHEC) between January 2017 and December 2021 who had not been screened was retrieved, and the patients were invited to participate in the study. The data were collected using a structured questionnaire, and IBM Statistical Package for Social Sciences version 26 was used for the analysis. p < 0.05 was considered statistically significant. One hundred and twenty-nine patients (37.4%) did not attend DR screening for the period under study. The study response rate was 80.6%. The mean ± SD age of the respondents was 51.5 ± 10.9 years. The majority of the study respondents were female (62.5%), people living in rural settings (53.8%), and farmers (22.1%). Time constraints, poor knowledge about DR, and long waiting periods at the DR screening center were the main barriers to the uptake of DR screening. Compared to respondents in urban communities, those in rural settings were significantly concerned about cost (p < 0.001), travel distance to the MPHEC (p < 0.001), and poor information about DR screening (p = 0.002). More than half of the respondents (63.5%) had discontinued using pharmacotherapy for DM. There is a high rate of nonadherence to diabetes (DM) and DR treatment in PNG. There is a need for public health campaigns about DM and strategic DR screening at the community level in PNG and similar countries. Full article

Type 2 diabetes mellitus (T2DM) is a multisystemic disease with a high global burden and chronic complications. Sexual dysfunction (SD) in patients with T2DM is an often-overlooked complication, despite its high impact on quality of life (QoL). Female sexual disorders can affect women of reproductive age as well as menopausal women. Proposed mechanisms are intertwining a variety of physiological, neurological, vascular, hormonal, and psychological variables. The impairment of sexual function has been linked to hyperglycemia, insulin resistance, chronic low-grade inflammation, endothelial dysfunction, neuropathy, and hormonal abnormalities. There are many different manifestations of female sexual dysfunction, such as insufficient sexual desire, diminished arousal, difficulty in eliciting orgasm, and pain during sexual engagement. Numerous studies have shown that the QoL of patients living with diabetes mellitus (DM) is lower than that of those without DM. SD in women with T2DM leads to deteriorated QoL. Treatment must be individualized based on the diagnosis and the sexual dysfunction as well as underlying medical, psychological, and interpersonal issues. The goal of modern medical care for patients living with diabetes is not to delay death but to improve their health and QoL. The present review article aimed to raise awareness about female sexual dysfunction in patients with T2DM and to provide an overview of its impact on QoL. Full article

Diabetes is the leading cause of chronic kidney disease (CKD), with nearly half of all cases of kidney failure requiring kidney replacement therapy. While attention is often focused on the profound effects kidney failure has on the quality of life, the principal cause of complications and death among patients with diabetes and CKD is cardiovascular disease (CVD). These risks are often underappreciated by both healthcare professionals and patients. Sodium–glucose cotransporter 2 (SGLT-2) inhibitors were originally developed and approved as glucose-lowering agents for treating type 2 diabetes (T2D). However, agents within the SGLT-2 inhibitor class have since demonstrated robust benefits for CKD, atherosclerotic cardiovascular disease (ASCVD), and heart failure (HF) outcomes. Specifically, dedicated kidney disease and HF outcome trials have shown markedly reduced rates of kidney failure, CVD and HF events, and death among people (with and without diabetes) with CKD. SGLT-2 inhibitors will be used by primary care clinicians, nephrologists, and cardiologists across a range of cardiovascular and kidney conditions and diabetes. Knowledge and awareness of the benefits and key safety considerations, and risk mitigation strategies for these medications is imperative for clinicians to optimize the use of these life-saving therapies. Full article

Similar microorganisms, via similar mechanisms, play a role in the development of both pancreatic cancer (PC) and type 2 diabetes (T2D). Since the new onset of T2D is potentially one of the earliest signs of PC, it is highly plausible that a common denominator might be responsible for both, as the growth of the cancer will take a longer time to manifest compared to the insulin resistance. Although a variety of host-dependent factors and susceptibility play a role, and the mechanisms connecting the two diseases remain poorly understood, future well-designed trials should hypothesize whether a microbial intervention (modification and/or transplantation) results in a lower incidence and the better treatment of both diseases since the T2D–PC–gut microbiome interconnection seems scientifically logical. Full article

Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been linked to beneficial effects on cardiovascular risk factors, blood pressure, body weight, and lipid profile, according to a substantial body of literature. Significant cardiac and renal benefits with the use of SGLT2 inhibitors have been shown in patients with type 2 diabetes, as well as in those with heart failure and/or chronic kidney disease (CKD), regardless of diabetes status, in subsequent large cardiovascular outcome trials. Thus, SGLT2 inhibitors have become a mainstay of therapy for type 2 diabetes in patients with established cardiovascular disease and CKD due to their benefits for the heart and kidneys. Based on data from randomized controlled trials and meta-analyses, this article attempts to present a thorough review of the mechanism of action, as well as the benefits of SGLT2 inhibitors for cardiac and renal protection. On the basis of a growing body of literature on diabetes and other conditions, clinical practice guidelines have been updated to suggest the use of SGLT2 inhibitors in specific patient populations. These modifications will also be concisely described, based on evidence-based medicine principles. Full article