Category Archives: Diabetes

Group of metabolic disorders

Medical condition

Diabetes mellitus (DM), commonly known as just diabetes, is a group of metabolic disorders characterized by a high blood sugar level over a prolonged period of time.[11] Symptoms often include frequent urination, increased thirst and increased appetite.[2] If left untreated, diabetes can cause many health complications.[2] Acute complications can include diabetic ketoacidosis, hyperosmolar hyperglycemic state, or death.[3] Serious long-term complications include cardiovascular disease, stroke, chronic kidney disease, foot ulcers, damage to the nerves, damage to the eyes and cognitive impairment.[2][5]

Diabetes is due to either the pancreas not producing enough insulin, or the cells of the body not responding properly to the insulin produced.[12] There are three main types of diabetes mellitus:[2]

Type 1 diabetes must be managed with insulin injections.[2] Prevention and treatment of type 2 diabetes involves maintaining a healthy diet, regular physical exercise, a normal body weight, and avoiding use of tobacco.[2] Type 2 diabetes may be treated with medications such as insulin sensitizers with or without insulin.[15] Control of blood pressure and maintaining proper foot and eye care are important for people with the disease.[2] Insulin and some oral medications can cause low blood sugar.[16] Weight loss surgery in those with obesity is sometimes an effective measure in those with type 2 diabetes.[17] Gestational diabetes usually resolves after the birth of the baby.[18]

As of 2019[update], an estimated 463million people had diabetes worldwide (8.8% of the adult population), with type 2 diabetes making up about 90% of the cases.[10] Rates are similar in women and men.[19] Trends suggest that rates will continue to rise.[10] Diabetes at least doubles a person's risk of early death.[2] In 2019, diabetes resulted in approximately 4.2million deaths.[10] It is the 7th leading cause of death globally.[20][21] The global economic cost of diabetes-related health expenditure in 2017 was estimated at US$727 billion.[10] In the United States, diabetes cost nearly US$327billion in 2017.[22] Average medical expenditures among people with diabetes are about 2.3 times higher.[23]

The classic symptoms of untreated diabetes are unintended weight loss, polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger).[24] Symptoms may develop rapidly (weeks or months) in type 1 diabetes, while they usually develop much more slowly and may be subtle or absent in type 2 diabetes.[25]

Several other signs and symptoms can mark the onset of diabetes although they are not specific to the disease. In addition to the known symptoms listed above, they include blurred vision, headache, fatigue, slow healing of cuts, and itchy skin. Prolonged high blood glucose can cause glucose absorption in the lens of the eye, which leads to changes in its shape, resulting in vision changes. Long-term vision loss can also be caused by diabetic retinopathy. A number of skin rashes that can occur in diabetes are collectively known as diabetic dermadromes.[26]

People with diabetes (usually but not exclusively in type 1 diabetes) may also experience diabetic ketoacidosis (DKA), a metabolic disturbance characterized by nausea, vomiting and abdominal pain, the smell of acetone on the breath, deep breathing known as Kussmaul breathing, and in severe cases a decreased level of consciousness. DKA requires emergency treatment in hospital.[27] A rarer but more dangerous condition is hyperosmolar hyperglycemic state (HHS), which is more common in type 2 diabetes and is mainly the result of dehydration caused by high blood sugars.[27]

Treatment-related low blood sugar (hypoglycemia) is common in people with type 1 and also type 2 diabetes depending on the medication being used. Most cases are mild and are not considered medical emergencies. Effects can range from feelings of unease, sweating, trembling, and increased appetite in mild cases to more serious effects such as confusion, changes in behavior such as aggressiveness, seizures, unconsciousness, and rarely permanent brain damage or death in severe cases.[28][29] Rapid breathing, sweating, and cold, pale skin are characteristic of low blood sugar but not definitive.[30] Mild to moderate cases are self-treated by eating or drinking something high in rapidly absorbed carbohydrates. Severe cases can lead to unconsciousness and must be treated with intravenous glucose or injections with glucagon.[31]

All forms of diabetes increase the risk of long-term complications. These typically develop after many years (1020) but may be the first symptom in those who have otherwise not received a diagnosis before that time.[citation needed]

The major long-term complications relate to damage to blood vessels. Diabetes doubles the risk of cardiovascular disease[32] and about 75% of deaths in people with diabetes are due to coronary artery disease.[33] Other macrovascular diseases include stroke, and peripheral artery disease.[citation needed]

The primary complications of diabetes due to damage in small blood vessels include damage to the eyes, kidneys, and nerves.[34] Damage to the eyes, known as diabetic retinopathy, is caused by damage to the blood vessels in the retina of the eye, and can result in gradual vision loss and eventual blindness.[34] Diabetes also increases the risk of having glaucoma, cataracts, and other eye problems. It is recommended that people with diabetes visit an eye doctor once a year.[35] Damage to the kidneys, known as diabetic nephropathy, can lead to tissue scarring, urine protein loss, and eventually chronic kidney disease, sometimes requiring dialysis or kidney transplantation.[34] Damage to the nerves of the body, known as diabetic neuropathy, is the most common complication of diabetes.[34] The symptoms can include numbness, tingling, pain, and altered pain sensation, which can lead to damage to the skin. Diabetes-related foot problems (such as diabetic foot ulcers) may occur, and can be difficult to treat, occasionally requiring amputation. Additionally, proximal diabetic neuropathy causes painful muscle atrophy and weakness.

There is a link between cognitive deficit and diabetes. Compared to those without diabetes, those with the disease have a 1.2 to 1.5-fold greater rate of decline in cognitive function.[36] Having diabetes, especially when on insulin, increases the risk of falls in older people.[37]

Diabetes mellitus is classified into six categories: type 1 diabetes, type 2 diabetes, hybrid forms of diabetes, hyperglycemia first detected during pregnancy, "unclassified diabetes", and "other specific types".[40] The "hybrid forms of diabetes" contains slowly evolving, immune-mediated diabetes of adults and ketosis-prone type 2 diabetes. The "hyperglycemia first detected during pregnancy" contains gestational diabetes mellitus and diabetes mellitus in pregnancy (type 1 or type 2 diabetes first diagnosed during pregnancy). The "other specific types" are a collection of a few dozen individual causes. Diabetes is a more variable disease than once thought and people may have combinations of forms.[41] The term "diabetes", without qualification, refers to diabetes mellitus.[42]

Type1 diabetes is characterized by loss of the insulin-producing beta cells of the pancreatic islets, leading to insulin deficiency. This type can be further classified as immune-mediated or idiopathic. The majority of type1 diabetes is of an immune-mediated nature, in which a T cell-mediated autoimmune attack leads to the loss of beta cells and thus insulin.[43] It causes approximately 10% of diabetes mellitus cases in North America and Europe. Most affected people are otherwise healthy and of a healthy weight when onset occurs. Sensitivity and responsiveness to insulin are usually normal, especially in the early stages. Although it has been called "juvenile diabetes" due to the frequent onset in children, the majority of individuals living with type 1 diabetes are now adults.[6]

"Brittle" diabetes, also known as unstable diabetes or labile diabetes, is a term that was traditionally used to describe the dramatic and recurrent swings in glucose levels, often occurring for no apparent reason in insulin-dependent diabetes. This term, however, has no biologic basis and should not be used.[44] Still, type1 diabetes can be accompanied by irregular and unpredictable high blood sugar levels, and the potential for diabetic ketoacidosis or serious low blood sugar levels. Other complications include an impaired counterregulatory response to low blood sugar, infection, gastroparesis (which leads to erratic absorption of dietary carbohydrates), and endocrinopathies (e.g., Addison's disease).[44] These phenomena are believed to occur no more frequently than in 1% to 2% of persons with type1 diabetes.[45]

Type1 diabetes is partly inherited, with multiple genes, including certain HLA genotypes, known to influence the risk of diabetes. In genetically susceptible people, the onset of diabetes can be triggered by one or more environmental factors,[46] such as a viral infection or diet. Several viruses have been implicated, but to date there is no stringent evidence to support this hypothesis in humans.[46][47] Among dietary factors, data suggest that gliadin (a protein present in gluten) may play a role in the development of type 1 diabetes, but the mechanism is not fully understood.[48][49]

Type 1 diabetes can occur at any age, and a significant proportion is diagnosed during adulthood. Latent autoimmune diabetes of adults (LADA) is the diagnostic term applied when type 1 diabetes develops in adults; it has a slower onset than the same condition in children. Given this difference, some use the unofficial term "type 1.5 diabetes" for this condition. Adults with LADA are frequently initially misdiagnosed as having type 2 diabetes, based on age rather than a cause.[50]

Type 2 diabetes is characterized by insulin resistance, which may be combined with relatively reduced insulin secretion.[12] The defective responsiveness of body tissues to insulin is believed to involve the insulin receptor. However, the specific defects are not known. Diabetes mellitus cases due to a known defect are classified separately. Type 2 diabetes is the most common type of diabetes mellitus.[2] Many people with type 2 diabetes have evidence of prediabetes (impaired fasting glucose and/or impaired glucose tolerance) before meeting the criteria for type 2 diabetes.[51] The progression of prediabetes to overt type 2 diabetes can be slowed or reversed by lifestyle changes or medications that improve insulin sensitivity or reduce the liver's glucose production.[52]

Type 2 diabetes is primarily due to lifestyle factors and genetics.[53] A number of lifestyle factors are known to be important to the development of type 2 diabetes, including obesity (defined by a body mass index of greater than 30), lack of physical activity, poor diet, stress, and urbanization.[38] Excess body fat is associated with 30% of cases in people of Chinese and Japanese descent, 6080% of cases in those of European and African descent, and 100% of Pima Indians and Pacific Islanders.[12] Even those who are not obese may have a high waisthip ratio.[12]

Dietary factors such as sugar-sweetened drinks are associated with an increased risk.[54][55] The type of fats in the diet is also important, with saturated fat and trans fats increasing the risk and polyunsaturated and monounsaturated fat decreasing the risk.[53] Eating white rice excessively may increase the risk of diabetes, especially in Chinese and Japanese people.[56] Lack of physical activity may increase the risk of diabetes in some people.[57]

Adverse childhood experiences (ACEs), including abuse, neglect, and household difficulties, increase the likelihood of type 2 diabetes later in life by 32%, with neglect having the strongest effect.[58]

Gestational diabetes resembles type 2 diabetes in several respects, involving a combination of relatively inadequate insulin secretion and responsiveness. It occurs in about 210% of all pregnancies and may improve or disappear after delivery.[59] It is recommended that all pregnant women get tested starting around 2428 weeks gestation.[60] It is most often diagnosed in the second or third trimester because of the increase in insulin-antagonist hormone levels that occurs at this time.[60] However, after pregnancy approximately 510% of women with gestational diabetes are found to have another form of diabetes, most commonly type 2.[59] Gestational diabetes is fully treatable, but requires careful medical supervision throughout the pregnancy. Management may include dietary changes, blood glucose monitoring, and in some cases, insulin may be required.[61]

Though it may be transient, untreated gestational diabetes can damage the health of the fetus or mother. Risks to the baby include macrosomia (high birth weight), congenital heart and central nervous system abnormalities, and skeletal muscle malformations. Increased levels of insulin in a fetus's blood may inhibit fetal surfactant production and cause infant respiratory distress syndrome. A high blood bilirubin level may result from red blood cell destruction. In severe cases, perinatal death may occur, most commonly as a result of poor placental perfusion due to vascular impairment. Labor induction may be indicated with decreased placental function. A caesarean section may be performed if there is marked fetal distress[62]or an increased risk of injury associated with macrosomia, such as shoulder dystocia.[63]

Maturity onset diabetes of the young (MODY) is a rare autosomal dominant inherited form of diabetes, due to one of several single-gene mutations causing defects in insulin production.[64] It is significantly less common than the three main types, constituting 12% of all cases. The name of this disease refers to early hypotheses as to its nature. Being due to a defective gene, this disease varies in age at presentation and in severity according to the specific gene defect; thus there are at least 13 subtypes of MODY. People with MODY often can control it without using insulin.[65]

Some cases of diabetes are caused by the body's tissue receptors not responding to insulin (even when insulin levels are normal, which is what separates it from type2 diabetes); this form is very uncommon. Genetic mutations (autosomal or mitochondrial) can lead to defects in beta cell function. Abnormal insulin action may also have been genetically determined in some cases. Any disease that causes extensive damage to the pancreas may lead to diabetes (for example, chronic pancreatitis and cystic fibrosis). Diseases associated with excessive secretion of insulin-antagonistic hormones can cause diabetes (which is typically resolved once the hormone excess is removed). Many drugs impair insulin secretion and some toxins damage pancreatic beta cells, whereas others increase insulin resistance (especially glucocorticoids which can provoke "steroid diabetes"). The ICD-10 (1992) diagnostic entity, malnutrition-related diabetes mellitus (MRDM or MMDM, ICD-10 code E12), was deprecated by the World Health Organization (WHO) when the current taxonomy was introduced in 1999.[66]Yet another form of diabetes that people may develop is double diabetes. This is when a type 1 diabetic becomes insulin resistant, the hallmark for type 2 diabetes or has a family history for type 2 diabetes.[67] It was first discovered in 1990 or 1991.

The following is a list of disorders that may increase the risk of diabetes:[68]

Insulin is the principal hormone that regulates the uptake of glucose from the blood into most cells of the body, especially liver, adipose tissue and muscle, except smooth muscle, in which insulin acts via the IGF-1.[citation needed] Therefore, deficiency of insulin or the insensitivity of its receptors play a central role in all forms of diabetes mellitus.[70]

The body obtains glucose from three main sources: the intestinal absorption of food; the breakdown of glycogen (glycogenolysis), the storage form of glucose found in the liver; and gluconeogenesis, the generation of glucose from non-carbohydrate substrates in the body.[71] Insulin plays a critical role in regulating glucose levels in the body. Insulin can inhibit the breakdown of glycogen or the process of gluconeogenesis, it can stimulate the transport of glucose into fat and muscle cells, and it can stimulate the storage of glucose in the form of glycogen.[71]

Insulin is released into the blood by beta cells (-cells), found in the islets of Langerhans in the pancreas, in response to rising levels of blood glucose, typically after eating. Insulin is used by about two-thirds of the body's cells to absorb glucose from the blood for use as fuel, for conversion to other needed molecules, or for storage. Lower glucose levels result in decreased insulin release from the beta cells and in the breakdown of glycogen to glucose. This process is mainly controlled by the hormone glucagon, which acts in the opposite manner to insulin.[72]

If the amount of insulin available is insufficient, or if cells respond poorly to the effects of insulin (insulin resistance), or if the insulin itself is defective, then glucose is not absorbed properly by the body cells that require it, and is not stored appropriately in the liver and muscles. The net effect is persistently high levels of blood glucose, poor protein synthesis, and other metabolic derangements, such as metabolic acidosis in cases of complete insulin deficiency.[71]

When glucose concentration in the blood remains high over time, the kidneys reach a threshold of reabsorption, and the body excretes glucose in the urine (glycosuria).[73] This increases the osmotic pressure of the urine and inhibits reabsorption of water by the kidney, resulting in increased urine production (polyuria) and increased fluid loss. Lost blood volume is replaced osmotically from water in body cells and other body compartments, causing dehydration and increased thirst (polydipsia).[71] In addition, intracellular glucose deficiency stimulates appetite leading to excessive food intake (polyphagia).[74]

Diabetes mellitus is diagnosed with a test for the glucose content in the blood, and is diagnosed by demonstrating any one of the following:[66]

A positive result, in the absence of unequivocal high blood sugar, should be confirmed by a repeat of any of the above methods on a different day. It is preferable to measure a fasting glucose level because of the ease of measurement and the considerable time commitment of formal glucose tolerance testing, which takes two hours to complete and offers no prognostic advantage over the fasting test.[78] According to the current definition, two fasting glucose measurements above 7.0mmol/L (126mg/dL) is considered diagnostic for diabetes mellitus.

Per the WHO, people with fasting glucose levels from 6.1 to 6.9mmol/L (110 to 125mg/dL) are considered to have impaired fasting glucose.[79] People with plasma glucose at or above 7.8mmol/L (140mg/dL), but not over 11.1mmol/L (200mg/dL), two hours after a 75gram oral glucose load are considered to have impaired glucose tolerance. Of these two prediabetic states, the latter in particular is a major risk factor for progression to full-blown diabetes mellitus, as well as cardiovascular disease.[80] The American Diabetes Association (ADA) since 2003 uses a slightly different range for impaired fasting glucose of 5.6 to 6.9mmol/L (100 to 125mg/dL).[81]

Glycated hemoglobin is better than fasting glucose for determining risks of cardiovascular disease and death from any cause.[82]

There is no known preventive measure for type1 diabetes.[2] Type2 diabeteswhich accounts for 8590% of all cases worldwidecan often be prevented or delayed[83] by maintaining a normal body weight, engaging in physical activity, and eating a healthy diet.[2] Higher levels of physical activity (more than 90 minutes per day) reduce the risk of diabetes by 28%.[84] Dietary changes known to be effective in helping to prevent diabetes include maintaining a diet rich in whole grains and fiber, and choosing good fats, such as the polyunsaturated fats found in nuts, vegetable oils, and fish.[85] Limiting sugary beverages and eating less red meat and other sources of saturated fat can also help prevent diabetes.[85] Tobacco smoking is also associated with an increased risk of diabetes and its complications, so smoking cessation can be an important preventive measure as well.[86]

The relationship between type 2 diabetes and the main modifiable risk factors (excess weight, unhealthy diet, physical inactivity and tobacco use) is similar in all regions of the world. There is growing evidence that the underlying determinants of diabetes are a reflection of the major forces driving social, economic and cultural change: globalization, urbanization, population aging, and the general health policy environment.[87]

Diabetes management concentrates on keeping blood sugar levels as close to normal, without causing low blood sugar. This can usually be accomplished with dietary changes, exercise, weight loss, and use of appropriate medications (insulin, oral medications).

Learning about the disease and actively participating in the treatment is important, since complications are far less common and less severe in people who have well-managed blood sugar levels.[88][89] Per the American College of Physicians, the goal of treatment is an HbA1C level of 7-8%.[90] Attention is also paid to other health problems that may accelerate the negative effects of diabetes. These include smoking, high blood pressure, metabolic syndrome obesity, and lack of regular exercise.[91] Specialized footwear is widely used to reduce the risk of ulcers in at-risk diabetic feet although evidence for the efficacy of this remains equivocal.[92]

People with diabetes can benefit from education about the disease and treatment, dietary changes, and exercise, with the goal of keeping both short-term and long-term blood glucose levels within acceptable bounds. In addition, given the associated higher risks of cardiovascular disease, lifestyle modifications are recommended to control blood pressure.[93][94]

Weight loss can prevent progression from prediabetes to diabetes type 2, decrease the risk of cardiovascular disease, or result in a partial remission in people with diabetes.[95][96] No single dietary pattern is best for all people with diabetes.[97] Healthy dietary patterns, such as the Mediterranean diet, low-carbohydrate diet, or DASH diet, are often recommended, although evidence does not support one over the others.[95][96] According to the ADA, "reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia", and for individuals with type 2 diabetes who cannot meet the glycemic targets or where reducing anti-glycemic medications is a priority, low or very-low carbohydrate diets are a viable approach.[96] For overweight people with type 2 diabetes, any diet that achieves weight loss is effective.[97][98]

Most medications used to treat diabetes act by lowering blood sugar levels through different mechanisms. There is broad consensus that when people with diabetes maintain tight glucose control keeping the glucose levels in their blood within normal ranges they experience fewer complications, such as kidney problems or eye problems.[99][100] There is however debate as to whether this is appropriate and cost effective for people later in life in whom the risk of hypoglycemia may be more significant.[101]

There are a number of different classes of anti-diabetic medications. Type1 diabetes requires treatment with insulin, ideally using a "basal bolus" regimen that most closely matches normal insulin release: long-acting insulin for the basal rate and short-acting insulin with meals.[102] Type 2 diabetes is generally taken with medication that is taken by mouth (e.g. metformin) although some eventually require injectable treatment with insulin or GLP-1 agonists.[103]

Metformin is generally recommended as a first-line treatment for type2 diabetes, as there is good evidence that it decreases mortality.[8] It works by decreasing the liver's production of glucose.[104] Several other groups of drugs, mostly given by mouth, may also decrease blood sugar in type 2 diabetes. These include agents that increase insulin release (sulfonylureas), agents that decrease absorption of sugar from the intestines (acarbose), agents that inhibit the enzyme dipeptidyl peptidase-4 (DPP-4) that inactivates incretins such as GLP-1 and GIP (sitagliptin), agents that make the body more sensitive to insulin (thiazolidinedione) and agents that increase the excretion of glucose in the urine (SGLT2 inhibitors).[104] When insulin is used in type2 diabetes, a long-acting formulation is usually added initially, while continuing oral medications.[8] Doses of insulin are then increased until glucose targets are reached.[8][105]

Cardiovascular disease is a serious complication associated with diabetes, and many international guidelines recommend blood pressure treatment targets that are lower than 140/90mmHg for people with diabetes.[106] However, there is only limited evidence regarding what the lower targets should be. A 2016 systematic review found potential harm to treating to targets lower than 140 mmHg,[107] and a subsequent systematic review in 2019 found no evidence of additional benefit from blood pressure lowering to between 130 - 140mmHg, although there was an increased risk of adverse events.[108]

2015 American Diabetes Association recommendations are that people with diabetes and albuminuria should receive an inhibitor of the renin-angiotensin system to reduce the risks of progression to end-stage renal disease, cardiovascular events, and death.[109] There is some evidence that angiotensin converting enzyme inhibitors (ACEIs) are superior to other inhibitors of the renin-angiotensin system such as angiotensin receptor blockers (ARBs),[110] or aliskiren in preventing cardiovascular disease.[111] Although a more recent review found similar effects of ACEIs and ARBs on major cardiovascular and renal outcomes.[112] There is no evidence that combining ACEIs and ARBs provides additional benefits.[112]

The use of aspirin to prevent cardiovascular disease in diabetes is controversial.[109] Aspirin is recommended by some in people at high risk of cardiovascular disease, however routine use of aspirin has not been found to improve outcomes in uncomplicated diabetes.[113] 2015 American Diabetes Association recommendations for aspirin use (based on expert consensus or clinical experience) are that low-dose aspirin use is reasonable in adults with diabetes who are at intermediate risk of cardiovascular disease (10-year cardiovascular disease risk, 510%).[109] National guidelines for England and Wales by the National Institute for Health and Care Excellence (NICE) recommend against the use of aspirin in people with type 1 or type 2 diabetes who do not have confirmed cardiovascular disease.[102][103]

Weight loss surgery in those with obesity and type 2 diabetes is often an effective measure.[17] Many are able to maintain normal blood sugar levels with little or no medications following surgery[114] and long-term mortality is decreased.[115] There is, however, a short-term mortality risk of less than 1% from the surgery.[116] The body mass index cutoffs for when surgery is appropriate are not yet clear.[115] It is recommended that this option be considered in those who are unable to get both their weight and blood sugar under control.[117]

A pancreas transplant is occasionally considered for people with type1 diabetes who have severe complications of their disease, including end stage kidney disease requiring kidney transplantation.[118]

In countries using a general practitioner system, such as the United Kingdom, care may take place mainly outside hospitals, with hospital-based specialist care used only in case of complications, difficult blood sugar control, or research projects. In other circumstances, general practitioners and specialists share care in a team approach. Home telehealth support can be an effective management technique.[119]

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In 2017, 425million people had diabetes worldwide,[120] up from an estimated 382million people in 2013[121] and from 108million in 1980.[122] Accounting for the shifting age structure of the global population, the prevalence of diabetes is 8.8% among adults, nearly double the rate of 4.7% in 1980.[120][122] Type2 makes up about 90% of the cases.[19][38] Some data indicate rates are roughly equal in women and men,[19] but male excess in diabetes has been found in many populations with higher type 2 incidence, possibly due to sex-related differences in insulin sensitivity, consequences of obesity and regional body fat deposition, and other contributing factors such as high blood pressure, tobacco smoking, and alcohol intake.[123][124]

The WHO estimates that diabetes resulted in 1.5million deaths in 2012, making it the 8th leading cause of death.[15][122] However another 2.2million deaths worldwide were attributable to high blood glucose and the increased risks of cardiovascular disease and other associated complications (e.g. kidney failure), which often lead to premature death and are often listed as the underlying cause on death certificates rather than diabetes.[122][125] For example, in 2017, the International Diabetes Federation (IDF) estimated that diabetes resulted in 4.0million deaths worldwide,[120] using modeling to estimate the total number of deaths that could be directly or indirectly attributed to diabetes.[120]

Diabetes occurs throughout the world but is more common (especially type 2) in more developed countries. The greatest increase in rates has however been seen in low- and middle-income countries,[122] where more than 80% of diabetic deaths occur.[126] The fastest prevalence increase is expected to occur in Asia and Africa, where most people with diabetes will probably live in 2030.[127] The increase in rates in developing countries follows the trend of urbanization and lifestyle changes, including increasingly sedentary lifestyles, less physically demanding work and the global nutrition transition, marked by increased intake of foods that are high energy-dense but nutrient-poor (often high in sugar and saturated fats, sometimes referred to as the "Western-style" diet).[122][127] The global number of diabetes cases might increase by 48% between 2017 and 2045.[120]

Diabetes was one of the first diseases described,[128] with an Egyptian manuscript from c. 1500 BCE mentioning "too great emptying of the urine."[129] The Ebers papyrus includes a recommendation for a drink to take in such cases.[130] The first described cases are believed to have been type1 diabetes.[129] Indian physicians around the same time identified the disease and classified it as madhumeha or "honey urine", noting the urine would attract ants.[129][130]

The term "diabetes" or "to pass through" was first used in 230BCE by the Greek Apollonius of Memphis.[129] The disease was considered rare during the time of the Roman empire, with Galen commenting he had only seen two cases during his career.[129] This is possibly due to the diet and lifestyle of the ancients, or because the clinical symptoms were observed during the advanced stage of the disease. Galen named the disease "diarrhea of the urine" (diarrhea urinosa).[131]

The earliest surviving work with a detailed reference to diabetes is that of Aretaeus of Cappadocia (2nd or early 3rdcentury CE). He described the symptoms and the course of the disease, which he attributed to the moisture and coldness, reflecting the beliefs of the "Pneumatic School". He hypothesized a correlation between diabetes and other diseases, and he discussed differential diagnosis from the snakebite, which also provokes excessive thirst. His work remained unknown in the West until 1552, when the first Latin edition was published in Venice.[131]

Two types of diabetes were identified as separate conditions for the first time by the Indian physicians Sushruta and Charaka in 400500CE with one type being associated with youth and another type with being overweight.[129] Effective treatment was not developed until the early part of the 20th century when Canadians Frederick Banting and Charles Herbert Best isolated and purified insulin in 1921 and 1922.[129] This was followed by the development of the long-acting insulin NPH in the 1940s.[129]

The word diabetes ( or ) comes from Latin diabts, which in turn comes from Ancient Greek (diabts), which literally means "a passer through; a siphon".[132] Ancient Greek physician Aretaeus of Cappadocia (fl. 1stcentury CE) used that word, with the intended meaning "excessive discharge of urine", as the name for the disease.[133][134] Ultimately, the word comes from Greek (diabainein), meaning "to pass through,"[132] which is composed of - (dia-), meaning "through" and (bainein), meaning "to go".[133] The word "diabetes" is first recorded in English, in the form diabete, in a medical text written around 1425.

The word mellitus ( or ) comes from the classical Latin word melltus, meaning "mellite"[135] (i.e. sweetened with honey;[135] honey-sweet[136]). The Latin word comes from mell-, which comes from mel, meaning "honey";[135][136] sweetness;[136] pleasant thing,[136] and the suffix -tus,[135] whose meaning is the same as that of the English suffix "-ite".[137] It was Thomas Willis who in 1675 added "mellitus" to the word "diabetes" as a designation for the disease, when he noticed the urine of a person with diabetes had a sweet taste (glycosuria). This sweet taste had been noticed in urine by the ancient Greeks, Chinese, Egyptians, Indians, and Persians.

The 1989 "St. Vincent Declaration"[138][139] was the result of international efforts to improve the care accorded to those with diabetes. Doing so is important not only in terms of quality of life and life expectancy but also economically expenses due to diabetes have been shown to be a major drain on health and productivity-related resources for healthcare systems and governments.

Several countries established more and less successful national diabetes programmes to improve treatment of the disease.[140]

People with diabetes who have neuropathic symptoms such as numbness or tingling in feet or hands are twice as likely to be unemployed as those without the symptoms.[141]

In 2010, diabetes-related emergency room (ER) visit rates in the United States were higher among people from the lowest income communities (526 per 10,000 population) than from the highest income communities (236 per 10,000 population). Approximately 9.4% of diabetes-related ER visits were for the uninsured.[142]

The term "type1 diabetes" has replaced several former terms, including childhood-onset diabetes, juvenile diabetes, and insulin-dependent diabetes mellitus (IDDM). Likewise, the term "type2 diabetes" has replaced several former terms, including adult-onset diabetes, obesity-related diabetes, and noninsulin-dependent diabetes mellitus (NIDDM). Beyond these two types, there is no agreed-upon standard nomenclature.[143]

Diabetes mellitus is also occasionally known as "sugar diabetes" to differentiate it from diabetes insipidus.[144]

In animals, diabetes is most commonly encountered in dogs and cats. Middle-aged animals are most commonly affected. Female dogs are twice as likely to be affected as males, while according to some sources, male cats are more prone than females. In both species, all breeds may be affected, but some small dog breeds are particularly likely to develop diabetes, such as Miniature Poodles.[145]

Feline diabetes is strikingly similar to human type 2 diabetes. The Burmese, Russian Blue, Abyssinian, and Norwegian Forest cat breeds are at higher risk than other breeds. Overweight cats are also at higher risk.[146]

The symptoms may relate to fluid loss and polyuria, but the course may also be insidious. Diabetic animals are more prone to infections. The long-term complications recognized in humans are much rarer in animals. The principles of treatment (weight loss, oral antidiabetics, subcutaneous insulin) and management of emergencies (e.g. ketoacidosis) are similar to those in humans.[145]

Inhalable insulin has been developed.[147] The original products were withdrawn due to side effects.[citation needed] Afrezza, under development by the pharmaceuticals company MannKind Corporation, was approved by the United States Food and Drug Administration (FDA) for general sale in June 2014.[148] An advantage to inhaled insulin is that it may be more convenient and easy to use.[149]

Transdermal insulin in the form of a cream has been developed and trials are being conducted on people with type2 diabetes.[150][151]

The Diabetes Control and Complications Trial (DCCT) was a clinical study conducted by the United States National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) that was published in the New England Journal of Medicine in 1993. Test subjects all had type 1 diabetes and were randomized to a tight glycemic arm and a control arm with the standard of care at the time; people were followed for an average of seven years, and people in the treatment had dramatically lower rates of diabetic complications. It was as a landmark study at the time, and significantly changed the management of all forms of diabetes.[101][152][153]

The United Kingdom Prospective Diabetes Study (UKPDS) was a clinical study conducted by Z that was published in The Lancet in 1998. Around 3,800 people with type 2 diabetes were followed for an average of ten years, and were treated with tight glucose control or the standard of care, and again the treatment arm had far better outcomes. This confirmed the importance of tight glucose control, as well as blood pressure control, for people with this condition.[101][154][155]

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Vaccine hesitancy has erupted due to many factors. From rising numbers of breakthrough infections leading to doubts to vaccine side-effects reflecting another layer of myths and misconceptions, many people with chronic illnesses have refrained from taking the COVID shot.

But when you're a diabetic, it is important to understand how important it is to get your COVID vaccines.

While vaccine side-effects are mild and fade away in a day or two, without the risk of transmission, COVID infections can land you up in serious condition. From mild, moderate to severe infections, you can go on to develop fungal infections, which according to experts were seen in people with high blood sugar levels.

Considering the damage caused by coronavirus infections is much higher, everyone should get their COVID vaccines as soon as possible.

Read more: Coronavirus and Diabetes: Steps a diabetic patient must take to stay healthy

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Coronavirus vaccination: What people with diabetes should know about COVID vaccines? - Times of India

Nearly half of adults prescribed metformin after a new diagnosis of type 2 diabetes have stopped taking it by 1 year, new data show.

The findings, from a retrospective analysis of administrative data from Alberta, Canada, during 2012-2017, also show that the fall-off in metformin adherence was most dramatic during the first 30 days, and in most cases, there was no concomitant substitution of another glucose-lowering drug.

While the majority with newly diagnosed type 2 diabetes were prescribed metformin as first-line therapy, patients started on other agents incurred far higher medication and healthcare costs.

The data were recently published online in Diabetic Medicine by David J. T. Campbell, MD, PhD, of the University of Calgary, Alberta, Canada, and colleagues.

"We realized that even if someone is prescribed metforminthat doesn't mean they're staying on metformin even for a year...the drop-off rate is really quite abrupt," Campbell told Medscape Medical News. Most who discontinued had A1c levels above 7.5%, so it wasn't that they no longer needed glucose-lowering medication, he noted.

One reason for the discontinuations, he said, is that patients might not realize they need to keep taking the medication.

"When a physician is seeing a person with newly diagnosed diabetes, I think it's important to remember that they might not know the implications of having a chronic condition. A lot of times we're quick to prescribe metformin and forget about it...Physicians might write a script for 3 months and three refills and not see the patient again for a year...We may need to keep a closer eye on these folks and have more regular follow-up, and make sure they're getting early diabetes education."

Side effects are an issue, but not for most. "Any clinician who prescribes metformin knows there are side effects, such as upset stomach, diarrhea, and nausea. But certainly, it's not half [who experience these]...A lot of people just aren't accepting of having to take it lifelong, especially since they probably don't feel any better on it," Campbell said.

James Flory, MD, an endocrinologist at Memorial Sloan Kettering Cancer Center, New York City, told Medscape Medical Newsonly about 25% of patients taking metformin experience gastrointestinal side effects.

Moreover, he noted that the drop-off in adherence is also seen with antihypertensive and lipid-lowering drugs that have fewer side effects than metformin. He pointed to a "striking example" of this, a 2011 randomized trial published in the New England Journal of Medicine, and as reported by Medscape Medical News, showingoverall rates of adherence to these medications was only around 50%, even among people who had already had a myocardial infarction.

"People really don't want to be on these medications...They have an aversion to being medicalized and taking pills. If they're not being pretty consistently prompted and reminded and urged to take them, I think people will find rationalizations, reasons for stopping...I think people want to handle things through lifestyle and not be on a drug," noted Flory, who has also published on the subject of metformin adherence.

Moreover, Flory explained, "These drugs don't make people feel better. None of them do. At best they don't make you feel worse. You have to really believe in the chronic condition and believe that it's hurting you and that you can't handle it without the drugs to motivate you to keep taking them."

Communication with the patient is key, he said.

"I don't have empirical data to support this, but I feel it's helpful to acknowledge the downsides to patients. I tell them to let me know [if they're having side effects] and we'll work on it. Don't just stop taking the drug and never circle back." At the same time, he added, "I think it's important to emphasize metformin's safety and effectiveness."

For patientsexperiencing gastrointestinal side effects, options including switching to extended-release metformin or lowering the dose.

Also, while patients are typically advised to take metformin with food, some experience diarrhea when they do that and prefer to take it at bedtime than with dinner. "If that's what works for people, that's what they should do," Flory advised.

"It doesn't take a lot of time to emphasize to patients the safety and this level of flexibility and control they should be able to exercise over how much they take and when. These things should really help."

Campbell and colleagues analyzed 17,932 individuals with incident type 2 diabetes diagnosed between April 1, 2012 and March 31, 2017. Overall,89% receivedmetformin monotherapy as their initial diabetes prescription, 7.6% startedmetformin in combination with another glucose-lowering drug, and 3.3% were prescribed a nonmetformin diabetes medication. (Those prescribed insulin as their first diabetes medication were excluded.)

The most commonly coprescribed drugs with metformin were sulfonylureas (in 47%) and DPP-4 inhibitors (28%). Of those initiated with only nonmetformin medications, sulfonylureas were also the most common (53%) and dipeptidyl peptidase-4 (DPP-4) inhibitorssecond (21%).

The metformin prescribing rate of 89% reflects current guidelines, Campbell noted.

"In hypertension, clinicians weren't really following the guidelines...they were prescribing more expensive drugs than the guidelines say...We showed that in diabetes, contrary to hypertension, clinicians really are generally following the clinical practice guidelines...The vast majority who are started on metformin are started on monotherapy. That was reassuring to us. We're not paying for a bunch of expensive drugs when metformin would do just as well," he said.

However, the proportion who had been dispensed metformin to cover the prescribed number of days dropped by about 10% after 30 days, by a further 10% after 90 days, and yet again after 100 days, resulting in just 54% remaining on the drug by 1 year.

Factors associated with higher adherence included older age, presence of comorbidities, and highest versus lowest neighborhood income quintile.

Those who had been prescribed nonmetformin monotherapy had about twice the total healthcare costs of those initially prescribed metformin monotherapy. Higher healthcare costs were seen among patients who were younger, had lower incomes, higher baseline A1c, had more comorbidities, and were men.

Campbell noted that "a lot has changed since 2017...At least in Canada, the sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists were supposed to be reserved as second-line agents in patients with cardiovascular disease, but more and more they're being thought of as first-line agents in high-risk patients."

"I suspect as those guidelines are transmitted to primary care colleagues who are doing the bulk of the prescribing we'll see more and more uptake of these agents."

Indeed, Flory said, "The metformin data at this point are very dated and the body of trials showing health benefits for it is actually very weak compared to the big trials that have been done for the newer agents, to the point where you can imagine a consensus gradually forming where people start to recommend something other than metformin for nearly everybody with type 2 diabetes. The cost implications are just huge, and I think the safety implications as well."

According to Flory, the SGLT2 inhibitors "are fundamentally not as safe as metformin. I think they're very safe drugs large good studies have established that but if you're going to give drugs to a large number of people who are pretty healthy at baseline the safety standards have to be pretty high."

Just the elevated risk of euglycemic diabetic ketoacidosis alone is reason for pause, Flory believes. "Even though it's manageable...metformin just doesn't have a safety problem like that. I'm very comfortable prescribing SGLT2 inhibitors, but If I'm going to give a drug to a million people and have nothing go wrong with any of them, that would be metformin, not an SGLT2 [inhibitor]."

Campbell and colleagues will be conducting a follow-up of prescribing data through 2019, which will of course include the newer agents. They'll also investigate reasons for drug discontinuation and outcomes of those who discontinue versus continue metformin.

Campbell has reported no relevant financial relationships. Flory consults for a legal firm on litigation related to insulin analog pricing issues, not for or pertaining to a specific company.

Diabet Med. Published online June 16, 2021. Abstract

Miriam E. Tucker is a freelance journalist based in the Washington DC area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

For more diabetes and endocrinology news, follow us on Twitter and Facebook.

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Half Abandon Metformin Within a Year of Diabetes Diagnosis - Medscape

SAN DIEGO--(BUSINESS WIRE)--Tandem Diabetes Care, Inc. (NASDAQ: TNDM), a leading insulin delivery and diabetes technology company, today reported its financial results for the quarter ended June 30, 2021 and updated its sales guidance for the year ending December 31, 2021.

Second Quarter 2021 Highlights

In comparing the second quarter of 2021 to the same period of 2020:

We achieved record-high sales in the second quarter by expanding and further penetrating the U.S. insulin pump market, and through the rapid uptake of our technology internationally where our business opportunity is still in its early stages, said John Sheridan, president and chief executive officer. Our worldwide installed base is now nearly 270,000 people, and we are on track to achieve our goal of bringing the benefits of our technology to more than half a million customers by year-end 2024.

Second Quarter 2021 Financial Results

Domestic pump shipments increased 40 percent to 20,665 pumps in the second quarter of 2021 from 14,735 pumps in the same period of 2020. Domestic sales were $127.6 million, an increase of 43 percent compared to $89.3 million in the second quarter of 2020. International pump shipments increased 233 percent to 13,152 pumps in the second quarter of 2021 from 3,952 pumps in the same period of 2020. International sales were $44.6 million, an increase of 123 percent compared to $20.0 million in the second quarter of 2020.

Gross profit for the second quarter of 2021 increased 70 percent to $92.5 million, compared to $54.4 million for the same period of 2020. Gross margin increased to 54 percent in the second quarter of 2021 from 50 percent in the same period of 2020.

For the second quarter of 2021, operating expenses totaled $87.0 million, compared to $66.4 million for the same period of 2020. Operating income totaled $5.4 million, compared to an operating loss of $12.0 million for the same period of 2020. Operating margin for the second quarter of 2021 was 3 percent of sales compared to negative 11 percent for the same period of 2020. For the second quarter of 2021, Adjusted EBITDA(1) was $23.8 million, or 14 percent of sales, compared to $6.6 million, or 6 percent of sales, for the same period of 2020.

Net income for the second quarter of 2021 was $4.0 million, which included a $0.3 million non-cash charge for the change in fair value of certain outstanding warrants and $1.5 million of interest expense related to the Companys convertible senior notes. This is compared to a net loss of $27.1 million for the second quarter of 2020, which included a $14.3 million non-cash charge for the change in fair value of certain warrants outstanding at that time and $3.2 million of interest expense related to the Companys convertible senior notes.

Cash Balance and Liquidity

As of June 30, 2021, the Company had $545.3 million in cash, cash equivalents and short-term investments. This represents a $31.9 million increase in the second quarter of 2021, and a $60.4 million increase since December 31, 2020.

2021 Annual Guidance Update

For the year ending December 31, 2021, the Company is updating its financial guidance as follows:

(1)

EBITDA is a non-GAAP financial measure defined as net income (loss) excluding income taxes, interest and other non-operating items and depreciation and amortization. Adjusted EBITDA further adjusts for the change in fair value of common stock warrants and non-cash stock-based compensation expense. This definition of Adjusted EBITDA may differ from similar measures used by other companies, even when similar terms are used to identify such measures. Adjusted EBITDA is a key measure used by the Company to evaluate operating performance, generate future operating plans and make strategic decisions for the allocation of capital. The Company presents Adjusted EBITDA to provide information that may assist investors in understanding its financial results. However, Adjusted EBITDA is not intended to be a substitute for net income (loss).

Non-GAAP Financial Measures

Certain non-GAAP financial measures are presented in this press release, including Adjusted EBITDA, to provide information that may assist investors in understanding the Companys financial results and assessing its prospects for future performance. We believe these non-GAAP financial measures are important indicators of our operating performance because they exclude items that are unrelated to, and may not be indicative of, our core operating results. These non-GAAP financial measures, as we calculate them, may not necessarily be comparable to similarly titled measures of other companies and may not be appropriate measures for comparing the performance of other companies relative to the Company. These non-GAAP financial results are not intended to represent, and should not be considered to be more meaningful measures than, or alternatives to, measures of operating performance as determined in accordance with GAAP. To the extent we utilize such non-GAAP financial measures in the future, we expect to calculate them using a consistent method from period to period. A reconciliation of each of the GAAP financial measures to the most directly comparable non-GAAP financial measures has been provided under the heading Reconciliation of GAAP versus Non-GAAP Financial Results in the financial statement tables attached to this press release. Consistent with SEC regulations, we have not provided a reconciliation of forward-looking non-GAAP financial measures to the most directly comparable GAAP financial measures in reliance on the unreasonable efforts exception set forth in the applicable regulations, because there is substantial uncertainty associated with predicting any future adjustments that we may make to our GAAP financial measures in calculating our non-GAAP financial measures.

Conference Call

The Company will hold a conference call and simultaneous webcast today at 4:30pm Eastern Time (1:30pm Pacific Time). The link to the webcast will be available by accessing the Events & Presentations tab in the Investor Center of the Tandem Diabetes Care website at http://investor.tandemdiabetes.com, and will be archived for at least 30 days. To listen to the conference call via phone, please dial 855-427-4396 (U.S./Canada) or 484-756-4261 (International) and use the participant code 6897987.

About Tandem Diabetes Care, Inc.

Tandem Diabetes Care, Inc. (www.tandemdiabetes.com) is a medical device company dedicated to improving the lives of people with diabetes worldwide through relentless innovation and revolutionary customer experience. The Company takes an innovative, user-centric approach to the design, development and commercialization of products for people with diabetes who use insulin. Tandems flagship product, the t:slim X2 insulin pump, is capable of remote software updates using a personal computer and features integrated continuous glucose monitoring. Tandem is based in San Diego, California.

Tandem Diabetes Care, Inc., t:slim X2 and Control-IQ are trademarks of Tandem Diabetes Care, Inc.

Follow Tandem Diabetes Care on Twitter @tandemdiabetes; use #tslimX2 and $TNDM.Follow Tandem Diabetes Care on Facebook at http://www.facebook.com/TandemDiabetes.Follow Tandem Diabetes Care on LinkedIn at https://www.linkedin.com/company/tandemdiabetes.

Forward-Looking Statements

This press release contains forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Exchange Act of 1934, as amended, that concern matters that involve risks and uncertainties that could cause actual results to differ materially from those anticipated or projected in the forward-looking statements. These forward-looking statements include statements regarding, among other things, the Companys projected financial results, and the factors impacting the Companys business momentum. The Companys actual results may differ materially from those indicated in these forward-looking statements due to numerous risks and uncertainties. For instance, the Companys ability to achieve projected financial results will be impacted by market acceptance of the Companys existing products and products under development by physicians and people with diabetes; the Companys ability to establish and sustain operations to support international sales, including expansion into additional geographies; changes in reimbursement rates or insurance coverage for the Companys products; the Companys ability to meet increasing operational and infrastructure requirements from higher customer interest and a larger base of existing customers; the Companys ability to complete the development and launch of new products when anticipated; the potential that newer products, or other technological breakthroughs for the monitoring, treatment or prevention of diabetes, may render the Companys products obsolete or less desirable; the depth and duration of the evolving COVID-19 pandemic, and the global response thereto; reliance on third-party relationships, such as outsourcing and supplier arrangements; global economic conditions; and other risks identified in the Companys most recent Annual Report on Form 10-K, Quarterly Report on Form 10-Q, and other documents that the Company files with the Securities and Exchange Commission. Readers are cautioned not to place undue reliance on these forward-looking statements, which speak only as of the date of this release. Tandem undertakes no obligation to update or review any forward-looking statement in this press release because of new information, future events or other factors.

TANDEM DIABETES CARE, INC.

CONDENSED CONSOLIDATED BALANCE SHEETS

(in thousands)

June 30,

December 31,

2021

2020

(Unaudited)

Assets

Current assets:

Cash, cash equivalents and short-term investments

$

545,302

$

484,936

Accounts receivable, net

80,212

82,195

Inventories

66,705

63,721

Other current assets

6,066

6,383

Total current assets

698,285

637,235

Property and equipment, net

48,890

50,022

Operating lease right-of-use assets

31,499

19,773

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Tandem Diabetes Care Announces Second Quarter 2021 Financial Results and Updated Full Year 2021 Sales Guidance - Business Wire

Tanner Johnson's fiancee, Brynn Woodyard, pins on his second lieutenant bars at the commissioning ceremony for Cadet Squadron 14 at the U.S. Air Force Academy in Colorado Springs, Colo., May 25, 2021. Johnson was the first person diagnosed with Type 1 diabetes to commission into the U.S. military. (USAFA Association of Graduates Webguy)

A year before Tanner Johnson was due to graduate from the U.S. Air Force Academy in Colorado, he was lying in a hospital bed and doctors were telling his family he had two hours to live.

His organs were shutting down due to complications caused by Type 1 diabetes, an autoimmune condition where the body attacks the cells that make insulin.

Type 1 diabetes usually affects young children and runs in families, but none of Johnsons relatives were diabetic. He was nearly 22 when he was diagnosed in May 2020, two months after most cadets had been sent home as the academy scrambled to contain the fast-spreading coronavirus.

Johnson pulled through the worst of the health crisis and began to deal with his new reality.

The doctors said I would have to take insulin shots every day for the rest of my life, I would not be able to fly, I would not be allowed in the military, and wouldnt be allowed to return to the academy and graduate, Johnson said.

But he refused to accept what they said and set out to prove them wrong. He hoped to become the first person to be commissioned into the U.S. military with a medical condition that, up until then, was automatically disqualifying.

If you have Type 1, you become not deployable because you are taking insulin shots, said Lt. Col. Amy Carpenter, an assistant professor of biology at the academy and a certified diabetes counselor.

Air Force Academy cadet Tanner Johnson, right, wrestles against a University of Minnesota athlete in 2018. He continued wrestling competitively after he was diagnosed with Type 1 diabetes at the start of his senior year. (USAFA Athletics)

During her first decade in the military, Carpenter advised newly diagnosed service members about living with diabetes and prepared them for the end of their military career.

Academy officials allowed Johnson to return and he was referred to Carpenter for counseling. But that wasnt what he was looking for.

He came to me and said, Maam, I know this is a long shot, but what if we could demonstrate that being a Type 1 diabetic does not have to be an automatic disqualifier? Carpenter said.

I thought, oh man, Ive never had an example where you have Type 1 diabetes and the military retains you. So I told him, Tanner, I know youre in great control, youre very knowledgeable about your condition, but get ready to get kicked out.

He didnt. Instead, Johnson did what everyone else did, and then some, to show that even with this condition, I could do everything that was required of me, and do it well, he said.

He continued competing with the wrestling team during his senior year, with the tiny needle of a continuous glucose monitor in his stomach, he said. He signed up for more activities and raised his grade point average to the highest it had ever been.

And he talked to anyone who would listen about why he should be allowed to commission, laying out convincing arguments, including that technology has made it possible for diabetics to live nearly normal lives.

Insulin pumps can deliver a steady, 24-hour stream of the vital hormone, with a boost at mealtimes, while continuous glucose monitors keep tabs on blood sugar.

Ten, 15 years ago, that technology didnt exist, Carpenter said. With it, its no longer true that, oh my God, I cant fly this airplane anymore because I have to prick my finger and check my blood sugar or give myself a shot. Now, a diabetic can just look at their smartwatch and see that their blood sugarsdropping too low, so theyd better drink some orange juice.

With Carpenters help, Johnson conducted independent research into Type 1 diabetics in the military and other professions.

Space Force 2nd Lt. Tanner Johnson shows the continuous glucose monitor he wears on his abdomen to monitor his blood sugar. Johnson commissioned into the Space Force at a ceremony at the U.S. Air Force Academy on May 25, 2021, becoming the first person diagnosed with Type 1 diabetes to be allowed to join the U.S. military. (Tanner Johnson)

He found that they serve as police, firefighters and in other frontline roles, and that the Federal Aviation Administration last year approved the first commercial pilot with Type 1 diabetes. He uses a continuous glucose monitor, like Johnson does.

There are no precedents for insulin-dependent diabetics joining the military, but Army Sgt. Joshua Kirkpatrick of the 449th Theater Aviation Brigade won the North Carolina National Guards NCO Best Warrior of the year competition in 2017, three years after he was diagnosed with Type 1. He was already in the military when he became diabetic.

He entered the competition because from day one when I was diagnosed with diabetes, they were constantly telling me that Im unfit for the Army, Kirkpatrick said in an interview posted on the Defense Visual Information Distribution Service at the time. They said theres no way I can compete with everybody else, and constantly I showed them I could.

Attempts to reach Kirkpatrick for comment were unsuccessful. His former unit said he had left the Guard. The DVIDS report said proceedings were underway in 2017 to discharge him.

With time counting down to the day Johnson would have to leave the Air Force Academy, he continued to plead his case to be allowed to commission. Last fall, he approached academy superintendent Lt. Gen. Richard Clark and asked if he could have 10 minutes of his time.

We spoke for nearly an hour, Johnson recalled. He said if I could wrestle and do everything required of me at the academy, there was no reason we couldnt find a job for me in the military. And he went to bat for me.

Tanner Johnson is sworn in as a U.S. Space Force officer by his grandfather, retired Army Lt. Col. Terry Johnson, at a ceremony at the U.S. Air Force Academy in Colorado Springs, Colo., May 25, 2021. A year earlier, Tanner Johnson was diagnosed with Type 1 diabetes and was told his military career was over. (USAFA Association of Graduates)

Air Force Academy Cadet 1st Class Tanner Johnson, left, marches with Cadet Squadron 14 in the graduation parade at the Colorado Springs, Colo., service academy, May 25, 2021. Johnson was commissioned that day into the U.S. Space Force, becoming the first person diagnosed with Type 1 diabetes to be allowed to serve in the U.S. military. (Karin Zeitvogel)

There were still times when it seemed that hed fail, but just weeks before the Class of 2021 became the largest graduating class in academy history on May 26, Johnson learned he would march into the football stadium with his squadron, wearing a grey sash to indicate that he was joining the Space Force.

Johnson and his wife, Brynn, arrived last week at Vandenberg Space Force Base in California, where the newly minted second lieutenant hopes to become an orbital warfare officer and help the U.S. use satellites to give it an advantage in space, he said.

He also hopes he can spur change and spare others the anguish he went through when he was diagnosed. He wants to be the guy who demonstrates that the policy should change, not the exception to an existing rule, Carpenter said.

I was devastated to learn I had diabetes, and then I had to deal with the fact that everything Id worked for might be taken away because the military might not accept me, he said. I want to be an example so that, when someone is diagnosed in the future, they wont have that hanging over them.

I want people to say, Look at this guy, look at what hes doing. I may never be an astronaut, like my mom seems to think I will, but I can manage my condition and serve my country, he said.

And if the astronaut door ever opens to diabetics, he added after the briefest reflection, Ill walk through it.

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A year after doctors said he wouldn't be allowed to commission, Air Force Academy graduate joins the Space Force - Stars and Stripes

Introduction

Diabetes mellitus (DM), a collective term for heterogeneous metabolic disorders whose main finding is chronic hyperglycemia, is a public health issue that has caused burdens of morbidity, mortality, and economic impact on individuals, families, health systems, and national economies.13 The global prevalence of DM in 2019 was estimated to be 9.3% (463 million people), with a projection of 10.2% (578 million people) for 2030 and 10.9% (700 million people) for 20452. Approximately, 90% of DM cases are attributed to type 2 diabetes mellitus (T2DM).2,3 Remarkably, China has witnessed one of the most dramatic rises in the prevalence of DM anywhere in the world and accounts for the largest number of individuals with 114 million cases of DM, mainly T2DM.46 Given that the cause of the rising prevalence of DM remains unclear, there is an urgent need to identify high-risk individuals and to implement targeted prevention to tackle diabetes.

Currently, obesity is a nearly global epidemic, affecting more than 20% of the general population.79 Metabolic syndrome and obesity frequently co-exist, allowing the categorization of obesity into different body mass index (BMI)-metabolic status phenotypes. It is suggested that 87% of overweight/obesity are not able to develop DM, but obtain some degree of fat-induced insulin resistance, which is not sufficient to cause diabetes.8 In contrast to metabolically unhealthy obesity (MUO), an estimated 1545% of individuals with obesity present insulin sensitivity, favorable glucose, blood pressure, hormone, lipid profiles, and inflammation levels despite excess adiposity; these are classified as the metabolically healthy obese (MHO).7,1012 In contrast, 530% of normal weight individuals do not present metabolically health, categorized as metabolically unhealthy-normal weight (MU-NW), which is defined as metabolically obese of normal weight.7 Obviously, taking the current epidemic of obesity and sub-phenotypes into consideration, one size fits all approaches to tackle obesity seem inappropriate.7 The association between BMI-metabolic status phenotypes and the risk of DM remains controversial, especially for MHO.1315 Several studies have reported that MHO individuals were not at increased risk for DM, in comparison with the metabolically healthy non-obese and may not benefit from lifestyle interventions.13,16 However, some studies have provided evidence that MHO is significantly associated with increased risk of incident DM.14,15

Overall, the evidence is inconsistent, especially for different ethnicities. The results of extant research may not be applicable to the Chinese population. Given that there are no universally and uniformly accepted standards to define obesity phenotypes,17 it is necessary to notice that BMI-metabolic status phenotypes can be identified by geographic regions of the word and ethnicity independently.7,9 Additionally, the classification of obese sub-phenotypes is not explicit, for some BMI categories of obesity and overweight were always combined in previous studies. Thus, to better understand the roles of different BMI-metabolic status phenotypes for incident DM, we measured the incidence density of DM by phenotypes and investigated the effects of metabolic health and obesity phenotypes on the risk of incident DM. We focused on repeated observations of the same individual at each follow-up examination in this longitudinal study to identify the high-risk and low-risk BMI-metabolic status phenotypes for early prevention of DM among the Chinese population.

A population-based prospective cohort study was established in Jiangsu province, China. The baseline survey was conducted between April and July 2017, and samples were selected using multistage-stratified sampling methods from Jurong Zhengjiang and Yandu Yancheng, two cities in Jiangsu province (Supplementary Figure S1). In the first stage, three district/town-level units were randomly chosen from Jurong and Yandu, respectively. Then eight to nine neighborhood/village-level units were randomly selected from every district/town-level unit and about 100 residents per neighborhood/village-level units were randomly sampled. Individuals aged 18 years and over at the time of enrollment, without mental disorders, pregnancy or a diagnosis of DM were eligible for this study. With the help and support of local community councils, residents living at their registered address and having permanent living records of Chinese nationality were invited. The final sample of 5318 participants fell within 50 neighborhoods/villages; 5250 participants with written informed consent were included with a response rate of 98.72%.

Overall, 5250 residents participated in the baseline survey which consisted of a questionnaire, physical and laboratory examination. Several participants with particular missing values at baseline were excluded: uncompleted questionnaires (n = 36), physical examination not done (n = 32) and no blood sample available (n = 36). We further excluded participants who were migrant workers and moved from city to city frequently (n = 71), those who had used antidiabetics before (or had a self-reported history of DM) (n = 186), as well as those who were newly diagnosed with diabetes at the baseline survey (n=637). According to the criteria of The Working Group on Obesity in China, the classification of BMI was defined as follows:18 underweight (BMI < 18.5 kg/m2), normal (18.5 BMI < 24.0 kg/m2), overweight (24.0 BMI < 28.0 kg/m2) and obesity (BMI 28.0 kg/m2). After removing the underweight individuals (n = 57) from baseline survey, 4195 participants were further classified into six groups according to the BMI-metabolic status phenotypes and received follow-ups (Supplementary Figure S1). Subsequently, two follow-up visits for data collection took place from July to August 2018 (re-investigated n = 3043) and from July to August, 2020 (re-investigated n = 3003), respectively. After excluding those participants without at least one follow-up examination and those who did not complete the physical or laboratory examination, with missing data preventing definition of BMI-metabolic status phenotypes and outcomes during follow-up (n = 554), we pooled data from the population study (baseline in April to July, 2017) which consisted of 3641 participants, and its two follow-ups examination (July to August, 2018: n=3007; July to August, 2020: n=2975) for our longitudinal data analysis. This resulted in a final analysis sample of 9623 observations across three time points (Figure 1). Thus, we obtained an analysis dataset with repeated observations, including 2345 participants with three observations and 1292 with two observations.

Figure 1 Flowchart for selection of study participants.

This study was conducted in accordance with the Declaration of Helsinki. The study was viewed and approved by the Ethics Review Committee of Zhongda Hospital, Southeast University and Jiangsu Provincial Centre for Disease Control and Prevention (JSJK2017-B003-02). Every participant provided written informed consent.

All enrolled participants completed an interview conducted by experienced local health workers using a standardized questionnaire to collected information regarding their demographic characteristics (age, gender, education level and self-reported drug history, history of chronic disease and family history of DM), as well as behavioral characteristics (smoking status, drinking status and regular physical activity). These characteristics were further categorized as follows: education level (junior high school or below/ senior high school or above), drug history (no/yes/unclear), history of chronic disease (no/yes) and family history of DM (no/yes/unclear). Smoking status was divided as follows: never (non-smoker) and ever (current smoker or ex-smoker), and drinking status as (never/ever). Regular exercise was grouped as follows: no and yes (recreational sports activities more than 30 minutes per time, more than three times a week). Weight was measured with a digital scale to the nearest 0.1kg with light clothes and height was measured to the nearest 0.1 cm using a wall-mounted stadiometer. BMI was calculated from weight and height (BMI=weight/height2), and normal weight, overweight and obesity were defined as 18.5 BMI < 24.0 kg/m2, 24.0 BMI < 28.0 kg/m2, and BMI 28 kg/m2, respectively.18 Participants were asked to have at least a 5-min rest in a seated position before their systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured using electronic sphygmomanometers. Waist circumference (WC) and hip circumference were measured using a tape with a metric scale under standardized procedures, with the participants in a standing position. The thresholds for WC were specified according to the International Diabetes Foundation (IDF) for the Chinese populations (WC > 80cm for females and WC > 90cm for males).19 For detecting central obesity in the Chinese adult population, a waist-to-height ratio 0.50 was considered as the optimal cut-off value.20 According to the World Health Organization (WHO), the cut-off values for metabolic complications for waist-tohip ratio are also defined (0.85 in women and 0.90 in men).19 Forearm venous blood samples were collected and measured for biochemical characteristics after overnight fasting for more than 8 hours before examination. Subsequently, standard oral glucose tolerance tests (OGTT) (75g anhydrous glucose) were administered and conducted without eating breakfast; 2 hours later, a second blood sample was taken for 2-hour plasma glucose (2hPG). Blood tests were all conducted in the same central laboratory (Adicon, Nanjing China) by the same method to maintain consistency, and included fasting plasma glucose (FPG), 2hPG, glycosylated hemoglobin (HbA1c), aspartate aminotransferase, alanine transaminase, gamma glutamyl transferase, serum total bilirubin, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol (HDL-C), total cholesterol and triglyceride (TG). The method of data collection and blood sample testing for the two follow-up examinations was exactly as same as for the baseline survey. All variables, including behavioral, anthropometric and biochemical characteristics, were assessed repeatedly at each follow-up examination (2018 and 2020).

The National Cholesterol Education Program Adult Treatment Panel III (ATP III), a standard operating protocol, was applied to define metabolic status.7,21 Metabolically healthy was defined as participants meeting fewer than three of the following five criteria:21 (1) Elevated WC with population-specific definitions (> 90 cm for men and > 80 cm for women);19 (2) elevated FPG (> 100 mg/dl) or using glucose-lowering agents; (3) reduced HDL-C (< 40 mg/dl for men or < 50 mg/dl for women); (4) elevated TG ( 150 mg/dl) or using lipid-lowing drugs; (5) elevated SBP ( 130 mmHg) or DBP ( 85 mmHg), or using anti-hypertensive drugs. Based on criteria for BMI of the Working Group on obesity in China, alongside the metabolic status, participants were grouped according to the following phenotypes:22 (1) metabolically healthy normal weight (MH-NW); (2) metabolically healthy overweight (MH-OW); (3) metabolically healthy obesity (MHO); (4) metabolically unhealthy normal weight (MU-NW); (5) metabolically unhealthy overweight (MU-OW); and (6) metabolically unhealthy obesity (MUO).

Diabetes was defined according to the diagnostic criteria of the WHO:2325 an FPG level 7.0mmol/L (126mg/dl) and/or a 2hPG value 11.1mmol/L (200mg/dl) and/or an HbA1c 6.5%.

We used meanstandard deviation(SD), median with inter quartile range, or numbers with percentages to present baseline characteristics of participants when appropriate. One-way analysis of variance, the KruskalWallis tests for continuous variables or two-sided 2 tests for categorical variables were introduced for statistical evaluations of demographic and behavioral characteristics, as well as anthropometric and biochemical characteristics among the six BMI-metabolic status phenotypes at baseline. Bonferroni corrections were applied for multiple comparisons. Person-year was calculated from the baseline survey until participants were lost to follow-up or at the end of the follow-up period (August, 2020), and the incidence density of diabetes was calculated per 100 person-years. Given the correlations between repetitive observations at each follow-up examination in the longitudinal study, which violated independence assumptions required for traditional regression procedures,26 and to increase the analytical power, robust generalized estimating equation (GEE) models with a binary distribution using a log link and exchange structure were applied for the pooled analysis sample. The correlation coefficients between two repetitive outcome measurements at each follow-up times were approximately equal (Supplementary Table S1). Risk ratios (RRs) and 95% confidence intervals (CIs) were adopted to estimate associations of BMI-metabolic status phenotypes with diabetes. We also carried out several analyses adjusted for potential confounding variables in multivariable models sequentially. Model a was adjusted for follow-up time, age, and gender. Model b was adjusted for follow-up time, demographic characteristics (age, gender, education level, drug history, history of chronic disease and family history of diabetes) and behavioral characteristics (smoking status, drinking status, and regular physical activity). Additionally, baseline characteristics were compared between participants in our cohort and those who were lost to follow-up (Supplementary Table S2). Sensitivity analyses were also undertaken to assess the stability and robustness of our findings. We re-ran the analysis for patients with unmodified BMI-metabolic status phenotype and we also excluded those with prediabetes who showed impaired fasting glycaemia (IFG) (6.1 mmol/L FPG level<7.0 mmol/L and/or 2hFPG level<7.8 mmol/L) and impaired glucose tolerance (IGT) (FPG level<7.0 mmol/L and/or 7.8 2hFPG level<11.1 mmol/L),23 to examine whether the results were consistent. Stata software (version 15.1, College Station, Texas) was applied for all the statistical analyses, with two-sided P-values < 0.05 indicating the statistical significance level.

Of 4195 participants invited to join the cohort, 3641 (86.79%) were included in our final analyses. Hence, a total sample of 9623 observations (April to July, 2017: n = 3641; July to August, 2018: n = 3007; July to August, 2020: n = 2975) were pooled for the longitudinal data analysis (Figure 1). Briefly, the mean (SD) age of the total 3641 individuals was 51.61 (8.75) years at study entry. The distribution of ATP III criteria for metabolic status between metabolic healthy and unhealthy was present in Supplementary Figure S2. The prevalence of MH-NW, MH-OW, MHO, MU-NW, MU-OW and MUO was 28.56%, 23.21%, 5.36%, 6.95%, 21.51% and 14.42% at baseline, respectively. The baseline demographic and behavioral characteristics, as well as anthropometric and biochemical characteristics, were compared among six BMI-metabolic status phenotypes and summarized in Table 1. There were significant differences detected for age, gender, drug history, history of chronic disease, drinking status and regular physical activity among different phenotypes (P < 0.05). Additionally, education level, family history of diabetes and smoking status were comparable (P > 0.05). The MH-OW, MHO, MU-NW, MU-OW and MUO phenotypes showed significantly higher values of all the anthropometric characteristics than MH-NW (Table 1). In terms of biochemical characteristics, there were significant differences among different phenotypes (P < 0.01) (Table 1).

Table 1 Baseline Characteristics of the Body Mass Index-Metabolic Status Phenotypes

The cohort with an average follow-up time of 1.64 years per person included 3641 participants and a total of 5982 person-years. During the follow-up period, 415 cases of new-onset diabetes occurred and the overall incidence density was 6.94% person-years. Among the six BMI-status phenotypes defined at baseline, MUO showed the highest incidence density of DM (12.08% person-years) at the end of follow-up (Table 2). The incidence density of DM increased with the BMI-metabolic status phenotypes transformation to metabolically unhealthy and greater BMI (Z=5.84, Ptrend < 0.001) (Table 2).

Table 2 Diabetes Incidence Density at the End of Follow-Up (Until August, 2020) Among Six Body Mass Index-Metabolic Status Phenotypes at Baseline

In the GEE model, associations of ATP III components, BMI categories and metabolic status with incident DM were analyzed and presented respectively in Table 3. All ATP III components were significantly associated with incident DM except LDL-C. Associations were detected between the number of metabolic unhealthy components found in an individual and DM (Table 3; Supplementary Figure S3). The RR for DM risk gradually increased with the increase in the number of components when compared with participants without any metabolically unhealthy components (Ptrend < 0.001) (Table 3).

Table 3 The Association of Body Mass Index, Metabolic Status and Adult Treatment Panel III Components with Diabetes

Compared with those of normal weight, only the obese group (Adjusted RR = 1.70; 95% CI=1.332.17; P < 0.001) presented an increased risk of DM. The metabolically unhealthy group showed an increased risk of incident DM when compared with metabolically healthy individuals (Adjusted RR = 2.48; 95% CI = 2.062.98; P < 0.001). Interaction analysis showed that BMI interacted multiplicatively with metabolic status to contribute to DM risk (Pinteraction = 0.015) (Table 3).

Interaction analyses failed to detect any significant association between BMI-metabolic status phenotypes and follow-up time (Pinteraction = 0.649). As is shown in Table 4, GEE analyses were further performed to detect the associations between BMI-metabolic status phenotypes and DM risk. It revealed that the MH-OW group were at a decreased risk of incident DM (Adjusted RR = 0.65; 95% CI = 0.470.90; P = 0.009) and no significant associations were found for MHO (Adjusted RR = 0.99; 95% CI = 0.631.53; P = 0.949) individuals when compared with the MH-NW phenotype. However, the MU-NW (Adjusted RR = 1.81; 95% CI = 1.282.55; P = 0.001), MU-OW (Adjusted RR = 2.02; 95% CI = 1.572.61; P < 0.001) and MUO phenotypes (Adjusted RR = 2.48; 95% CI = 1.893.26; P < 0.001) were associated with increased DM risk in comparison with MH-NW, among which the MUO phenotype showed the highest RR (Ptrend < 0.001) (Table 4).

Table 4 The Association Between Body Mass Index-Metabolic Status Phenotypes and Diabetes

In the stratified analyses, associations between BMI-metabolic phenotypes and DM risk were evaluated based on age and gender, separately. As is shown in Figure 2, only MU-OW (Adjusted RR = 2.11; 95% CI = 1.203.73; P = 0.010) and MUO (Adjusted RR = 2.37; 95% CI = 1.344.18; P = 0.003) phenotypes showed an increased diabetes risk in comparison with MH-NW among those individuals with age < 50 years. Those in the MU-NW (Adjusted RR = 2.12; 95% CI = 1.323.42; P = 0.002) MU-OW (Adjusted RR = 2.01; 95% CI = 1.352.99; P = 0.001) and MUO (Adjusted RR = 3.04; 95% CI = 2.024.56; P < 0.001) groups seemed more likely to suffer DM across all phenotypes among individuals aged 50 to 59 years. For the age groups 60, similar results were found to those for the main analysis of the total sample and no significant association was detected for the MU-NW phenotype (Figure 2; Supplementary Table S3). For male participants, MH-OW (Adjusted RR = 0.54; 95% CI = 0.350.82; P = 0.004) presented a decreased risk of DM compared with MH-NW, while, only the MU-OW (Adjusted RR = 1.54; 95% CI = 1.062.24; P = 0.025) and MUO (Adjusted RR = 1.73; 95% CI = 1.172.57; P = 0.006) phenotypes showed increased risk. Meanwhile, the associations of MU-NW, MU-OW and MUO with DM risk were more evident in female individuals (P < 0.001) (Figure 3; Supplementary Table S4).

Figure 2 The association of body mass index-metabolic status phenotypes with diabetes in an analysis stratified by age. Adjusted for follow-up time, demographic characteristics (gender, education level, drug history, history of chronic disease and family history of diabetes) and behavioral characteristics (smoking status, drinking status, regular physical activity).

Abbreviation: BMI, body mass index.

Figure 3 The association of body mass index-metabolic status phenotypes with diabetes in an analysis stratified by gender. Adjusted for follow-up time, demographic characteristics (age (numeric), education level, drug history, history of chronic disease and family history of diabetes) and behavioral characteristics (smoking status, drinking status, regular physical activity).

Abbreviation: BMI, body mass index.

A series of sensitivity analyses were undertaken to examine the robustness of our findings. The results of the analysis in patients with unmodified BMI-metabolic status phenotype were similar to the main results except that it failed to detect the association between MH-OW and DM risk (Supplementary Table S5). After removing participants with IFG/IGT, the results of sensitivity analysis were consistent with those outcomes reported in the main analysis (Supplementary Table S6). We also conducted sensitivity analyses of stratification based on age and gender, and the results did not essentially change (Supplementary Tables S7S10).

Furthermore, comparison of baseline characteristics was also carried out between the participants who were included in the analytic sample and those excluded because of loss to follow-up (Supplementary Table S2). No statistically significant difference was detected for the distribution of BMI-metabolic status phenotypes at baseline between the study population and individuals who were lost to follow-up (P > 0.05) (Supplementary Table S2).

Diabetes is a serious, long-term condition, which is considered as burdensome and costly disease.2 An epidemiological study reveals that 11% of Chinese people have suffered from DM, with a significant proportion remaining undiagnosed.5 As a result, the challenges for developing integrated care for DM and its complications are numerous in China.27 Hence, we should put emphasis on early screening of the high-risk population in the prevention of diabetes. In addition, obesity is expanding worldwide, and it has also become a major public health problem in China.2830 A previous study suggested that obesity is a condition which is related to multiple medical, psychological and social problems, and the most harmful could be DM.31 Considering that DM risk might vary among obese sub-phenotypes,28 stratification of obesity could be used to identify and target people at risk effectively, aiming at efficient distribution of limited financial resources. However, current guidelines for obesity management are not adequately supported by evidence from clinical studies among Chinese populations.32 In our study, we evaluated the effect of metabolic health status and obesity phenotypes on the DM risk in the Chinese population. MU-NW, MU-OW and MUO individuals were at increased risk for DM, in contrast to MH-OW and MHO phenotypes. As far as we know, this is the first study to use a GEE model, which took repeated data obtained at each follow-up in a longitudinal study into consideration, to examine the effect of metabolic health alongside obesity phenotypes on DM risk in the Chinese population.

The associations of obese phenotypes and DM risk have been evaluated by several studies, but the results remain controversial.13,15,33 Until now, available studies have focused on prospective or retrospective cohort studies, analyzing MHO phenotype and DM by applying a logistic regression model or Cox proportional hazards regression model,13,14 which only take the baseline information into consideration and cannot take advantage of the data from repetitive measurements at each follow-up to analyze changes in each variable. In addition, previous studies put emphasis on MHO; the diabetes risk, especially among MH-OW, MU-NW, MU-OW and MUO phenotypes in comparison with MH-NW, remains less examined, especially for the Chinese population. Recently, a study conducted by Barkas et al aimed to investigate the relationship between MHO and T2DM risk in statin-treated patients and suggested that the MHO phenotype might not significantly increase the T2DM risk and that the metabolically unhealthy non-obese presented an increased risk,13 which were similar to the findings in our study. However, their study focused on statin-treated patients and set non-obesity as comparison. In our study, the participants were from a community-based prospective cohort study and the categories of BMI-metabolic status phenotypes were explicit and appropriate to detect the association. A study carried out by Wang et al without a 2-h OGTT test suggested that significantly increased risk of DM was detected for all the individuals with baseline MHO, MU-NW, and MUO phenotypes, which was not consistent with our findings. No significant association was found between MHO and DM risk in our study.15 A recent network meta-analysis suggested that MUO groups posed the highest risk for diabetes and MH-OW/ MHO/ MU-NW/ MU-OW individuals also showed increased risk when compared with MH-NW,34 presenting partially similar results to our study. Taken together, the inconsistency of studies mainly concentrates on the MHO/MH-OW phenotypes. Therefore, the possible reasons for controversy may be as follows: First, ethnicity and population were diverse. Second, in our study, MH-NW was set as the comparison when exploring the effect of BMI-metabolic status phenotypes on DM risk instead of using overweight and normal weight group as a combination. Third, the criteria of BMI were inconsistent with our study and inappropriate for the Chinese population. At present, the BMI ranges recommend by WHO are mainly suitable for the Western populations, among which the BMI range of 2529.9 kg/m2 was defined as overweight and BMI30 kg/m2 as obesity. Moreover, the BMI criteria proposed by scientists in Asian countries (overweight: 2324.9 kg/m2; obesity: 25 kg/m2) are also inappropriate for the Chinese population, because the Asian criteria did not include the data from mainland China and Taiwan China.18,35 It is important and necessary to define the optimal range for overweight and obesity in DM prevention among the Chinese population.18 Thus, the definition of BMI in our study was in accordance with the criteria of The Working Group on Obesity in China.18

MHO is a novel concept obtained by stratifying individuals with obesity according to metabolic status.7,36 The findings of our study highlighted the effect of metabolic health status in predicting incident DM, as decreased risk was found for MH-OW and no significant association was detected for MHO phenotype. Moreover, metabolic abnormalities may play a much more important role in developing DM rather than exclusively BMI, as MU-NW, MU-OW and MUO all posed increased risk in our study. Interestingly, our study also showed that only in the older groups (more than 60 years) can the MH-OW phenotype be significantly associated with decreased risk of DM. A study suggested that obesity might not be diabetogenic, and not all metabolically healthy individuals with obesity were at the same risk of diabetes onset.34 It has been proposed that adipose tissue as an endocrine organ produces different adipocytokines, which could be associated with wide range of metabolic diseases.37 Therefore, the diagnosis of obesity phenotypes should remain an indication to initiate prevention, even though the individuals with certain phenotypes without DM at the time of diagnosis.7 In recent years, studies have explored the effectiveness of weight loss by stratifying individuals according to obesity phenotypes.38,39 A previous study also suggested that MHO individuals could not benefit to the same extent as those with unhealthy obesity from interventions involving losing weight.7 Given the frequently unsuccessful anti-obesity interventions and limitations of healthcare resources,7,9 it is a challenge of clinical practice to identify which individuals with obesity may be able to benefit the most from interventions, especially for the prevention of DM. Nevertheless, current guidelines recommended for weight loss are aimed at all obesity with no distinction according to BMI-metabolic status phenotypes.32 Notably, DM poses a huge health burden on China, and the substantial increase of diabetes-related burden shows an uninterrupted challenge as well.40 Therefore, novel strategies for targeted DM prevention need to be developed. Given that the prevalence of obesity continues to escalate, a strategy based on different obese phenotypes is imperative to enhance the efficacy and effectiveness of the prevention of DM,36 with promising methods to prioritize and identify the high-risk individuals who could benefit greatly and be the most suitable for intervention. It is worth mentioning that the MUO phenotype presented the highest risk, and needs to be accorded much more importance. Our findings highlighted the MU-OW and MU-NW phenotypes are also important groups for targeted prevention.

Several merits of this study deserve to be pointed out. First, our findings were based on a longitudinal study, making full use of repeated measurement data obtained at each follow-up examinations, which clarified the time sequence of correlation and took the time-independent variables into account by using GEE models. Second, both demographic and behavioral characteristics were adjusted to minimize potential confounding. Sensitivity analyses also showed the consistency and robustness of the results. Third, it is an advantage in the delimitation of obesity phenotypes in our study that the focus on BMI criteria for the Chinese population and the use of ATP III criteria of metabolic status were much more stringent and clinically relevant for the Chinese population.

However, there are some limitations. First, potential bias could not be avoided in our study, because the information on behavioral characteristics, drug history, history of chronic disease and family history of DM was self-reported. Second, because of the lack of repetitive investigations on dietary habits and nutritional information during follow-up examinations, we have not adjusted for them in our present study. Additionally, lack of test item of insulin resistance is also a limitation. Moreover, the majority of participants in this study were rural inhabitants. Thus, it may not be representative of the general population of China, which limits the generalizability of our findings.

In summary, in the Chinese population, the MH-OW and MHO phenotypes did not show an increased risk of incident diabetes. MU-NW, MU-OW and MUO were found to show a significantly increased risk of DM. Future studies are needed to extend the findings and elucidate whether some BMI-metabolic status phenotypes can be targeted for optimizing prevention and therapeutic strategies to mitigate the obviously increased prevalence of DM.

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

This research is supported by the National Key Research and Development Program of China (2016YFC1305700).

All authors declared that they have no conflict of interests.

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The study found having a strong, black coffee to wake you up after a disturbed night's sleep could impair control of blood sugar levels.

Research from the Centre for Nutrition, Exercise & Metabolism at the University of Bath (UK) looked at the effect of broken sleep and morning coffee across a range of different metabolic markers.

The scientists showed that whilst one night of poor sleep has limited impact on our metabolism, drinking coffee as a way to rouse you from a slumber can have a negative effect on blood glucose (sugar) control.

To gather their findings, the physiologists at the University of Bath asked 29 healthy men and women to undergo three different overnight experiments in a random order:

READ MORE:Diabetes type 2 symptoms: Three subtle warning signs of high blood sugar in your hands

In each of these tests, blood samples from participants were taken following the glucose drink which in energy content (calories) mirrored what might typically be consumed for breakfast.

Their findings highlight that one night of disrupted sleep did not worsen participants' blood glucose/ insulin responses at breakfast, when compared to a normal night's sleep.

However, strong black coffee consumed before breakfast substantially increased the blood glucose response to breakfast by around 50 percent.

Although population-level surveys indicate that coffee may be linked to good health, past research has previously demonstrated that caffeine has the potential to cause insulin resistance.

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This new study therefore reveals that the common remedy of drinking coffee after a bad night's sleep may remedy the problem of feeling sleepy but could create another by limiting your body's ability to tolerate the sugar in your breakfast.

Professor James Betts, Co-Director of the Centre for Nutrition, Exercise and Metabolism at the University of Bath who oversaw the work, explained: "We know that nearly half of us will wake in the morning and, before doing anything else, drink coffee - intuitively the more tired we feel, the stronger the coffee.

"This study is important and has far-reaching health implications as up until now we have had limited knowledge about what this is doing to our bodies, in particular for our metabolic and blood sugar control.

"Put simply, our blood sugar control is impaired when the first thing our bodies come into contact with is coffee, especially after a night of disrupted sleep. We might improve this by eating first and then drinking coffee later if we feel we still need it. Knowing this can have important health benefits for us all."

Lead researcher, Harry Smith from the Department for Health at Bath added: "These results show that one night of disrupted sleep alone did not worsen participants' blood glucose/insulin response to the sugary drink compared to a normal night of sleep which will be reassuring to many of us. However, starting a day after a poor night's sleep with a strong coffee did have a negative effect on glucose metabolism by around 50 percent.

"As such, individuals should try to balance the potential stimulating benefits of caffeinated coffee in the morning with the potential for higher blood glucose levels and it may be better to consume coffee following breakfast rather than before.

"There is a lot more we need to learn about the effects of sleep on our metabolism, such as how much sleep disruption is necessary to impair our metabolism and what some of the longer-term implications of this are, as well as how exercise, for instance, could help to counter some of this."

Many people have type 2 diabetes without realising.

According to the NHS, this is because symptoms do not necessarily make you feel unwell.

Symptoms of type 2 diabetes include:

According to the NHS, you should see a GP if you have any of the symptoms of type 2 diabetes or you're worried you may have a higher risk of getting type 2 diabetes.

"You'll need a blood test, which you may have to go to your local health centre for if it cannot be done at your GP surgery."

Read more:
Diabetes type 2 warning: Study issues serious warning about having coffee in the morning - Daily Express

MORE people than ever are at risk of diabetes - and some may be developing it without a clue.

Charities have warned the UK is facing a diagnosis timebomb after many people missed vital GP appointments during the pandemic.

1

Already some 4.9 million people in the UK are estimated to have diabetes, of which there are various forms.

But of those, some 850,000 people are living with type 2 diabetes but are yet to be diagnosed - a figure up 150,000 in the last year, according to Diabetes UK.

Staggering stats reveal people can live for up to 10 years with type 2 diabetes - the most common type - before being diagnosed.

On top of this, some 2.1 million people have a blood sugar level that is higher than normal, but not bad enough to be diagnosed with diabetes.

This is called prediabetes, or borderline diabetes, and means a person is on track to get a diagnosis if they dont act fast.

There are likely to be many more who are not aware they are in this category.

A further 13.6 million people in the UK are at risk of developing type 2 diabetes - but many will not know.

These people are overweight - the key driver of type 2 diabetes. Having a family member with the disease or being African-Carribean are also example of risk factors.

These people can start making changes, such as eating healthier, to prevent a diagnosis as early as possible.

Meanwhile, the pandemic has had a huge impact on people already living with a diagnosis.

Diabetes is a complex disease to manage. But concerning figures show nearly 2.5million people already with the condition missed vital checks over Covid.

GPs have performed 41 per cent fewer health checks in the last year, analysis by Diabetes UK found in June.

The backlog could be putting sufferers at risk of Covid death, heart attacks and strokes among other complications.

The total number of cases of diabetes is expected to reach 5.5 million people by 2030.

Diabetes UK chief executive Chris Askew said: We're sitting on a diabetes timebomb. Missed appointments and missed or delayed diagnoses can devastate lives.

Prediabetes is a grey area.

It is when someones blood glucose levels are higher than normal but not yet high enough to be classed as diabetes.

In the UK, around 7 million people are estimated to have prediabetes, according to Diabetes.co.uk.

People often dont notice the symptoms and put them down to something else, such as their stress levels or their age

Experts say prediabetes is a critical stage in the development of the disease because this is when people still have the ability to slow down, or even halt, the condition.

But prediabetes has no symptoms, Dr Prash Vas, consultant in Diabetes at London Bridge Hospital, told The Telegraph.

He said: [Prediabetes] has no symptoms. As your blood sugar levels go higher, the body will mount symptoms.

Even this group of individuals can have complications, such as a three times higher risk of developing eye problems such as diabetic retinopathy. There is also an increased chance of developing kidney problems and early nerve damage.

According to Dan Howarth, head of care at Diabetes UK, symptoms of diabetes wont kick in till blood sugar levels are around 11mmol/L, even though anything above 7.8mmol/L after eating is considered too high.

Even then, people often dont notice the symptoms and put them down to something else, such as their stress levels or their age, Dr Howarth said.

If your doctor is concerned you have pre-diabetes they will usually do either a HbA1c test, a fasting plasma glucose (FPG) test, or an OGTT test.

The NHS says type 2 diabetes is often diagnosed following blood or urine tests for something else.

Symptoms of diabetes can go completely missed because people think they are caused by something else.

Or their symptoms dont necessarily make them feel unwell, so they are not even acknowledged.

The most common early signs of type 2 diabetes are frequent urination, extreme thirst, and persistent hunger.

You should visit your GP if you are:

There are other symptoms that may alert you to this disease.

These include:

Factors such as age, family history and ethnicity can increase a persons likelihood of having diabetes.

The condition usually develops slowly when someone is over the age of 40 years old.

However, the risk starts increasing from the age of 25 if you are African-Caribbean, Black African, or South Asian.

Generally studies have found that people of African-Caribbean, black African or south Asian descent are two to four times more likely to develop type 2 diabetes than those from a white background.

Obesity is fuelling type 2 diabetes, accounting for 80 to 85 per cent of someones chances of developing the condition.

Just because you have one or more risk factors for diabetes, it doesnt mean you will get it.

However, its best to be wary so that you can prevent the condition now. Because the symptoms of type 2 diabetes are not always obvious, its really important to be aware of these risk factors, charities say.

Risk factors include if you:

You can take the "Know Your Risk" for type 2 diabetes quiz to find out your risk of getting type 2 diabetes.

The rapid quiz asks about age, weight, if someone in the family has diabetes and if you have been told you have high blood pressure, for example.

It will then give a score between zero and 47 points.

The higher the risk level, the more likely it is that person will develop type 2 diabetes in the next 10 years. For example, one out of four people with high risk will get type 2 diabetes in the next 10 years.

If someones score is moderate or high they can refer themselves to a local service for support remotely or online, without having to go through a healthcare professional.

Read more from the original source:
Do you have hidden diabetes? The 15 signs to watch out for... - The US Sun

NEW YORK, July 20, 2021 /PRNewswire/ --JDRF, the leading global funder of Type 1 diabetes research, and the Association of Diabetes Care & Education Specialists, the largest organization dedicated to diabetes care and education specialists, proudly announce a new partnership. Together, the organizations seek to support the diabetes community through educational programs and resources to improve patient/healthcare professional dialogue and health outcomes.

"As an organization rooted in family, JDRF is excited to partner with the team at ADCES to continue supporting and enriching the T1D community," says Kristin Jahnke, JDRF director of community engagement. "By collaborating with healthcare providers throughout the ADCES network, we can increase the accessibility of our newly diagnosed resources and educational programs to serve the T1D community across the U.S.."

Utilizing the collaborative networks of both organizations, the partnerships aim to increase recipients of the JDRF Bag of Hope and the JDRF Teen and Adult No Limits care kits. Both organizations also hope to equip more healthcare professionals with the knowledge and tools to strengthen the relationship between those with Type 1 diabetes and healthcare providers.

"Diabetes care and education specialists are the front line in person-centered, quality care. We are honored to work with ADCES members and JDRF to support children and adults with Type 1 diabetes," said Kate Thomas, ADCES chief advocacy and external affairs officer. "Through this partnership, we hope to build bridges between healthcare professionals and the people with diabetes whom they serve. Together, we can improve outcomes and well-being for all."

JDRF and ADCES are committed to offering resources to help educate healthcare providers and support those with Type 1 diabetes throughout all stages of life. Health disparities affect numerous populations, including members of the diabetes community. It disproportionately affects Black, Hispanic, and Native American people and those living in rural and underserved communities. This collaboration will help both organizations reach a broader audience and offer resources to meet the needs of diverse communities.

About JDRFJDRF's mission is to accelerate life-changing breakthroughs to cure, prevent and treat T1D and its complications. To accomplish this, JDRF has invested more than $2.5 billion in research funding since our inception. We are an organization built on a grassroots model of people connecting in their local communities, collaborating regionally for efficiency and broader fundraising impact, and uniting on a national stage to pool resources, passion, and energy. We collaborate with academic institutions, policymakers, and corporate and industry partners to develop and deliver a pipeline of innovative therapies to people living with T1D. Our staff and volunteers throughout the United States and our five international affiliates are dedicated to advocacy, community engagement and our vision of a world without T1D. For more information, please visit jdrf.org or follow us on Twitter (@JDRF), Facebook (@myjdrf), and Instagram (@jdrfhq).

About the Association of Diabetes Care & Education Specialists: ADCES is an interdisciplinary professional membership organization dedicated to improving prediabetes, diabetes and cardiometabolic care through innovative education, management and support. With more than 12,000 professional members including nurses, dietitians, pharmacists and others, ADCES has a vast network of practitioners working to optimize care and reduce complications. ADCES offers an integrated care model that lowers the cost of care, improves experiences and helps its members lead so better outcomes follow. Learn more at DiabetesEducator.org, or visit us on Facebookor LinkedIn(Association of Diabetes Care & Education Specialists), Twitter (@ADCESdiabetes) and Instagram(@ADCESdiabetes).

SOURCE JDRF; Association of Diabetes Care & Education Specialists

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JDRF and the Association of Diabetes Care & Education Specialists announce new partnership - PRNewswire