Innovation in diabetic care : from patient-centered care to public policies to reduce the impact of diabetes

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2022Introdução A diabetes, nomeadamente a diabetes tipo 2, é uma doença crónica, que necessita de cuidados de saúde em continuidade, de longa duração e muitas vezes multidisciplinares. A diabetes consome vastos recursos de saúde, financeiros e de assistência social, exigindo, em todos os níveis de cuidados de saúde, e às famílias um grande esforço. Sendo uma doença que exige capacitação do paciente, literacia, adesão ao tratamento e promoção de comportamentos saudáveis, é também o paradigma de uma doença onde a relação com os profissionais de saúde e o cuidado centrado no paciente são fatores fundamentais para seu controle. A saúde tem sido palco de muitas inovações, tanto tecnológicas, como também de gestão, prática clínica, farmacológicas, dispositivos vários e uso da informação. Os cuidados na diabetes e outras doenças crónicas estão na linha de frente do desenvolvimento, testagem e implementação destas inovações, o que iremos ilustrar ao longo deste trabalho. Objetivo Identificar e analisar como a inovação nos cuidados prestados aos doentes com diabetes tem vindo a alterar a capacidade de prestar cuidados centrados no doente, e demonstrar abertura a novas iniciativas e ao desenvolvimento de políticas públicas de gestão em saúde, financiamento, tecnologia/informação e sociais com vista providenciar melhores cuidados e reduzir os impactos desta doença. Neste contexto, é nosso objetivo descrever, conceptualizar e sistematizar como a inovação tem evoluído e influenciado os cuidados ao paciente diabético e identificar os respetivos impactos. Métodos Procedeu-se à revisão da literatura usando as bases de dados PubMed, Scopus e Word of Science, pesquisando a associação entre diabetes tipo 2 e inovação. Foram encontrados 254 artigos. A partir da seleção desses trabalhos foi efetuada uma busca manual de artigos a descrever, ilustrar e avaliar as inovações identificadas, num total de 69 artigos.Resultados No âmbito dos cuidados aos doentes com diabetes, foram identificados dezasseis processos de inovação com inegável relevância em quatro áreas – três casos de inovação em gestão, quatro financeiras, seis tecnológicas e três de ação social. Conclusão Constata-se que as diversas categorias de inovação estão interligadas e são complementares, possibilitando oferecer melhores cuidados centrados no paciente, ao mesmo tempo que vislumbram a necessidade de proceder ao “redesenho” dos sistemas e serviços de saúde. Admite-se que, no futuro, a sua adequada integração acarretaria melhores cuidados e permitiria reduzir o impacto da diabetes, podendo vir a ser o modelo a utilizar no manejo de outras doenças crónicas.Background Diabetes, namely type-2 diabetes, is a chronic disease that requires continuous, long-term, and often multidisciplinary medical care. Diabetes consumes a vast amount of health, financial and social care resources, demanding great efforts at all levels of health care and families. As a disease that requires patient training, literacy, adherence to treatment, and the promotion of healthy behaviors, it is also the paradigm of a disease where health professionals’ relationship and patient-centered care are key factors for its control. Health has been the scene of many innovations, both technological, as well as management, clinical practice, medication, a wide variety of devices, and information uses. Diabetic, and of other chronic diseases, is at the forefront of the development, testing, and implementation of these innovations, which we will illustrate throughout this work. Aim Identify and analyze how innovation in care provided to patients with diabetes has been changing the ability to provide patient-centered care, and open-up new initiatives and development of public policies in health, financing, technological/information and social management with the view to provide better care and reduce the impacts of this disease. In this context, we will describe, conceptualize and systematize how innovation has evolved and influenced diabetic patient care and identify the respective impacts. Methods A literature review was carried out using PubMed, Scopus, and Word of Science databases, investigating the association between type 2 diabetes and innovation. Two hundred and fifty-four articles were found. From the research, a manual search of articles aiming to describe, exemplify, and evaluate the innovations in diabetes care, was carried out, resulting in a total of 69 articles.Results Four main areas were identified within the scope of diabetes patients’ care, in which innovation processes are present with undeniable relevance – management, financial, technological, and social action, which will be analyzed on the course of this work. Conclusion It was possible to observe that the different categories of innovation are interconnected and complementary, making it possible to offer better patient-centered care, while at the same time envisioning the need to “redesign” of health systems and services. It is accepted that, in the future, their appropriate integration would lead to better care and reduce the impact of diabetes, as well as potentially become the model that could be used in the management of other chronic diseases

Nutritional basis of type 2 diabetes remission.

Roy Taylor and colleagues explain how type 2 diabetes can be reversed by weight loss and avoidance of weight regai

Physiological and psychological determinants of long-term diet-induced type 2 diabetes (T2DM) remission:A narrative review

Type 2 diabetes mellitus (T2DM) is a highly prevalent metabolic disease, causing a heavy burden on healthcare systems worldwide, with related complications and anti-diabetes drug prescriptions. Recently, it was demonstrated that T2DM can be put into remission via significant weight loss using low-carbohydrate diets (LCDs) and very low-energy diets (VLEDs) in individuals with overweight and obesity. Clinical trials demonstrated remission rates of 25–77%, and metabolic improvements such as improved blood lipid profile and blood pressure were observed. In contrast, clinical trials showed that remission rate declines with time, concurrent with weight gain, or diminished weight loss. This review aims to discuss existing literature regarding underlying determinants of long-term remission of T2DM including metabolic adaptations to weight loss (e.g., role of gastrointestinal hormones), type of dietary intervention (i.e., LCDs or VLEDs), maintaining beta (β)-cell function, early glycemic control, and psychosocial factors. This narrative review is significant because determining the factors that are associated with challenges in maintaining long-term remission may help in designing sustainable interventions for type 2 diabetes remission.</p

Optimum nutritional strategies for cardiovascular disease prevention and rehabilitation (BACPR)

Nutrition has a central role in both primary and secondary prevention of cardiovascular disease (CVD) yet only relatively recently has food been regarded as a treatment, rather than as an adjunct to established medical and pharmacotherapy. As a field of research, nutrition science is constantly evolving making it difficult for patients and practitioners to ascertain best practice. This is compounded further by the inherent difficulties in performing double-blind randomised controlled trials. This paper covers dietary patterns that are associated with improved cardiovascular outcomes, including the Mediterranean Diet but also low-carbohydrate diets and the potential issues encountered with their implementation. We suggest there must be a refocus away from macronutrients and consideration of whole foods when advising individuals. This approach is fundamental to practice, as clinical guidelines have focussed on macronutrients without necessarily considering their source, and ultimately people consume foods containing multiple nutrients. The inclusion of food-based recommendations aids the practitioner to help the patient make genuine and meaningful changes in their diet. We advocate that the cardioprotective diet constructed around the traditional Mediterranean eating pattern (based around vegetables and fruits, nuts, legumes, and unrefined cereals, with modest amounts of fish and shellfish, and fermented dairy products) is still important. However there are other approaches that can be tried, including low-carbohydrate diets. We encourage practitioners to adopt a flexible dietary approach, being mindful of patient preferences and other comorbidities that may necessitate deviations away from established advice, and advocate for more dietitians in this field to guide the multi-professional team

Tennessee Diabetes Action Report, February 2021

https://digitalcommons.memphis.edu/govpubs-tn-dept-health-diabetes-action-report/1000/thumbnail.jp

Inflammatory potential of diet and bone mineral density in a senior Mediterranean population : a cross-sectional analysis of PREDIMED-Plus study

Inflammation could play a key role in tissue damage and bone metabolism. The modified dietary inflammatory score (M-DIS) is a validated tool to estimate the inflammatory potential of the diet. In the present study, we evaluate the associations between the M-DIS and bone mineral density (BMD) in a senior Mediterranean population with overweight/obesity and metabolic syndrome. Baseline cross-sectional association between the M-DIS and bone mineral density was assessed in 1134 participants of the multicenter PREDIMED-Plus trial (aged 55-75 with overweight/obesity and metabolic syndrome). BMD was measured using Dual-energy X-ray Absorptiometry scans and participants answered a food frequency questionnaire to determine the M-DIS. BMD was categorized as low BMD when T score was equal or lower than -1 and normal BMD in another case. Associations between BMD and M-DIS were evaluated by using linear and logistic regressions adjusted by other co-variates. Participants in the top tertile of the M-DIS had a lower BMD at total femur [β (95% CI) − 0.02 (− 0.04, − 0.01)], trochanter areas [β (95% CI) − 0.03 (− 0.05, − 0.01)] and lumbar spine area [β (95% CI) − 0.03 (− 0.07, 0.01)] (but in the last case, measures were less precise and hence not statistically significant) compared to those in the lower M-DIS tertile. Multiple logistic regression analyses showed that the odds of the total femur and femoral trochanter osteopenia/osteoporosis were higher in participants in the top tertile compared to those in the lowest tertile of M-DIS [OR (95% CI) 1.71 (1.12, 2.64), P for trend 0.015; 2.02 (1.29, 3.21), P for trend 0.002, respectively]. A high pro-inflammatory diet, measured by the M-DIS, is associated with lower BMD in a senior Mediterranean population with metabolic syndrome. The online version contains supplementary material available at 10.1007/s00394-021-02751-5

Relationships between hyperinsulinaemia, magnesium, vitamin D, thrombosis and COVID-19: rationale for clinical management

Risk factors for COVID-19 patients with poorer outcomes include pre-existing conditions: obesity, type 2 diabetes mellitus, cardiovascular disease (CVD), heart failure, hypertension, low oxygen saturation capacity, cancer, elevated: ferritin, C reactive protein (CRP) and D-dimer. A common denominator, hyperinsulinaemia, provides a plausible mechanism of action, underlying CVD, hypertension and strokes, all conditions typified with thrombi. The underlying science provides a theoretical management algorithm for the frontline practitioners. Vitamin D activation requires magnesium. Hyperinsulinaemia promotes: magnesium depletion via increased renal excretion, reduced intracellular levels, lowers vitamin D status via sequestration into adipocytes and hydroxylation activation inhibition. Hyperinsulinaemia mediates thrombi development via: fibrinolysis inhibition, anticoagulation production dysregulation, increasing reactive oxygen species, decreased antioxidant capacity via nicotinamide adenine dinucleotide depletion, haem oxidation and catabolism, producing carbon monoxide, increasing deep vein thrombosis risk and pulmonary emboli. Increased haem-synthesis demand upregulates carbon dioxide production, decreasing oxygen saturation capacity. Hyperinsulinaemia decreases cholesterol sulfurylation to cholesterol sulfate, as low vitamin D regulation due to magnesium depletion and/or vitamin D sequestration and/or diminished activation capacity decreases sulfotransferase enzyme SULT2B1b activity, consequently decreasing plasma membrane negative charge between red blood cells, platelets and endothelial cells, thus increasing agglutination and thrombosis. Patients with COVID-19 admitted with hyperglycaemia and/or hyperinsulinaemia should be placed on a restricted refined carbohydrate diet, with limited use of intravenous dextrose solutions. Degree/level of restriction is determined by serial testing of blood glucose, insulin and ketones. Supplemental magnesium, vitamin D and zinc should be administered. By implementing refined carbohydrate restriction, three primary risk factors, hyperinsulinaemia, hyperglycaemia and hypertension, that increase inflammation, coagulation and thrombosis risk are rapidly managed

Metabolic Phenotypes and Step by Step Evolution of Type 2 Diabetes: A New Paradigm.

Unlike bolus insulin secretion mechanisms, basal insulin secretion is poorly understood. It is essential to elucidate these mechanisms in non-hyperinsulinaemia healthy persons. This establishes a baseline for investigation into pathologies where these processes are dysregulated, such as in type 2 diabetes (T2DM), cardiovascular disease (CVD), certain cancers and dementias. Chronic hyperinsulinaemia enforces glucose fueling, depleting the NAD+ dependent antioxidant activity that increases mitochondrial reactive oxygen species (mtROS). Consequently, beta-cell mitochondria increase uncoupling protein expression, which decreases the mitochondrial ATP surge generation capacity, impairing bolus mediated insulin exocytosis. Excessive ROS increases the Drp1:Mfn2 ratio, increasing mitochondrial fission, which increases mtROS; endoplasmic reticulum-stress and impaired calcium homeostasis ensues. Healthy individuals in habitual ketosis have significantly lower glucagon and insulin levels than T2DM individuals. As beta-hydroxybutyrate rises, hepatic gluconeogenesis and glycogenolysis supply extra-hepatic glucose needs, and osteocalcin synthesis/release increases. We propose insulin's primary role is regulating beta-hydroxybutyrate synthesis, while the role of bone regulates glucose uptake sensitivity via osteocalcin. Osteocalcin regulates the alpha-cell glucagon secretory profile via glucagon-like peptide-1 and serotonin, and beta-hydroxybutyrate synthesis via regulating basal insulin levels. Establishing metabolic phenotypes aids in resolving basal insulin secretion regulation, enabling elucidation of the pathological changes that occur and progress into chronic diseases associated with ageing