Diet and diabetes

Provides current evidence regarding the differing diets in diabetes prevention and management once type 2 diabetes mellitus (T2DM) arises, including the role in management of complications such as = hypoglycaemia. Background Guidelines for the prevention and management of type 2 diabetes mellitus (T2DM) reinforce lifestyle management, yet advice to guide general practitioners on principles around dietary choices is needed. Objective This article provides current evidence regarding the differing diets in diabetes prevention and management once T2DM arises, including the role in management of complications such as hypoglycaemia. Discussion Diets should incorporate weight maintenance or loss, while complementing changes in physical activity to optimise the metabolic effects of dietary advice. Using a structured, team-care approach supports pragmatic and sustainable individualised plans, while incorporating current evidence-based dietary approaches

Early type 2 diabetes treatment intensification with glucagon-like peptide-1 receptor agonists in primary care: An Australian perspective on guidelines and the global evidence

Early and intensive management of type 2 diabetes has been shown to delay disease progression, reduce the risk of cardiorenal complications and prolong time to treatment failure. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are being increasingly recognized for their potential in early disease management, with recent guideline updates recommending second-line use of this injectable drug class alongside oral glucose-lowering drugs. GLP-1RAs target at least six of the eight core defects implicated in the pathogenesis of type 2 diabetes and offer significant glycaemic and weight-related improvements over other second-line agents in head-to-head trials. In addition, placebo-controlled clinical trials have shown cardiovascular protection with GLP-1RA use. Even so, this therapeutic class is underused in primary care, largely owing to clinical inertia and patient-related barriers to early intensification with GLP-1RAs. Fortunately, clinicians can overcome barriers to treatment acceptance through patient education and training, and management of treatment expectations. In this review we comment on global and Australian guideline updates and evidence in support of early intensification with this therapeutic class, and provide clinicians with practical advice for GLP-1RA use in primary care

Sodium-glucose cotransporter 2 inhibitor effects on heart failure hospitalization and cardiac function: systematic review

Aims: To systematically review randomized controlled trials assessing effects of sodium–glucose cotransporter 2 inhibitors (SGLT2is) on hospitalization for heart failure (HHF) and cardiac structure/function and explore randomized controlled trial (RCT)-derived evidence for SGLT2i efficacy mechanisms in heart failure (HF). Methods and results: Systematic searches of Medline and Embase were performed. In seven trials [3730–17 160 patients; low risk of bias (RoB)], SGLT2is significantly reduced the relative risk of HHF by 27–39% vs. placebo, including in two studies in patients with HF with reduced ejection fraction with or without type-2 diabetes mellitus (T2DM). Improvements in conventional cardiovascular risk factors, including glycaemic levels, cannot account for these effects. Five trials (56–105 patients; low RoB) assessed the effects of 6–12 months of SGLT2i treatment on left ventricular structure/function; four reported significant improvements vs. placebo, and one did not. Five trials (low RoB) assessed SGLT2i treatment effects on serum N-terminal pro B-type natriuretic peptide levels; significant reductions vs. placebo were reported after 8–12 months (two studies; 3730–4744 patients) but not ≤12 weeks (three studies; 80–263 patients). Limited available RCT-derived evidence suggests various possible cardioprotective SGLT2i mechanisms, including improved haemodynamics (natriuresis and reduced interstitial fluid without blood volume contraction/neurohormonal activation) and vascular function, enhanced erythropoiesis, reduced tissue sodium and epicardial fat/inflammation, decreased sympathetic tone, and beneficial changes in cellular energetics. Conclusions: Sodium–glucose cotransporter 2 inhibitors reduce HHF regardless of T2DM status, and reversal of adverse left ventricular remodelling likely contributes to this efficacy. Hypothesis-driven mechanistic trials remain sparse, although numerous trials are planned or ongoing

Systematic review of the effects of sodium-glucose cotransporter 2 inhibitors on hospitalization for heart failure and cardiac structure or function, and exploratory assessment of potential mechanisms

In the past 5 years, there has been a profound shift in the therapeutic focus of trials of sodium-glucose cotransporter 2 inhibitors (SGLT2is). Although initially explored and introduced as glucose-lowering agents for patients with type 2 diabetes mellitus (T2DM), 1 clinical investigation of these molecules has evolved towards heart failure (HF) and chronic kidney disease (CKD) outcomes in patients with and without T2DM. We systematically reviewed randomized controlled trial (RCT) data assessing the effects of SGLT2 is compared with placebo on hospitalization for HF (HHF), cardiac structure and cardiac function, in a PRISMA-compliant manner. We also reviewed, in an exploratory manner, mechanistic evidence for how SGLT2 is may exert their benefits

Use of 50/50 premixed insulin analogs in Type 2 Diabetes: systematic review and clinical recommendations

IntroductionPremixed insulin analogs represent an alternative to basal or basal–bolus insulin regimens for the treatment of type 2 diabetes (T2D). “Low-mix” formulations with a low rapid-acting to long-acting analog ratio (e.g., 25/75) are commonly used, but 50/50 formulations (Mix50) may be more appropriate for some patients. We conducted a systematic literature review to assess the efficacy and safety of Mix50, compared with low-mix, basal, or basal–bolus therapy, for insulin initiation and intensification.MethodsMEDLINE, EMBASE, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, LillyTrials.com, and NovoNordisk-trials.com were searched (11 or 13 Dec 2016) using terms for T2D, premixed insulin analogs, and/or Mix50. Studies (randomized, nonrandomized, or observational; English only) comparing Mix50 with other insulins (except human) and reporting key efficacy [glycated hemoglobin (HbA1c), fasting and postprandial glucose] and/or safety (hypoglycemia, weight gain) outcomes were eligible for inclusion. Narrative reviews, letters, editorials, and conference abstracts were excluded. Risk of bias in randomized trials was assessed using the Cochrane tool.ResultsMEDLINE and EMBASE searches identified 716 unique studies, of which 32 met inclusion criteria. An additional three studies were identified in the other databases. All 19 randomized trials except one were open label; risk of other biases was generally low. Although not conclusive, the evidence suggests that Mix50 may provide better glycemic control (HbA1c reduction) and, particularly, postprandial glucose reduction in certain patients, such as those with high carbohydrate diets and Asian patients, than low-mix and basal therapy. Based on this evidence and our experience, we provide clinical guidance on factors to consider when deciding whether Mix50 is appropriate for individual patients.ConclusionsMix50 may be more suitable than low-mix therapy for certain patients. Clinicians should consider not only efficacy and safety but also patient characteristics and preferences when tailoring insulin treatment to individuals with T2D

General Practice Management of Type 2 Diabetes: 2016–18

[Extract] Diabetes is a national health priority. The Australian National Diabetes Strategy 2016–2020was released by the Australian Government in November 2013. The number of people with type 2 diabetes is growing, most likely the result of rising overweight and obesity rates, lifestyle and dietary changes, and an ageing population. Within 20 years, the number of people in Australia with type 2 diabetes may increase from an estimated 870,000 in 2014, to more than 2.5 million.1The most socially disadvantaged Australians are twice as likely to develop diabetes. If left undiagnosed or poorly managed, type 2 diabetes can lead to coronary artery disease (CAD), stroke, kidney failure, limb amputations and blindness. The early identification and optimal management of people with type 2 diabetes is therefore critical. General practice has the central role in type 2 diabetes management across the spectrum, from identifying those at risk right through to caring for patients at the end of life. These guidelines give up-to-date, evidence-based information tailored for general practice to support general practitioners (GPs) and their teams in providing high-quality management.1In the development of the 2016–18 edition of General practice management of type 2 diabetes, The Royal Australian College of General Practitioners (RACGP) has focused on factors relevant to current Australian clinical practice. The RACGP has used the skills and knowledge of your general practice peers who have an interest in diabetes management and are members of the RACGP Specific Interests Diabetes Network. This publication has been produced in accordance with the rules and processes outlined in the RACGP’s conflict of interest (COI) policy. The RACGP’s COI policy is available at www.racgp.org.au/support/policies/organisationalThis edition represents 19 years of a successful relationship between the RACGP and Diabetes Australia. We acknowledge the support of the RACGP Expert Committee – Quality Care, the Medical Education and Scientific Committee of Diabetes Australia, and RACGP staff in the development of these guideline

Shared medical appointments and mindfulness for Type 2 diabetes : a mixed-methods feasibility study

Introduction: Type 2 diabetes (T2DM) is a major health concern with significant personal and healthcare system costs. There is growing interest in using shared medical appointments (SMAs) for management of T2DM. We hypothesize that adding mindfulness to SMAs may be beneficial. This study aimed to assess the feasibility and acceptability of SMAs with mindfulness for T2DM within primary care in Australia. Materials and Methods: We conducted a single-blind randomized controlled feasibility study of SMAs within primary care for people with T2DM living in Western Sydney, Australia. People with T2DM, age 21 years and over, with HbA1c > 6.5% or fasting glucose >7.00 mmol/L within the past 3 months were eligible to enroll. The intervention group attended six 2-h programmed SMAs (pSMAs) which were held fortnightly. pSMAs included a structured education program and mindfulness component. The control group received usual care from their healthcare providers. We collected quantitative and qualitative data on acceptability as well as glycemic control (glycated hemoglobin and continuous glucose monitoring), lipids, anthropometric measures, blood pressure, selfreported psychological outcomes, quality of life, diet, and physical activity using an ActiGraph accelerometer. Results: Over a 2-month period, we enrolled 18 participants (10 females, 8 males) with a mean age of 58 years (standard deviation 9.8). We had 94.4% retention. All participants in the intervention group completed at least four pSMAs. Participants reported that attending pSMAs had been a positive experience that allowed them to accept their diagnosis and empowered them to make changes, which led to beneficial effects including weight loss and better glycemic control. Four pSMA participants found the mindfulness component helpful while two did not. All of the seven participants who contributed to qualitative evaluation reported improved psychosocial wellbeing and found the group setting beneficial. There was a significant difference in total cholesterol levels at 12 weeks between groups (3.86 mmol/L in intervention group vs. 4.15 mmol/L in the control group; p = 0.025) as well as pain intensity levels as measured by the PROMIS-29 (2.11 vs. 2.38; p = 0.034). Conclusion: pSMAs are feasible and acceptable to people with T2DM and may result in clinical improvement. A follow-up fully-powered randomized controlled trial is warranted. Clinical Trial Registration: Australia and New Zealand Clinical Trial Registry, identifier ACTRN12619000892112

Introduction to diabetes

This chapter contains sections titled: * Incidence and prevalence of diabetes * Overview of diabetes * Management strategies * Management targets and regimens * Short-term complications * Long-term complications * Psychological aspects * Diabetes management requires integrated approaches * People with diabetes\u27 needs, capacities and resources * Health professionals\u27 needs * Integration - is it possible? * Complementary therapies * Summary * References<br /

Protocol for a rapid evidence review of traditional and complementary medicine for people with diabetes receiving palliative or end-of-life care

Background: Rapid review methods are increasingly used as an alternative to systematic reviews when there is time, resource or other logistical constraints. The Cochrane Rapid Reviews Methods Group recommends further methodological development and publishing protocols to improve the transparency and quality of the review. The authors of this paper were invited to provide timely, expert input for the revision of the 2010 Guidelines for Providing Palliative and End of Life Care for People with Diabetes (Guidelines), Australia, regarding the evidence-based use of traditional and complementary medicine (T&CM). The inclusion and consideration of T&CM in guidelines is often ad-hoc and would benefit from more systematic methods. Evidence of efficacy on clinical outcomes is not the only reason to review an intervention. Other reasons relevant to the T&CM context is: interventions that are commonly used by people with diabetes in the palliative care setting, have potentially high costs or risks, or present a conflict in choices between individual and societal perspectives. Method: The aim this review is to rapidly identify and synthesise the highest quality evidence about the safety and efficacy of a selection of T&CM interventions and provide timely information to update the Guidelines. The review has two stages 1) a rapid scoping review to inform the framing of the review questions and identify important modifying factors and 2) a rapid evidence review of up to 20 T&CM interventions to inform the Guidelines. Project constraints include limiting the number of interventions for appraisal and databases to be searched, and including only papers published in English. Searches and evidence appraisals will be conducted by single reviewers, with one tenth to be checked by another reviewer. No meta-analyses or modelling will be undertaken. Discussion: The proposed rapid review protocol is designed to address the time and resource constraints of the Guidelines developers, and inform rapid review methodology. Notwithstanding the methodological constraints, the proposed protocol and its reporting will be transparent, systematic and reproducible

Managing Obesity in Primary Care: Breaking down the Barriers

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