Low carbohydrate meals or a small dose of insulin normalises one-hour blood glucose in a woman with normal glucose tolerance and elevated one-hour postload glucose: A case report

Diabetes is diagnosed by 2-hour BGL ≥ 11.1 mmol/L on OGTT, fasting BGL ≥ 7.0 mmol/L or HbA1C ≥ 6.5%. IFG and IGT are similarly diagnosed by elevated fasting and 2-hour BGLs. Although-hour BGL is routinely measured, results are classified as NGT if fasting and 2-hour levels are normal, irrespective of elevation at 1 hour. It has, however, been shown that 1-hour postload BGL is a strong predictor of future risk for type 2 diabetes and vascular disease, even in those with NGT. Additionally Meisinger et al. identified 1-hour postload glycaemia as a long-term predictor for all-cause mortality in men without diabetes. There is no normal range for 1-hour glucose, but ≥ 8.6 mmol/L has been identified as a cut-off marking increased cardiovascular and diabetes risk. It has been suggested that recognition and management of those with NGT and 1-hour glucose ≥ 8.6mmol/L may reduce incidence of diabetes and vascular events

Omitting follow-up food after initial hypoglycaemic treatment does not increase the likelihood of repeat hypoglycaemia

Introduction: Guidelines for self-treatment of hypoglycaemia specify initial treatment with quick-acting carbohydrate until blood glucose levels normalize and then follow-up with longer-acting carbohydrate. The few studies investigating follow-up show 29–57% omission or undertreatment with follow-up carbohydrate but do not investigate the association of this with repeat hypoglycaemia. This study aimed to develop, validate and administer a questionnaire to delineate this association. The timeframe targeted was 2 h post primary hypoglycaemic event (PPHE), the time influenced by long-acting carbohydrate. Methods: A questionnaire was generated, test–retest reliability assessed, and it was piloted on convenience samples from the target population. The final version was administered to all insulin-treated individuals attending an outpatient diabetes clinic over 4 weeks (169).Results: Questionnaire development: readability (69.6—standard/easy), test–retest reliability (Cohen’s kappa 0.57–0.91) and return rate (72.2%) were all acceptable. Questionnaire data: questionnaires were returned by 122 participants (63 males/59 females). Method of insulin administration was subcutaneous insulin injections (91%) and continuous subcutaneous insulin infusion (CSII) (9%). Repeat hypoglycaemia within 2 h PPHE was reported by 8.2% of respondents. There was no significant difference for age, gender and diabetes duration between those reporting repeat hypoglycaemia and those without. Consumption of follow-up longer-acting carbohydrate was reported by 58.2% of responders with 48% of these using long-acting and 52% medium-acting carbohydrate foods. Method of insulin administration and consumption of follow-up food were significantly associated with repeat hypoglycaemia (P = 0.015, 0.039) but presence or absence of symptoms and duration of action of carbohydrate were not significantly associated (P = 0.103, 0.629). Hierarchical logistic regression analysis showed omission of follow-up food PPHE was not a significant predictor of increased likelihood of repeat hypoglycaemia within 2 h PPHE, irrespective of method of insulin administration (P = 0.085). Conclusion: This study supports guidelines that recommend judicious, rather than routine use of follow-up longer-acting carbohydrate PPHE

Four Legs Good, Two Legs Bad? Animal Welfare vs the World Trade Organisation (Featuring Article XX of the General Agreement on Tariffs and Trade and Article 2 of the Technical Barriers to Trade

This article explores whether animal welfare can be deployed as a legitimate restriction on trade under the World Trade Organization framework. Article XX of the General Agreement on Tariffs and Trade and Article 2 of the Technical Barriers to Trade are traversed; along with the two relatively recent cases of US — Tuna II (DS381) and EC — Seal Products (DS400/401). While the World Trade Organization has traditionally demonstrated a reluctance to legitimise animal welfare based restrictions, contemporary World Trade Organization case law signals the possibility of a shifting landscape. The article argues that further development of coherent principles is required for the benefit of both animal welfare and trade certainty. This is particularly so in relation to the interrelated issues of extraterritoriality and coercion

Hypoglycemia in Insulin-Treated Adults on Established Nasogastric Feeding in the General Ward

Purpose: This study aimed to address 2 questions: First, what are the existing summary statistics of frequency of hypoglycemia in insulin-treated adults on established nasogastric feeding in the general ward? Second, to what extent does lack of homogeneity in defining, identifying, and reporting hypoglycemia affect these statistics? Methods: A systematic review of the literature documenting hypoglycemia in insulin-treated adults on nasogastric feeding for ≥ 3 days in the general ward was carried out. Data sources were PubMed, Embase, ProQuest, Cochrane, Directory of Open Access Journals, and PLoS. Search period was 1999 onward, postdating introduction of analog insulin. Results: Initially, 231 studies were identified, with 9 judged suitable for inclusion, according to inclusion/exclusion criteria. All included studies had as their primary objective the assessment of efficacy of insulin/feed regimens in the target population. Studies exhibited major heterogeneity. Definitions of hypoglycemia varied from < 60 mg/dL (3.3 mmol/L) to < 80 mg/dL (4.4 mmol/L), and 5 methods of reporting frequency of hypoglycemia were utilized, precluding pooled analysis. A descriptive synthesis of results was generated with some comparable results presented on a modified forest plot, showing 2.1% to 10.2% of patients with a hypoglycemic event and 1.1% to 5.4% blood glucose level < 70 mg/dL (3.9 mmol/L). Conclusions: Hypoglycemia is not uncommon in this population, but further research is needed for quantification. Standardized documentation and reporting methods incorporating sample size and study duration, such as hypoglycemic events per patient-days, would facilitate interstudy comparisons, as would documentation of hypoglycemia at the 2 most commonly defined levels: < 63 mg/dL (3.5 mmol/L) and < 70 mg/dL (3.9 mmol/L)

Hypoglycaemia in Inpatients with Diabetes on Nasogastric Feeding

Hypoglycaemia in patients with diabetes on nasogastric feeding is both potentially damaging and under-researched. We retrospectively reviewed 50 such inpatients to determine factors influencing hypoglycaemia. Our results showed 10.9% patient-days with =1 hypoglycaemic episode and 3.5% total blood glucose values <3.5mmol/L. There was an association between sulphonylurea treatment and increased and extended hypoglycaemia. Reducing diabetes treatment post-hypoglycaemia was associated with reduced subsequent hypoglycaemia but not increased hyperglycaemia.This study supports optimal blood glucose monitoring, insulin treatment and judicious medication reduction post-hypoglycaemia

Food selection for treatment of hypoglycaemia in insulin-treated diabetes: what happens in real life?

Hypoglycaemia is a feared complication of insulin-treated diabetes. Treatment recommendations vary worldwide and their implementation is poorly documented. The primary study objective was to assess adherence to broad guidelines of hypoglycaemic treatment; initially with quick-acting carbohydrate and follow up with long-acting carbohydrate. The secondary objective was to assess if initial treating carbohydrate quantity complied with current worldwide recommendations. Assessment was by questionnaire, which was validated, piloted and administered to all insulin-treated individuals attending routine outpatient diabetes clinic appointments over four weeks. The questionnaire response rate, readability and validity were acceptable at 74%, grade 6 level and 0.61 (Cohen's kappa), respectively. Assessment of broad guidelines for treatment of hypoglycaemia showed 78% of responders reported initial treatment with recommended foods, but only 40.8% of these were quick-acting carbohydrate. Only 55.8% reported ingesting follow-up food. Assessment of initial treating carbohydrate quantity showed 20.6% of responders used quantities exceeding all guidelines. Of the remaining, 46.4% used quantities consistent with the most liberal recommendations (European Association for the Study of Diabetes). Most study participants reported treating with recommended foods in quantities exceeding minimum recommendations, possibly attempting to resolve unpleasant symptoms of hypoglycaemia quickly. Failure of many to ingest follow-up food is concerning and warrants investigation. Increased patient education and standardisation of guidelines for treatment of hypoglycaemia are indicated