case study type 2 diabetic

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Case study: a patient with uncontrolled type 2 diabetes and complex comorbidities whose diabetes care is managed by an advanced practice nurse.

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Geralyn Spollett; Case Study: A Patient With Uncontrolled Type 2 Diabetes and Complex Comorbidities Whose Diabetes Care Is Managed by an Advanced Practice Nurse. Diabetes Spectr 1 January 2003; 16 (1): 32–36. https://doi.org/10.2337/diaspect.16.1.32

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The specialized role of nursing in the care and education of people with diabetes has been in existence for more than 30 years. Diabetes education carried out by nurses has moved beyond the hospital bedside into a variety of health care settings. Among the disciplines involved in diabetes education, nursing has played a pivotal role in the diabetes team management concept. This was well illustrated in the Diabetes Control and Complications Trial (DCCT) by the effectiveness of nurse managers in coordinating and delivering diabetes self-management education. These nurse managers not only performed administrative tasks crucial to the outcomes of the DCCT, but also participated directly in patient care. 1

The emergence and subsequent growth of advanced practice in nursing during the past 20 years has expanded the direct care component, incorporating aspects of both nursing and medical care while maintaining the teaching and counseling roles. Both the clinical nurse specialist (CNS) and nurse practitioner (NP) models, when applied to chronic disease management, create enhanced patient-provider relationships in which self-care education and counseling is provided within the context of disease state management. Clement 2 commented in a review of diabetes self-management education issues that unless ongoing management is part of an education program, knowledge may increase but most clinical outcomes only minimally improve. Advanced practice nurses by the very nature of their scope of practice effectively combine both education and management into their delivery of care.

Operating beyond the role of educator, advanced practice nurses holistically assess patients’ needs with the understanding of patients’ primary role in the improvement and maintenance of their own health and wellness. In conducting assessments, advanced practice nurses carefully explore patients’ medical history and perform focused physical exams. At the completion of assessments, advanced practice nurses, in conjunction with patients, identify management goals and determine appropriate plans of care. A review of patients’ self-care management skills and application/adaptation to lifestyle is incorporated in initial histories, physical exams, and plans of care.

Many advanced practice nurses (NPs, CNSs, nurse midwives, and nurse anesthetists) may prescribe and adjust medication through prescriptive authority granted to them by their state nursing regulatory body. Currently, all 50 states have some form of prescriptive authority for advanced practice nurses. 3 The ability to prescribe and adjust medication is a valuable asset in caring for individuals with diabetes. It is a crucial component in the care of people with type 1 diabetes, and it becomes increasingly important in the care of patients with type 2 diabetes who have a constellation of comorbidities, all of which must be managed for successful disease outcomes.

Many studies have documented the effectiveness of advanced practice nurses in managing common primary care issues. 4 NP care has been associated with a high level of satisfaction among health services consumers. In diabetes, the role of advanced practice nurses has significantly contributed to improved outcomes in the management of type 2 diabetes, 5 in specialized diabetes foot care programs, 6 in the management of diabetes in pregnancy, 7 and in the care of pediatric type 1 diabetic patients and their parents. 8 , 9 Furthermore, NPs have also been effective providers of diabetes care among disadvantaged urban African-American patients. 10 Primary management of these patients by NPs led to improved metabolic control regardless of whether weight loss was achieved.

The following case study illustrates the clinical role of advanced practice nurses in the management of a patient with type 2 diabetes.

A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 118–127 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lb.”), but no further action was taken.

Referred by his family physician to the diabetes specialty clinic, A.B. presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon.

A.B. also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken chromium picolinate, gymnema sylvestre, and a “pancreas elixir” in an attempt to improve his diabetes control. He stopped these supplements when he did not see any positive results.

He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. “What would knowing the numbers do for me?,” he asks. “The doctor already knows the sugars are high.”

A.B. states that he has “never been sick a day in my life.” He recently sold his business and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies.

During the past year, A.B. has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG).

A.B.’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.”

The medical documents that A.B. brings to this appointment indicate that his hemoglobin A 1c (A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health. 11

A.B. has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.

Physical Exam

A physical examination reveals the following:

Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6 kg/m 2

Fasting capillary glucose: 166 mg/dl

Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg

Pulse: 88 bpm; respirations 20 per minute

Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy

Thyroid: nonpalpable

Lungs: clear to auscultation

Heart: Rate and rhythm regular, no murmurs or gallops

Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally

Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle

Lab Results

Results of laboratory tests (drawn 5 days before the office visit) are as follows:

Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)

Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)

Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)

Sodium: 141 mg/dl (normal range: 135–146 mg/dl)

Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)

Lipid panel

• Total cholesterol: 162 mg/dl (normal: <200 mg/dl)

• HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)

• LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)

• Triglycerides: 177 mg/dl (normal: <150 mg/dl)

• Cholesterol-to-HDL ratio: 3.8 (normal: <5.0)

AST: 14 IU/l (normal: 0–40 IU/l)

ALT: 19 IU/l (normal: 5–40 IU/l)

Alkaline phosphotase: 56 IU/l (normal: 35–125 IU/l)

A1C: 8.1% (normal: 4–6%)

Urine microalbumin: 45 mg (normal: <30 mg)

Based on A.B.’s medical history, records, physical exam, and lab results, he is assessed as follows:

Uncontrolled type 2 diabetes (A1C >7%)

Obesity (BMI 32.4 kg/m 2 )

Hyperlipidemia (controlled with atorvastatin)

Peripheral neuropathy (distal and symmetrical by exam)

Hypertension (by previous chart data and exam)

Elevated urine microalbumin level

Self-care management/lifestyle deficits

• Limited exercise

• High carbohydrate intake

• No SMBG program

Poor understanding of diabetes

A.B. presented with uncontrolled type 2 diabetes and a complex set of comorbidities, all of which needed treatment. The first task of the NP who provided his care was to select the most pressing health care issues and prioritize his medical care to address them. Although A.B. stated that his need to lose weight was his chief reason for seeking diabetes specialty care, his elevated glucose levels and his hypertension also needed to be addressed at the initial visit.

The patient and his wife agreed that a referral to a dietitian was their first priority. A.B. acknowledged that he had little dietary information to help him achieve weight loss and that his current weight was unhealthy and “embarrassing.” He recognized that his glucose control was affected by large portions of bread and pasta and agreed to start improving dietary control by reducing his portion size by one-third during the week before his dietary consultation. Weight loss would also be an important first step in reducing his blood pressure.

The NP contacted the registered dietitian (RD) by telephone and referred the patient for a medical nutrition therapy assessment with a focus on weight loss and improved diabetes control. A.B.’s appointment was scheduled for the following week. The RD requested that during the intervening week, the patient keep a food journal recording his food intake at meals and snacks. She asked that the patient also try to estimate portion sizes.

Although his physical activity had increased since his retirement, it was fairly sporadic and weather-dependent. After further discussion, he realized that a week or more would often pass without any significant form of exercise and that most of his exercise was seasonal. Whatever weight he had lost during the summer was regained in the winter, when he was again quite sedentary.

A.B.’s wife suggested that the two of them could walk each morning after breakfast. She also felt that a treadmill at home would be the best solution for getting sufficient exercise in inclement weather. After a short discussion about the positive effect exercise can have on glucose control, the patient and his wife agreed to walk 15–20 minutes each day between 9:00 and 10:00 a.m.

A first-line medication for this patient had to be targeted to improving glucose control without contributing to weight gain. Thiazolidinediones (i.e., rosiglitizone [Avandia] or pioglitizone [Actos]) effectively address insulin resistance but have been associated with weight gain. 12 A sulfonylurea or meglitinide (i.e., repaglinide [Prandin]) can reduce postprandial elevations caused by increased carbohydrate intake, but they are also associated with some weight gain. 12 When glyburide was previously prescribed, the patient exhibited signs and symptoms of hypoglycemia (unconfirmed by SMBG). α-Glucosidase inhibitors (i.e., acarbose [Precose]) can help with postprandial hyperglycemia rise by blunting the effect of the entry of carbohydrate-related glucose into the system. However, acarbose requires slow titration, has multiple gastrointestinal (GI) side effects, and reduces A1C by only 0.5–0.9%. 13 Acarbose may be considered as a second-line therapy for A.B. but would not fully address his elevated A1C results. Metformin (Glucophage), which reduces hepatic glucose production and improves insulin resistance, is not associated with hypoglycemia and can lower A1C results by 1%. Although GI side effects can occur, they are usually self-limiting and can be further reduced by slow titration to dose efficacy. 14

After reviewing these options and discussing the need for improved glycemic control, the NP prescribed metformin, 500 mg twice a day. Possible GI side effects and the need to avoid alcohol were of concern to A.B., but he agreed that medication was necessary and that metformin was his best option. The NP advised him to take the medication with food to reduce GI side effects.

The NP also discussed with the patient a titration schedule that increased the dosage to 1,000 mg twice a day over a 4-week period. She wrote out this plan, including a date and time for telephone contact and medication evaluation, and gave it to the patient.

During the visit, A.B. and his wife learned to use a glucose meter that features a simple two-step procedure. The patient agreed to use the meter twice a day, at breakfast and dinner, while the metformin dose was being titrated. He understood the need for glucose readings to guide the choice of medication and to evaluate the effects of his dietary changes, but he felt that it would not be “a forever thing.”

The NP reviewed glycemic goals with the patient and his wife and assisted them in deciding on initial short-term goals for weight loss, exercise, and medication. Glucose monitoring would serve as a guide and assist the patient in modifying his lifestyle.

A.B. drew the line at starting an antihypertensive medication—the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec), 5 mg daily. He stated that one new medication at a time was enough and that “too many medications would make a sick man out of me.” His perception of the state of his health as being represented by the number of medications prescribed for him gave the advanced practice nurse an important insight into the patient’s health belief system. The patient’s wife also believed that a “natural solution” was better than medication for treating blood pressure.

Although the use of an ACE inhibitor was indicated both by the level of hypertension and by the presence of microalbuminuria, the decision to wait until the next office visit to further evaluate the need for antihypertensive medication afforded the patient and his wife time to consider the importance of adding this pharmacotherapy. They were quite willing to read any materials that addressed the prevention of diabetes complications. However, both the patient and his wife voiced a strong desire to focus their energies on changes in food and physical activity. The NP expressed support for their decision. Because A.B. was obese, weight loss would be beneficial for many of his health issues.

Because he has a sedentary lifestyle, is >35 years old, has hypertension and peripheral neuropathy, and is being treated for hypercholestrolemia, the NP performed an electrocardiogram in the office and referred the patient for an exercise tolerance test. 11 In doing this, the NP acknowledged and respected the mutually set goals, but also provided appropriate pre-exercise screening for the patient’s protection and safety.

In her role as diabetes educator, the NP taught A.B. and his wife the importance of foot care, demonstrating to the patient his inability to feel the light touch of the monofilament. She explained that the loss of protective sensation from peripheral neuropathy means that he will need to be more vigilant in checking his feet for any skin lesions caused by poorly fitting footwear worn during exercise.

At the conclusion of the visit, the NP assured A.B. that she would share the plan of care they had developed with his primary care physician, collaborating with him and discussing the findings of any diagnostic tests and procedures. She would also work in partnership with the RD to reinforce medical nutrition therapies and improve his glucose control. In this way, the NP would facilitate the continuity of care and keep vital pathways of communication open.

Advanced practice nurses are ideally suited to play an integral role in the education and medical management of people with diabetes. 15 The combination of clinical skills and expertise in teaching and counseling enhances the delivery of care in a manner that is both cost-reducing and effective. Inherent in the role of advanced practice nurses is the understanding of shared responsibility for health care outcomes. This partnering of nurse with patient not only improves care but strengthens the patient’s role as self-manager.

Geralyn Spollett, MSN, C-ANP, CDE, is associate director and an adult nurse practitioner at the Yale Diabetes Center, Department of Endocrinology and Metabolism, at Yale University in New Haven, Conn. She is an associate editor of Diabetes Spectrum.

Note of disclosure: Ms. Spollett has received honoraria for speaking engagements from Novo Nordisk Pharmaceuticals, Inc., and Aventis and has been a paid consultant for Aventis. Both companies produce products and devices for the treatment of diabetes.

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Nutrient patterns and risk of diabetes mellitus type 2: a case-control study

Morteza haramshahi 1 ,
Thoraya Mohamed Elhassan A-Elgadir 2 ,
Hamid Mahmood Abdullah Daabo 3 ,
Yahya Altinkaynak 4 ,
Ahmed Hjazi 5 ,
Archana Saxena 6 ,
Mazin A.A. Najm 7 ,
Abbas F. Almulla 8 ,
Ali Alsaalamy 9 &
Mohammad Amin Kashani 10

BMC Endocrine Disorders volume 24 , Article number: 10 ( 2024 ) Cite this article

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Backgrounds

Although the significance of diet in preventing or managing diabetes complications is highlighted in current literature, there is insufficient evidence regarding the correlation between nutrient patterns and these complications. The objective of this case-control study is to investigate this relationship by analyzing the dietary intake of nutrients in participants with and without type 2 diabetes (T2D).

A case-control study was conducted at the Tabriz Center of Metabolism and Endocrinology to investigate the relationship between nutrient patterns and type 2 diabetes (T2D). The study enrolled 225 newly diagnosed cases of T2D and 225 controls. The dietary intake of nutrients was assessed using a validated semi-quantitative food frequency questionnaire (FFQ). Principal component analysis using Varimax rotation was used to obtain nutrient patterns. Logistic regression analysis was performed to estimate the risk of T2D.

The participants’ mean (SD) age and BMI were 39.8 (8.8) years and 27.8 (3.6) kg/m2, respectively. The results identified three major nutrient patterns. The first nutrient pattern was characterized by high consumption of sucrose, animal protein, vitamin E, vitamin B1, vitamin B12, calcium, phosphorus, zinc, and potassium. The second nutrient pattern included fiber, plant protein, vitamin D, Riboflavin, Vitamin B5, copper, and Magnesium. The third nutrient pattern was characterized by fiber, plant protein, vitamin A, riboflavin, vitamin C, calcium, and potassium. Individuals in the highest tertile of nutrient pattern 3 (NP3) had a lower risk of T2D compared to those in the lowest tertile after adjusting for confounders. The odds ratio was 0.52 with a 95% confidence interval of 0.30–0.89 and a P_trend of 0.039.

This study found that conforming to a nutrient pattern consisting of plant protein, vitamin C, vitamin A, vitamin B2, potassium, and calcium is linked to a lower likelihood of developing T2D.The initial results suggest that following a nutrient pattern that includes these nutrients may reduce the risk of T2D. However, further research is required to confirm the relationship between nutrient patterns and T2D.

Peer Review reports

Type 2 diabetes is a significant concern for public health in developed nations. It leads to high rates of illness and death and places a significant financial burden on healthcare systems [ 1 , 2 ]. In the past few decades, there has been a sharp increase in the occurrence of diabetes, and is expected to continue increasing, with an estimated 693 million people living with the disease by 2045 [ 1 ]. Complications associated with type 2 diabetes can also contribute to premature death. A concerning aspect of the disease is that a significant proportion of cases (40%) go undetected [ 3 ], and there is also an increasing prevalence of prediabetes, which raises the risk of developing type 2 diabetes and other chronic diseases [ 1 ].

The connection between diet and type 2 diabetes has been extensively studied, including the examination of dietary patterns and individual foods or nutrient patterns [ 4 , 5 , 6 , 7 ]. Various sources have suggested that chronic diseases may be influenced by a combination of nutrients [ 8 ]. In the field of nutritional epidemiology, the examination of dietary patterns has emerged as a viable approach to investigate the correlation between diet and disease. This method involves using statistical techniques to combine multiple foods or nutrients into dietary or nutrient patterns, which are believed to provide a more detailed understanding of the connection between diet and disease. It has been suggested that the impact of individual nutrients or foods on chronic disease may be too subtle to detect, but their collective effect within a pattern may be more indicative [ 9 ].

There have been some recent studies examining the effect of nutrient patterns on chronic disease such as, non-alcoholic fatty liver, breast and gastric cancer, Polycystic Ovary Syndrome (PCOs) and metabolic syndrome [ 10 , 11 , 12 , 13 , 14 ]. For example, it was found that a nutrient pattern consisting mainly of protein, carbohydrates, and various sugars was linked to a higher risk of Metabolic Syndrome (MetS) in both men and women, whereas a pattern characterized by copper, selenium, and several vitamins was linked to greater odds of MetS [ 14 ]. A prospective study conducted among participants of the Tehran Lipid and Glucose Study indicates that a nutrient pattern rich in vitamin A, vitamin C, vitamin B6, potassium, and fructose is associated with a reduced risk of insulin-related disorders [ 15 ]. Although there have been limited investigations on the connection between nutrient patterns and the likelihood of developing diabetes, the present study seeks to explore this relationship by analyzing the adherence to different nutrient patterns and its effect on the risk of type 2 diabetes.

Study population

This study utilized a case-control design and involved participants between the ages of 18 and 60 who had been diagnosed with type 2 diabetes within the previous six months based on specific glucose level criteria (FBS levels of ≥ 126 mg/dl and 2 h-PG levels of ≥ 200 mg/dl [ 17 ]). Healthy individuals within the same age range were also included, with specific glucose level criteria (FBS levels of < 100 mg/dl and 2 h-PG levels of < 200 mg/dl [ 17 ]). The study excluded individuals with certain chronic diseases, Type 1 Diabetes, gestational diabetes, those following specific dietary patterns or taking certain medications, pregnant and breastfeeding women, those with a family history of diabetes or hypertension, and those who did not complete the food frequency questionnaire (more than 35 items) or whose reported energy intake was outside of a specific range (range of 800–4200 kcal [ 18 ]).

This study enrolled 450 adult participants, with 225 individuals in the case group and 225 in the control group. The case group was selected using a simple sampling method from patients diagnosed with diabetes at the Tabriz Center of Metabolism and Endocrinology as a referral center affiliated to tabriz University of Medical Sciences from January 2021 to March 2022, as well as through a two-stage cluster sampling method among patients referred to private endocrinologists to enhance the sample’s external validity. Participants in the control group were also selected through a two-stage cluster sampling method from individuals who had undergone blood glucose checkups at the Tabriz Center of Metabolism and Endocrinology, a referral center affiliated with Tabriz University of Medical Sciences, within the past six months. All participants provided informed consent at the beginning of the study. The study was financially supported by Tabriz University of Medical Sciences and is related to project NO. 1400/63,145.

Dietary assessment

To collect dietary intake information, personal interviews and a semi-quantitative food frequency questionnaire (FFQ) consisting of 168 food items were used [ 16 ]. The FFQ asked about the frequency of consumption for each item over the course of one year, with the year before diagnosis for the case group and the year before the interview for the control group. Participants were also asked about the frequency of consumption (per day, week, month, or year) for each type of food. to ensure consistency in measurements, a nutritionist provided instructions on converting the size of reported food items from household measures to grams using four scales. The quantity of food consumed by each individual was calculated based on their intake in grams and reported on a daily basis. The nutrient composition of all foods was derived by using modified nutritionist IV software.

Nutrient pattern assessment

We conducted factor analyses using a comprehensive set of 34 nutrients, encompassing various macronutrients, micronutrients, and other dietary components. These included sucrose, lactose, fructose, fiber, animal protein, plant protein, saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, cholesterol, as well as an array of vitamins and minerals such as A, D, E, K, C, thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), folate (B9), B12, calcium, phosphorus, iron, zinc, copper, magnesium, manganese, chromium, selenium, sodium, potassium, and caffeine. The dietary intake of these 34 nutrients per 1,000 Kcal of energy intake was computed and utilized as input variables. Subsequently, nutrient patterns (NPs) were derived through principal component analysis (PCA) with varimax rotation, based on the correlation matrix. Factor scores for each participant were then calculated by aggregating the frequency of consumption and multiplying it by the factor loadings across all 34 nutrients. To assess the statistical correlation between variables and evaluate the adequacy of the sample size, we employed the Bartlett test of sphericity ( P < 0.001) and the Kaiser-Mayer-Olkin test (0.71), respectively.

Assessment of other variables

To obtain the participants’ anthropometric measurements, weight and height were measured using a seca scale, and the participants’ BMI was determined by dividing their weight in kilograms by the square of their height in meters. Waist circumference was measured using a metal anthropometric tape, and the participants’ hip circumference was measured using a metal anthropometric tape while standing [ 17 ]. Daily physical activity was measured using a physical activity questionnaire [ 18 ], and personal questioning was employed to gather information on population and socioeconomic characteristics, including marital status, academic degree, and smoking.

Statistical analysis

Statistical analysis was performed using the Statistical Package Software for Social Science, version 21. The normality of the data was assessed using Kolmogorov-Smirnov’s test and histogram chart. The characteristics and dietary intakes of the case and control groups were presented as mean ± SD or median and frequency (percentages). Independent sample t-tests and chi-square tests were used to compare continuous and categorical variables, respectively, between the case and control groups.

The participants’ mean (SD) age and BMI were 39.8 (8.8) years and 27.8 (3.6) kg/m2, respectively. The mean (SD) BMI in the case group was 30.5 ± 4.1, and in the control group, it was 25.2 ± 3.2 kg/m2. The mean (SD) physical activity in the case group was 1121 ± 611 MET/min/week, and in the control group, it was 1598 ± 940 MET/min/week. There were significant differences in BMI and physical activity between the two groups. The mean (SD) waist circumference in the case group was 109.32 ± 10.28 cm, and in the control group, it was 87.25 ± 9.35 cm. The mean (SD) hip circumference in the case group was 107.25 ± 8.61 cm, and in the control group, it was 91.44 ± 6.17 cm. The study identified three primary nutrient patterns (NPs) with eigenvalues greater than 2. Table 1 displays the factor loadings for nutrient patterns, which accounted for 56.11% of the total nutrient variation. The high intake of sucrose, animal protein, phosphorus, zinc, potassium, calcium, vitamin E, vitamin B1 and vitamin B12 were the distinguishing features of the first pattern. The second nutrient pattern was positively associated with copper, magnesium, fiber, vitamin D, B2, B5 and plant protein but had a negative correlation with lactose and saturated fatty acids. On the other hand, the high intake of fiber, vitamin A, B2, vitamin C, plant protein and potassium were the distinguishing features of the third pattern.

The following are the characteristics of T2D patients compared to the control group, as shown in Table 2 : Higher BMI, More likely to be smokers, Lower physical activity levels, higher FBS, HbA1C, Insulin ( p < 0.05). Other variables did not differ significantly between the two groups ( p > 0.05). Additionally, T2D patients had a greater intake of energy and vitamin B3 but consumed less plant protein, vitamin A, vitamin E, vitamin B2, and zinc ( p < 0.05).

Table 3 summarizes the partial correlation coefficient between NPs and food sources, with NP1 showing a strong positive correlation with low-fat dairy, NP2 with refined grains, and NP3 with fruits and vegetables.

Table 4 demonstrates the relationships between NPs and T2D. After adjusting for age and sex, there was no significant link between each nutrient pattern (NP) and T2D. However, when adjusting for other factors such as BMI, physical activity, smoking, and energy intake, individuals in the highest tertile of NP1 and NP2 did not show a significant association with T2D compared to those in the lowest tertile. On the other hand, those in the highest tertile of NP3 had a lower probability of developing T2D than those in the lowest tertile (OR: 0.52, 95%CI: 0.30–0.89, P_trend = 0.039).

In this study, three major NPs were identified. After adjusting for potential confounders, we observed a significant inverse association between the Third NP and the odds of T2D. The high intake of fiber, vitamin A, B2, vitamin C, plant protein and potassium were the distinguishing features of the third pattern.

Dietary patterns, such as healthy, Mediterranean, traditional, and Western dietary patterns, have recently received significant attention in studying the connection between diet and health. When looking at the relationship between nutrients and disease incidence, it is more challenging to evaluate when considering individual foods and the metabolism of all nutrients together [ 19 ]. It is therefore more effective to take a broader view and consider diet as a whole. Dietary and nutrient patterns can have a greater impact on health than specific nutrients or nutritional groups. There is supporting evidence that links high calorie or high glycemic index foods with an increased risk of T2D. The quality of one’s diet is also associated with the risk, progression, and side effects of T2D [ 20 ]. Establishing a desirable food pattern has become a priority in public health efforts to prevent T2D. By studying dietary and nutrient patterns, we can gain a comprehensive understanding of an individual’s overall diet beyond just the consumption of specific nutrients and food groups. Moreover, it is easier for people to understand health recommendations when presented as dietary patterns rather than focusing solely on individual nutrients [ 19 ].

A previous cross-sectional study investigated the relationship between NPs and fasting glucose and glycated hemoglobin levels among apparently healthy black South Africans. The study stratified 2,010 participants by gender and urban/rural status and identified three nutrient patterns per stratum. In rural women, a nutrient pattern driven by starch, dietary fiber, and B vitamins was significantly associated with lower fasting glucose and glycated hemoglobin levels. A nutrient pattern that included vitamin B1, zinc, and plant protein was linked to notable decreases in glycated hemoglobin and fasting glucose levels in rural men. These findings suggest that nutrient patterns that are plant-based are linked to lower levels of fasting glucose and glycated hemoglobin [ 21 ].

Iwasaki et al. found that specific nutrient patterns were associated with lower risks of MetS. One nutrient pattern high in potassium, fiber, and vitamins, while another pattern high in vitamin B2, saturated fatty acids and calcium [ 22 ]. A recent study found that a nutrient pattern characterized by high intake of calcium, potassium, fats, cholesterol, vitamins B2, B12, A, D, K and C was positively linked to MetS [ 23 ]. Salehi-Sahlabadi et al. found that adhering to a nutrient pattern rich in potassium, vitamin A, fructose, vitamin C and vitamin B6 was negatively associated with the likelihood of NAFLD [ 11 ]. A nutrient pattern high in potassium, vitamin A, vitamin B6, vitamin C and fructose was associated with a reduced risk of hyperinsulinemia, IR, and dyslipidemia among participants in Tehran, according to a prospective study [ 11 , 24 , 25 ].

Due to several variations among studies exploring NPs linked to chronic diseases, including differences in the number of nutrients, populations, study designs and outcomes there has been a considerable diversity in the identified NPs, with only a few NPs being replicated across studies. Our study is the first of its kind to explore the correlation between nutrient patterns and T2D in this context.

In our study, there was no association between NPs 1 and 2 and T2D. This lack of correlation may be attributed to the absence of harmful nutrients or food categories linked to diabetes in these NPs. NP3 in this study, unlike other NPs, is positively associated with beneficial food groups such as nuts, fruits, plant oil and vegetables, and negatively associated with unhealthy food groups like red-processed meat, snacks, high-fat dairy and refined grains. A recent systematic review and meta-analysis found that individuals who consumed higher amounts of fruits and vegetables had a lower risk of developing type 2 diabetes [ 26 ]. Moreover, the consumption of vegetables was found to have an inverse relationship with ALT, TC and LDL levels among adults, while fruit consumption was associated with a positive reduction in visceral fat [ 27 , 28 ]. Another study suggested that an increased intake of vegetables and fruits could potentially lower the risk of MetS [ 29 ]. According to a study, greater nut consumption was significantly linked to a reduced prevalence of T2D [ 30 ]. Consuming fruits and vegetables is a crucial component of a healthful dietary pattern that can lower the risk of type 2 diabetes [ 31 ]. On the other hand, Consuming a Western dietary pattern, which primarily consists of fast foods, high-fat dairy, refined grains, soft drinks and processed meat has been found to be correlated with an increased risk of type 2 diabetes [ 31 ].

Several mechanisms have been identified that explain the positive associations between the components of NP 3 and T2D or its risk factors. Vitamin intake has been shown to play a role in the development of T2D through various pathways. Consuming vitamin C has been found to have beneficial effects in reducing the risk of type 2 diabetes mellitus. These effects can be attributed to the following actions of vitamin C: vasodilator, cytoprotective, platelet anti-aggregator and anti-mutagenic. To achieve this, the body increases the production of several substances including prostaglandin E1, PGI2, endothelial nitric oxide, and lipoxin A4. Additionally, the body restores the Arachidonic Acid content to normal levels [ 32 ]. Vitamin A has a multifaceted role in cell regulation beyond its antioxidant function. It contributes to gene regulation, epithelial cell integrity, and resistance to infection. Research suggests that vitamin A also enhances antioxidant enzyme function in the body. Research has indicated a link between vitamin A deficiency and type 2 diabetes mellitus (T2DM), which suggests that vitamin A may have a role in the biology of T2DM [ 33 ]. Moreover, a meta-analysis has found that replacing animal protein with plant protein can lead to minor improvements in glycemic control for individuals with diabetes [ 34 ]. According to a recent meta-analysis, increasing the consumption of fruits, especially berries, yellow vegetables, cruciferous vegetables, green leafy vegetables is associated with a lower risk of developing type 2 diabetes. These results support the recommendation to incorporate more fruits and vegetables into the diet as a way to prevent various chronic diseases, including type 2 diabetes [ 35 ]. A study showed that maintaining adequate potassium intake could regulate insulin secretion and carbohydrate metabolism, leading to the prevention of obesity and metabolic syndrome (MetS) [ 36 ].

A number of research studies conducted in the Western societies have shown that Western dietary pattern including higher intake of red meat, processed meat, and refined grains is significantly associated with increased risk of T2D [ 37 , 38 ]. For example, in the 12-years cohort prospective study, van Dam et al. investigated dietary pattern of 42,504 American white men at the age range of 40–75 years old using the FFQ. After controlling the confounders, the risk of T2D increased 60% in people adherent to the western-like dietary pattern [ 38 ]. The rapid process of change in lifestyle, diets, and physical activity that have been occurred as a result of extended urbanization, improved economic status, change of work pattern toward jobs, and change in the processes of producing and distributing nutrients during the recent years in developing countries have led people to more consumption of fast food and processed foods [ 20 ].

Significant research has been conducted on the impact of nutrient type and sequence on glucose tolerance. Multiple studies have shown that manipulating the sequence of food intake can enhance glycemic control in individuals with type 2 diabetes in real-life situations. The glucose-lowering effect of preload-based nutritional strategies has been found to be more pronounced in type 2 diabetes patients compared to healthy individuals. Moreover, consuming carbohydrates last, as part of meal patterns, has been proven to improve glucose tolerance and reduce the risk of weight gain [ 39 ]. Recent findings on meal sequence further emphasize the potential of this dietary approach in preventing and managing type 2 diabetes [ 40 ].

Several studies have shown that food from a short supply chain has a significant impact on metabolic syndrome. The length of the food supply chain is important in determining the risk of metabolic syndrome in a population [ 41 ]. Research indicates that people who consume food from short supply chains have a lower prevalence of metabolic syndrome compared to those who consume food from long supply chains. Specifically, food from short supply chains is associated with lower levels of triglycerides and glucose, which leads to a reduced occurrence of metabolic syndrome [ 42 ]. Adhering to the Mediterranean diet with a short supply chain is also found to significantly reduce the prevalence of metabolic syndrome. Therefore, these studies provide evidence that food from short supply chains positively affects metabolic parameters and the occurrence of metabolic syndrome [ 41 ].

The study we conducted presented several advantages. It was the first case-control research to investigate the correlation between nutrient patterns and the likelihood of developing type 2 diabetes (T2D). While numerous studies have explored the relationship between dietary patterns and diabetes, there is a scarcity of research specifically focusing on nutrient patterns in individuals with type 2 diabetes. Furthermore, the collection of dietary intake data was carried out through face-to-face interviews conducted by trained dieticians to minimize measurement errors. However, this study also had some limitations. Case-control studies are susceptible to selection and recall biases. Additionally, the use of factor analysis to identify patterns, and the potential influence of research decisions on the number of factors and nutrient factor loadings in each pattern, should be considered. Lastly, despite the use of a validated semi-quantitative FFQ (food frequency questionnaire), there remains a possibility of measurement error due to dietary recall. The study’s findings and limitations contribute to the ongoing discourse on the role of nutrient patterns in the development of T2D and the importance of considering these factors in future research and preventive strategies.

Conclusions

The results of this study indicate that conforming to a nutrient pattern consisting of plant protein, vitamin C, vitamin A, vitamin B2, potassium, and calcium is linked to a lower likelihood of developing T2D. Our investigation did not reveal any significant correlation between other nutrient patterns and T2D risk. However, additional research is necessary to authenticate these initial findings and establish the correlation between nutrient patterns and T2D.

Data availability

Upon reasonable request, the corresponding author can provide the datasets that were produced and analyzed during the current study.

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Acknowledgements

The researchers express their gratitude towards all the individuals who volunteered to take part in the study.

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Morteza haramshahi

Department of clinical biochemistry, College of medicine, King Khalid University, Abha, Saudi Arabia

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The study’s protocol was designed by M.K., M.H., and T.E., while H.A., Y.A., and A.H. carried out the research. A.S. analyzed the data and prepared the initial draft of the manuscript. M.N., A.FA., and A.A. interpreted the data and provided critical feedback on the manuscript. All authors reviewed and approved the final version of the manuscript.

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haramshahi, M., A-Elgadir, T.M.E., Daabo, H.M.A. et al. Nutrient patterns and risk of diabetes mellitus type 2: a case-control study. BMC Endocr Disord 24 , 10 (2024). https://doi.org/10.1186/s12902-024-01540-5

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Diagnosis and Treatment

Criteria for diagnosis.

HbA1c ≥ 6.5%

Fasting plasma glucose (FPG) ≥ 126 mg/dL

2 hour plasma glucose ≥ 200 mg/dL during an oral glucose tolerance test (OGTT)

In a patient with classic symptoms of hyperglycemia, a random plasma glucose ≥ 200 mg/dL

Treatment of type 2 diabetes mellitus (T2DM) focuses on decreasing blood glucose, increasing insulin secretion, or countering insulin resistance. Treatment of symptoms, such as diabetic retinopathy, nephropathy, or neuropathy requires additional and involved patient education, medications, and therapies.

Lifestyle Modifications

Treatment of obesity and other symptoms of metabolic syndrome is essential. Exercise is an effective intervention because it reduces postprandial blood glucose levels, diminishes insulin requirements, lowers triglyceride and cholesterol levels, and increases the level of HDL cholesterol. Physical activity also aids in weight reduction. Diet modifications include restricted yet consistent caloric intake appropriate for ideal weight and activity level. Dietary counselling is through medical nutrition therapy (MNT) should focus on achieving biometric goals (McCance & Huether, 2014).

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Pharmacological Interventions

Oral hypoglycemic medications are usually needed for optimal management of T2DM. Insulin may be need in later stages due to functional loss of beta cells of the pancreas (McCance & Huether, 2014).

Bariatric surgery may be indicated for patients who are morbidly obese and unresponsive to diet and exercise interventions. Currently, powerful evidence exists that shows bariatric surgery improves glycemic control in up to 80% of individuals with T2DM even before there is any significant weight loss (McCance & Huether, 2014).

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Genetic risk variants lead to type 2 diabetes development through different pathways

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Correlation of Platelet Indices in Patients With Type 2 Diabetes Mellitus and Associated Microvascular Complications: A Hospital-Based, Prospective, Case-Control Study

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1 Department of General Medicine, Sri Guru Ram Das University of Health Sciences, Amritsar, IND.
2 Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND.
PMID: 38601371
PMCID: PMC11005942
DOI: 10.7759/cureus.55959

Background Diabetic patients exhibit increased platelet activity. Insulin inhibits the activation of platelets. Therefore, a relative or absolute deficiency of insulin would increase platelet reactivity. The younger (larger) platelets are also more metabolically and enzymatically active. If detected early, microvascular complications could alert us regarding the possible macrovascular complications. Thus, the aims and objectives of the present study were to determine platelet indices in patients with type 2 diabetes mellitus with controls (non-diabetics) and to find an association of platelet indices with microvascular complications. Material & methods In this prospective case-control study conducted from 2021 to 2022 (2 years), a total number of 200 subjects were taken and were divided into two groups of 100 each, cases (I) and controls (II). The cases included patients of diabetes mellitus (DM) of a duration of more than 5 years, which were further divided into two groups of 50 each, IA and IB. Group IA consisted of patients with diabetes mellitus of a duration of more than five years with at least one microvascular complication and group IB was diabetics of more than five years duration without any microvascular complications, which includes diabetic retinopathy, diabetic nephropathy, and diabetic neuropathy. An automated cell counter (Thermo Fisher Scientific, Waltham, MA, US) provided hemoglobin values along with the platelet count and platelet indices, i.e. mean platelet volume (MPV), platelet large cell ratio (P-LCR), and platelet distribution width (PDW). Results The present study consisted of 200 subjects divided into 2 groups of 100 each, cases (I) and controls (II). The average MPV (9.4-12.3 femtolitre) in diabetics was 12.089±1.450 fL as compared to the controls where it was 9.464±1.424 fL with a statistically significant p-value of 0.001. PDW among the cases was 16.868±2.352 fL while in controls, it was 12.753±10.559 fL (p=0.001). The mean P-LCR was 34.975±8.056% among the cases, in comparison to the mean P-LCR among the controls, which was 26.031±7.004 (p=0.001). In this study, the MPV, PDW, and P-LCR were significantly raised in individuals having diabetes with microvascular complications when compared with patients without complications. The mean MPV in diabetics with complications was 12.5960±0.95660 fL and in those without complications was 11.5820±1.67609 fL (with a p-value of P = 2×10 -3 )which is statistically significant. Similar results were obtained in cases of PDW and P-LCR. The mean PDW in diabetics with complications was 17.1140±2.58228 fL and without complications was 15.6220±2.10532 fL ((with a p-value of P = 2×10 -3 )). The mean P-LCR in diabetics with microvascular complications was 35.408±3.5490% and without complications was 33.542±4.8694% (with a p-value of P = 3.1×10 -3 ). Conclusion Based on the findings of the present study, there is a statistical correlation between type 2 diabetes and variations in platelet indices, resulting in the associated microvascular complications. Higher MPV, PDW, and P-LCR values suggest that these parameters are more reliable predictors of early vascular complications in individuals with type 2 diabetes mellitus and can be utilized as an easy-to-use, low-cost method. They are a readily available, economical, practical, noninvasive, and simple-to-understand approach for assessing platelet dysfunction, which in turn helps anticipate the existence of microvascular complications.

Keywords: diabetic microvascular complications; endocrinology and diabetes; mean platelet volume(mpv); platelet indices; type 2 diabetes mellites.

Barriers to the Use of Insulin Therapy and Potential Solutions: A Narrative Review of Perspectives from the Asia–Pacific Region

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Published: 16 April 2024

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Roger Chen ORCID: orcid.org/0000-0001-6531-6389 1 , 2 ,
Azizul Hasan Aamir 3 ,
Mohammod Feroz Amin 4 ,
Pongamorn Bunnag 5 ,
Siew Pheng Chan 6 ,
Lixin Guo 7 ,
Mohammad E. Khamseh 8 ,
Viswanathan Mohan 9 ,
Nemencio Nicodemus Jr. 10 ,
Anthony Roberts 11 ,
Tri Juli Edi Tarigan 12 ,
Kyu-Chang Won 13 &
Roopa Mehta 14

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The rising prevalence of type 2 diabetes (T2D) is posing major challenges for the healthcare systems of many countries, particularly in the Asia–Pacific Region, in which T2D can present at younger ages and lower body mass index when compared with Western nations. There is an important role for insulin therapy in the management of T2D in these nations, but available evidence suggests that insulin is under-utilized and often delayed, to the detriment of patient prognosis. The authors of this article gathered as an advisory panel (representative of some of the larger Asia–Pacific nations) to identify their local barriers to insulin use in T2D, and to discuss ways in which to address these barriers, with their outputs summarized herein. Many of the key barriers identified are well-documented issues of global significance, including a lack of healthcare resources or of an integrated structure, insufficient patient education, and patient misconceptions about insulin therapy. Barriers identified as more innate to Asian countries included local inabilities of patients to afford or gain access to insulin therapy, a tendency for some patients to be more influenced by social media and local traditions than by the medical profession, and a willingness to switch care providers and seek alternative therapies. Strategies to address some of these barriers are provided, with hypothetical illustrative case histories.

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Introduction

The worldwide prevalence of diabetes, especially type 2 diabetes (T2D), is increasing, particularly throughout the Asia–Pacific region. In the 38 countries and territories in the Western Pacific Region (as defined by the International Diabetes Federation [IDF]), the prevalence of diabetes is predicted to increase from an estimated 11.9% in 2021 to 14.4% by 2045 [ 1 ]. Simultaneously, the prevalence of diabetes in the IDF South East Asia Region is estimated to increase from 8.7% to 11.3% by 2045 [ 1 ]. The recent ICMR-INDIAB study reports that there are 101 million individuals with diabetes in India alone [ 2 ]. Meanwhile, Pakistan (which is part of the World Health Organization [WHO] Eastern Mediterranean Region, but geographically located in South East Asia) is estimated to be the country with the highest age-adjusted prevalence of diabetes (30.8% in 2021) in the world [ 1 ]. Furthermore, as the proportion of undiagnosed diabetes in the Western Pacific and South East Asia regions is estimated to be ~50%, these figures are likely to be under-estimations [ 1 ].

The increase in prevalence of T2D across the Asia–Pacific region can be attributed to a multitude of factors, including rapid socio-economic growth and urbanization, which have resulted in changes in lifestyle behaviors, such as the increased consumption of energy-dense food and drinks. In many countries, foods high in sugar, fat, and carbohydrates are popular at social gatherings and religious festivals, and refined staple carbohydrates dominate many diets in the region [ 3 ]. Along with reductions in physical activity levels, particularly incidental activity, these dietary changes are contributing to a rise in the prevalence of overweight and obesity, and the increased risk of T2D.

Regional differences in genetic/ethnic predisposition and susceptibility are also important factors to consider. Compared with other ethnic groups, people from South Asia with T2D tend to develop the disease at a younger age and lower body mass index, and more often manifest with dysglycemia, dyslipidemia, and cardiovascular diseases compared with other ethnic groups [ 4 ]. Furthermore, given the heightened risk of premature development of cardiorenal complications in early onset T2D, early and intensive risk factor management is merited [ 5 ].

As β-cell dysfunction progresses over time, many people with T2D treated with oral glucose-lowering drugs become unable to achieve or maintain adequate glycemic control and will require insulin therapy [ 6 ]. There will also be a minority of people newly diagnosed with T2D who will benefit from early or immediate insulin introduction, such as those with considerable weight loss, ketosis, severe symptoms of hyperglycemia, or steroid-induced hyperglycemia [ 7 , 8 ]. It is also reported that the T2D subtype of severe insulin-deficient diabetes (SIDD), which often requires earlier initiation of insulin, is very common in South Asia [ 9 , 10 , 11 ]. Timely insulin initiation in all patients is necessary to achieve optimal glycemic control and to reduce diabetes-related complications [ 6 ].

The earlier onset of T2D, and more rapid decline in β-cell function and insulin secretion, among many populations in the Asia–Pacific region makes insulin one of the major treatment strategies to minimize the burden of diabetes-associated morbidity and mortality. However, despite the proven benefits and existing guidelines for the initiation of insulin therapy [ 12 , 13 ], insulin utilization and glycemic control remain suboptimal. For example, in Bangladesh, patients were shown to experience delayed diabetes treatment initiation of around 1.79 ± 3.26 years in an analysis of data collected in 2019 [ 14 ]. Furthermore, the 11-country First Basal Insulin Evaluation (FINE) Asia study, conducted using people enrolled in a registry between 2006 and 2008, demonstrated that insulin initiation was being delayed by ~9 years among people with inadequately controlled T2D, with HbA1c at time of initiation (10.5%) highest in patients from South East Asia [ 16 , 17 ]. With regards to glycemic control, poor target achievement has been reported in several countries. The 2019 annual report of the Australian National Diabetes Audit indicated that the mean HbA1c for ~4140 patients with T2D being treated at participating centers was 8.1%, which is above the general target of ≤ 7.0% recommended by the Australian Diabetes Society [ 18 ]. In India, the A 1 chieve study reported that the mean HbA1c in patients with T2D was 9.2% at the time of insulin initiation, and the prevalence of both macrovascular and microvascular complications was high [ 15 ]. In Iran, only 13.2% of patients with diabetes were achieving glycemic targets in 2016 [ 19 ].

Data from the WHO also indicate that insulin therapy is significantly underutilized in Asia compared with other regions. While ~75% of people with diabetes live outside of Europe and the United States, the WHO region of the Americas, the WHO European region, and the WHO Western Pacific region account for more than 60% of global revenue generated from insulin products, suggesting that the market in the WHO South-East Asia region is being significantly underserved [ 20 ]. The results of a 2021 analysis of insulin imports in 82 countries, including nine in Asia, indicate that there is a gap in many countries in Asia between the assumed insulin “need” and the actual number of patients who receive treatment, with an estimated supply:need ratio of 0.36 in the Asia region in 2018 (interquartile range [IQR]: 0.21–0.99) [ 21 ].

This author panel gathered for an advisory board meeting to explore and provide perspectives on the topic of barriers to insulin initiation in the Asia–Pacific region and to discuss potential solutions. This article summarizes the collective opinions of the authors, with hypothetical case studies included to illustrate how barriers to insulin initiation can be overcome. This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

What are the Reasons for Delayed Initiation of Insulin Therapy?

Many of the reasons behind the inappropriate delay in the initiation of insulin therapy apply globally and are well documented [ 22 , 23 , 24 , 25 , 26 , 27 ] (see Fig. 1 for a summary [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ]). The reasons are complex, and barriers exist at the patient, physician, and healthcare system level, and often overlap. Many of the negative attitudes among both healthcare professionals (HCPs) and patients with T2D toward starting insulin therapy and gaps in healthcare service provision were highlighted in the global DAWN (2001) and DAWN2 studies (2012), and are still prevalent today [ 28 , 30 , 31 ].

Common barriers to insulin initiation in people with T2D [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ]. T2D type 2 diabetes

What are the Barriers to Insulin Initiation in the Asia–Pacific Region?

Broadly, the barriers to insulin initiation identified above also apply to the highly heterogenous Asia–Pacific region. However, the prevalence and relevance of each barrier may vary depending on the region or population and their characteristics. Moreover, some barriers may be specific to a region, country, or population within a country, reflecting the unique socioeconomic, cultural, or healthcare system particularities of that region/population. An overview of key WHO Global Health Observatory indicators related to diabetes and diabetes management strategies is provided for a subset of countries within the Asia–Pacific region in Table 1 , highlighting the heterogeneity in population and healthcare circumstances across the region [ 32 ].

Suboptimal patient understanding and health education is a critical barrier to insulin initiation encountered across all of the Asia–Pacific countries represented by the author panel. Low levels of health education (or health literacy) can drive patient unawareness not only of the benefits of starting insulin therapy but also of diabetes in general and its progression. For example, a study of attitudes and beliefs in 33 Thai patients with T2D found that 18 patients had an incorrect understanding of the causes of T2D and five patients had no understanding of the causes at all [ 33 ]. Five patients mentioned that they wanted to control their T2D to avoid having to inject themselves with insulin [ 33 ]. Patients may view the use of insulin (and accompanying glucose monitoring) as an inconvenient lifelong sentence of drug dependence and complex regimens, which, if they are unable to master, can result in adverse outcomes and a decline in quality of life. Education levels in some regions also fail to dispel myths around the use of insulin. Patient miseducation on social media platforms is also a challenge, as it can embed a negative perception of the physician’s motivations and their relationships with the pharmaceutical industry. This may also drive a preference for alternative medicine or traditional ‘cures’ and raise doubts that insulin can prevent future complications or death. Preference for alternative medicine over modern ‘western’ medicine may also be rooted in tradition and cultural beliefs, as is often the case in India, China, and Bangladesh.

Barriers to insulin may also originate at a physician or healthcare system level. The growing complexities in international and locally recommended management pathways for people with T2D have delayed or stopped insulin initiation in favor of newer therapies, such as glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose co-transporter-2 (SGLT-2) inhibitors, in patients who are in need of treatment intensification and would benefit from insulin [ 34 ].

Primary care physicians initiate insulin in many countries in the Asia–Pacific region, although many lack confidence and the support of allied HCPs. In Indonesia, insulin is initiated by internal medicine specialists in the government healthcare service, although it can be prescribed by primary care physicians in private practice. In many regions including Iran and China, appropriate infrastructure for the delivery of diabetes education is not sufficient, as is an integrative multidisciplinary approach to diabetes care. Currently, a lack of a centralized healthcare system or fragmentation of care across discrete or siloed teams, long delays in referrals for insulin therapy, and suboptimal transfer of patient information between entities are important institutional-level challenges that need to be addressed.

Regarding the cost of insulin, in many countries in the Asia–Pacific region, including India, Pakistan, and Bangladesh, most expenditure associated with insulin and blood glucose monitoring is borne out-of-pocket by people with T2D. For example, middle-income individuals in India, who comprise 70–80% of the overall population, have to pay for their insulin [ 35 ] and, in Bangladesh, the average annual cost for medicines for people with T2D in 2019 was USD 474.5 [ 36 ]. In China, all diabetes drugs are included in the National Reimbursement Drug List (NRDL) but needles for insulin injection are not included, and most patients do not follow the guidance of changing needles for each injection. In Bangladesh, China and Malaysia, blood glucose monitors and strips are an out-of-pocket expense for patients, which can result in a lack of insulin titration, while, in Iran, there is variable reimbursement to cover the cost of new-generation insulins. Financial pressures can also be a concern for physicians. In some countries, including Bangladesh, India, and South Korea, physicians in private practice can be reluctant to start insulin therapy or switch to newer insulin analogues due to concerns that patients will switch physicians.

Specific barriers to insulin initiation highlighted by members of the author panel in the different subregions within the Asia–Pacific region are summarized in Table 2 .

How Can Barriers to Insulin Initiation Be Overcome in the Asia–Pacific Region?

Potential solutions to the barriers to insulin initiation in the Asia–Pacific region include patient, physician, and healthcare system initiatives, as well as access to new-generation insulin analogues and insulin delivery devices. Patient communication, education, and support are obligatory. Multidisciplinary teams can be key to initiating and titrating insulin, and overcoming physicians’ time constraints. These teams can include diabetes educators, diabetes specialist nurses, dieticians, and educated peer-support workers.

Inclusion of HCPs and team members with different ethnic backgrounds may help to overcome barriers in culture or language when communicating with patients [ 37 ]. For example, in Australia, which has a large migrant and culturally diverse population and many Australian-born indigenous populations, more than 300 languages are estimated to be spoken in the home and patients can experience language issues and require culturally appropriate care [ 38 , 39 ]. Patients from different cultures may also hold traditional beliefs regarding diabetes and insulin, and these should also be considered when providing care. Physicians from other medical specialties also need to be involved in educating patients about the benefits of insulin, for example cardiologists and ophthalmologists.

Patient education and training can be delivered via education programs run by medical societies, government departments, and pharmaceutical companies. For example, the Diabetic Association of Bangladesh runs a large network of healthcare centers across the country, and, along with providing care for patients with diabetes, organizes education programs and produces education materials for diabetes educators and other health professionals. The association also produces films to raise patient awareness. Diabetes Australia has extensive online resources related to living with diabetes, as well as live and virtual events. There may be the potential for a specific module on insulin therapy to be developed.

Raising awareness of diabetes and the benefits of insulin among the general population can also help to battle misconceptions and increase patient acceptance. Public campaigns on social media or local television are powerful channels of communicating with patients, as is the use of patient ‘influencers’ such as celebrities or trusted community leaders. One such initiative in Pakistan, run in collaboration with the local government and sponsored by the pharmaceutical industry, includes a video of a well-known cricketer with diabetes sharing the message that a healthy life without complications is possible. In Thailand, a program to recruit village health volunteers to support self-management in individuals with a high risk of T2D development has been found to increase scores on knowledge and self-efficacy for T2D prevention in both health volunteers and high-risk individuals in the community after 12 weeks. The authors suggest that the possibility of similar programs should also be explored in other countries in the Asia–Pacific region [ 40 ].

Physician education and support are also key to improving the use of insulin. Treating physicians need to understand the complex and heterogeneous nature of T2D to individualize treatment based on diverse and heterogeneous lifestyles, and taking into account phenotype, cultural, and economic factors [ 41 ]. Clear national guidelines emphasizing the role of insulin are key to providing this guidance.

As well as governmental health authorities, non-governmental organizations, medical associations, and the pharmaceutical industry can all play a role in the provision of continuing medical education and financial support. The use of novel types of educational tools, including interactive virtual patient simulation scenarios, electronic guidelines, and decision-support apps can all assist in training initiatives.

Some barriers to patient and physician acceptance of insulin may be removed with greater access to new-generation insulin analogues and improved insulin delivery devices. New-generation insulins demonstrate improved pharmacology, safety, and dosing time flexibility versus human insulin, along with simpler titration algorithms. Insulin delivery devices are easier to use, less painful, faster to teach compared with a vial and syringe, and are becoming smaller and more discrete to use. The latest insulin pumps are also moving towards a fully automated artificial pancreas closed-loop system, which will increase convenience for patients. While cost or variable insurance reimbursement remains a barrier, cost of insulin can be overcome in some regions if patients understand the benefits [ 42 ].

Conclusions

The Asia–Pacific region faces a huge healthcare challenge from the rising prevalence of T2D. Moreover, T2D can have a relatively early onset in many patients in this region, hence aggressive glycemic control is vital to limit the burden of diabetic complications, and insulin therapy is therefore likely to be widely beneficial. Many healthcare systems in the region are ill prepared to meet this challenge, however, due to being under-resourced, or from national healthcare policies that make insulin therapy widely unaffordable by excluding the reimbursement of insulin, or of insulin administration equipment, glucose monitors, test strips etc. Even where insulin is easily available, there are significant barriers to its timely use. These include a lack of time and confidence on the part of physicians, lack of integrated care, lack of patient education, and widespread misconceptions about the risks and difficulties of insulin use, and what the decision to start insulin therapy signifies about disease progression and life expectancy. These barriers are reported globally but there are others that are more intrinsic to the Asia–Pacific region, such as skepticism about ‘Western’ medicine, and a tendency for perceptions to be guided from parochial traditions, peer groups, and unverified (and often untrue) reports on social media. Meeting these challenges is a vitally important goal in the years ahead. In the long term, it will require HCPs to organize and lobby for increased patient education, systems of integrated care and resources, and patient access to insulin. In the shorter term, we must be alert to the indications for initiating insulin in individual patients, the barriers that we might need to be overcome to gain patient acceptance, and individualized tactics that might help to achieve this.

Illustrative Case Histories

Please note, the case histories included on the following pages are purely hypothetical and intended to illustrate the barriers discussed in the main text, with some suggested approaches to overcome these.

Case 1: Dae-Seong, Busan, South Korea: Common fears and misconceptions about insulin

Dae-Seong is a 54-year-old technician with type 2 diabetes of 6 years’ duration. He is married with two sons in secondary school and has a sedentary lifestyle. His oral glucose-lowering drugs have been slowly increased since diagnosis to attempt to achieve glucose control. Dae-Seong is currently on metformin 2000 mg daily, gliclazide 80 mg twice daily, linagliptin 5 mg daily, and atorvastatin 40 mg daily. He is not hypertensive and has no history of diabetes-related chronic complications. He has a body mass index of 25.3 kg/m 2 , with fasting glucose of 168 mg/dl (9.3 mmol/l), HbA1c 8.6%, and serum creatinine of 0.8 mg/dl (0.04 mmol/l).

Due to the fact that Dae-Seong is taking multiple glucose-lowering drugs but remains poorly controlled, it is suggested that his gliclazide should be substituted for basal insulin. Dae-Seong expresses a reluctance to start insulin and becomes visibly upset. On questioning, he reveals that he is concerned about injections and hypoglycemia, and he feels he has failed to manage his diabetes and asks how long he can expect to live.

Dae-Seong is reassured when the following points are explained to him:

There is no evidence of diabetic complications yet, so he can expect many years of good-quality life.

Insulin is used by patients with type 1 diabetes for an entire lifetime, and its role is to prevent complications and maintain health. Many patients with type 2 diabetes who begin insulin wish they had done so years earlier.

Modern basal insulins carry a very low risk of hypoglycemia, and impending hypoglycemia can be recognized and addressed. A regimen will be designed that introduces insulin at a low dose and builds slowly and simply until an appropriate dose is reached.

A meeting can be arranged with a specialist nurse who will demonstrate how easy and painless it is to administer insulin via a modern injector device.

Case 2: Pranav, Bangalore, India: Urgent need to initiate insulin earlier than guidelines appear to recommend, and risk of loss to follow-up

Pranav is a 32-year-old single man who works as a software development engineer. Six months ago, he was routinely assessed and found to have a body mass index of 30.2 kg/m 2 and HbA1c 7.8%. He was diagnosed with type 2 diabetes (T2D) and started on metformin 1000 mg per day along with sitagliptin 100 mg per day. Pranav recently returned to his surgery complaining of balanoposthitis and symptoms of lethargy, and questioning revealed that he also had signs of polyuria and polydipsia, and recent weight loss. Blood tests revealed his fasting blood glucose to be 280 mg/dl (15.5 mmol/l), his postprandial blood glucose to be 412 mg/dl (22.9 mmol/l), and his HbA1c to be 11.4%.

It is explained to Pranav that he really needs to begin insulin therapy immediately due to symptoms of gluco- and lipotoxicity. However, Pranav has read widely about T2D since being diagnosed because he has a family history of this disease. He is aware of guideline recommendations and understands insulin to be a ‘last-resort’ therapy. He argues that he could try other drugs such as glucagon-like peptide-1 receptor agonists, and sodium-glucose co-transporter-2 inhibitors, which could delay the need for insulin. He makes veiled suggestions about seeking a second opinion from another physician.

Pranav is reassured, however, when the following points are explained:

Guideline recommendations cover the broad T2D population and provide scope for individualization. His clinical course is atypical and likely to be linked to his family history.

Insulin is, in fact, not recommended as a treatment of last resort ; other, less potent, therapies are included as alternatives in early stage T2D only because traditional insulin products carried a risk of hypoglycemia and were considered more ‘invasive’. In fact, modern insulins carry a low risk of hypoglycemia, and impending hypoglycemia can be recognized and addressed.

People with type 1 diabetes (T1D) have no other options than insulin, and use it successfully for their entire lifetime to prevent complications and maintain health. Pranav’s presentation of T2D is similar to that of T1D.

In fact, Pranav has decompensated diabetes that could potentially be corrected by a temporary course of insulin. It is important for his health to get his glucose levels controlled, and then modifications of therapy can be considered, including withdrawal of insulin.

However, due to his young age, Pranav will live with diabetes for many years, so is at risk of developing complications. It is therefore illogical to delay the most effective therapy of all just because other T2D therapies are available; it is better to achieve good glycemic control now and maintain that for life.

Case 3: Inaya, Lahore, Pakistan: Peer-driven skepticism about insulin and modern medicine

Inaya is a 48-year-old mother of six who works part-time in a bakery. She has been diagnosed with type 2 diabetes for 4 years and, at a recent health check, she was found to have a body mass index of 27.7 kg/m 2 and HbA1c of 9.2%. Since Inaya has shown little interest in her diabetes, she has been prescribed a very simple regimen of two tablets per day of a metformin + dapagliflozin combination product. Due to worsening HbA1c, an attempt was made to prescribe liraglutide 18 months ago, but this was unsuccessful after she was initially resistant to injections and then complained of nausea.

Eye examinations show early signs of diabetic retinopathy, although Inaya does not perceive any loss of visual acuity.

It is suggested to Inaya that she should add basal insulin to her therapy to improve her glycemia, halt the progression of retinopathy, and prevent other potential complications. However, Inaya counters that she feels perfectly well and does not understand why she needs medicine at all, especially insulin. On further questioning, she reveals that she has read on social media that insulin is a dangerous drug that is over-hyped by ‘the establishment’ and pharmaceutical industry. Her mother has also persuaded her that such medicines were never needed by her generation, so she would rather not take any new drugs. Notes made by the team nurse who attempted to train Inaya in the use of liraglutide reveal, however, that she and Inaya share a love of cricket.

These case notes were then used to change the conversation towards subjects about which Inaya felt more positive. Inaya was persuaded to attend a further educational session with a diabetes nurse to learn more about her diabetes and insulin where she was told that:

Former Pakistan cricket captain Wasim Akram has insulin-treated diabetes.

This hero of hers has produced short educational films encouraging people like her to take their diabetes seriously, as they themselves had done.

Inaya is not alone in being influenced by social media platforms and non-expert peer groups, but she owes it to herself and to her children to seek out other perspectives on matters related to her health.

In this regard, her cricket hero and healthcare providers have her best interests at heart.

The nurse would provide Inaya with an opportunity to watch the videos made by her cricket heroes and to access other patient education assets with no obligation on her part.

Case 4: Aranya, Bangkok, Thailand: Difficulty affording insulin therapy due to lack of reimbursement

Aranya is a 62-year-old grandmother whose type 2 diabetes was no longer being controlled with metformin plus sulphonylurea (HbA1c of 8.6%). It was therefore suggested to her that basal insulin should be added, but the choice of agent was driven by cost, as Aranya is from a lower socio-economic background and universal health coverage provides only basic insulin products (neutral protamine Hagedorn, regular and premix) free of charge. However, twice-daily neutral protamine Hagedorn insulin resulted in a few mild hypoglycemia episodes (fasting blood glucose or overnight glucose of > 56 mg/dl to < 70 mg/dl [> 3.1 mmol/l to < 3.9 mmol/l]) not requiring assistance, and, as insulin titration progressed, these episodes became more frequent, but not severe. To reduce hypoglycemia, the sulphonylurea was discontinued and insulin re-titrated. With very careful meal management, Aranya was able to achieve her glycemic goal.

Nevertheless, Aranya developed negative feelings towards insulin because of the hypoglycemia. It was explained to Aranya that ‘second-generation’ insulins reduce the risk of hypoglycemic episodes, but Aranya remained reluctant to consider these, as they are not covered by universal health coverage.

In Thailand, cost can be a major issue, especially for underprivileged individuals. The universal health coverage, which covers approximately 80% of the Thai population, provides only basic insulins for people with diabetes free of charge, and glucose strips are not covered for patients with type 2 diabetes. Therefore, many insulin-treated patients have suboptimal glycemic control due to lack of adequate glucose monitoring and suboptimal insulin regimens.

The hospital diabetes care team and diabetes educators worked with Aranya to assess her willingness to pay to switch to a newer basal insulin once she was informed of the following:

Poor glycemic control leads to an increase in micro- and macrovascular complications.

Prevention of complications and glycemic control are well-recognized ways to effectively manage diabetes treatment costs.

The newer insulins reduce the occurrence of hypoglycemic episodes.

Well-managed diabetes can benefit a patient’s quality of life.

Case 5: Jirayu, Phuket, Thailand: Overcoming systemic difficulties through education of GPs

Jirayu is a 43-year-old IT specialist who works in Bangkok and has a body mass index of 32.6. He has been self-administering insulin for several months, with the advice and support from the diabetes care team from the hospital. Jirayu is due to move to a new area where face-to-face contact with a diabetes specialist will not initially be possible. Although Jirayu has been self-administering insulin successfully until now, he is concerned that healthcare professionals (HCPs) at the clinic near his new home will not be able to manage his diabetes treatment effectively and his condition will worsen.

Telehealth has been implemented in many hospitals in Thailand, and provides an alternative option for HCPs to keep in regular contact with their patients or patient caregivers. This system also allows HCPs to counsel on titration or adjustment of insulin dosage in patients who are not easily able to see a diabetes specialist. Jirayu decided to discuss with his new general practitioner (GP) about continuing keeping in contact with his diabetes care team via a teleconference app. His GP agreed upon this and suggested that treatment be based on shared decision-making. With this strategy, Jirayu’s diabetic condition could be well managed without regular face-to-face visits with a diabetes specialist.

To increase the number of diabetes educators in Thailand, the Thai Association of Diabetes Educators, among others, has provided regular training courses and a curriculum for HCPs or other medical personnel who are interested in diabetes care. This is a good opportunity for GPs who have to take care of patients with diabetes and want to improve their knowledge of and skills in diabetes management. They can also send their nurses or other medical personnel to attend the curriculum to better manage patients with diabetes. This is a practical strategy to improve diabetes care, including insulin management, in hospitals where there are no diabetes specialists.

Case 6: Peter, Sydney, Australia: Overcoming systemic difficulties through establishment of a multidisciplinary team

Peter is a 68-year-old retired man with an 8-year history of type 2 diabetes. He was admitted to the emergency department following a fall from a ladder. Medications on admission included metformin 1 g twice daily, empagliflozin 25 mg once daily, and linagliptin 5 mg once daily. He had previously trialed a glucagon-like peptide-1 receptor agonist but did not persist on this treatment due to gastrointestinal side effects. He had not consulted his family doctor for several years. Peter’s HbA1c on admission was 12%, his estimated glomerular filtration rate was 65 ml/min/1.73 m 2 , and his lipid levels were at target. He was not known to have any diabetes-related complications. He was assessed by the diabetes team, then discharged on twice-daily insulin. Due to hospital restrictions, a review was organized for 3 months. Peter was uncertain how to titrate his insulin or how long he should persist with the injections and what monitoring he needed. He was referred by his family doctor to an endocrinologist and diabetes educator. Management consisted of revision of injection technique, change of insulin needle length to 4 mm, advice regarding rotation of injection sites, and monitoring of his glucose levels prior to the injections prior to breakfast and dinner, as well as education regarding prevention and treatment of hypoglycemia.

A management plan was made in conjunction with the family doctor, including guidelines as to how to titrate the insulin and what glucose targets were appropriate. The family doctor continued to review Peter every few weeks, with the endocrinologist seeing Peter at 3- then 6-month intervals. The key factors in management were:

Communication between all healthcare professionals in a timely manner after discharge.

Guidelines delivered by the endocrinologist to the family doctor, with insulin adjustment algorithm based on self-monitoring of glucose.

A diabetes educator ensuring that insulin injections were appropriate with revision of sick day management.

Oversight by the endocrinologist.

Case 7: Dr. Thomas, Chennai, India: Reluctance to start insulin due to lack of confidence and clinical support

Dr. Thomas is a successful 35-year-old physician practicing in Chennai. However, he is often overwhelmed by the number of patients he has to see in a day. Although he has a special interest in diabetes care, he runs a solo practice with no dedicated dietician or diabetes educator, and has found it difficult to educate his patients regarding diabetes. He admits that he often sees patients with severe uncontrolled diabetes who are already taking 3–4 oral antidiabetic drugs, yet many continue to have a HbA1c value greater than 9%. While he is aware that he needs to consider initiating insulin, he is reluctant to do so because it would mean an extra 20–30 min of his time. Due to the long list of patients waiting outside his consultation room on any given day, he does not feel he can spare this time to initiate insulin.

When one of his patients develops a severe diabetic foot problem, Dr. Thomas decides that it is time he changes his daily practices. He joins a certificated course, which vastly improves his overall knowledge of treating diabetes. He also starts attending various diabetes meetings, where he learns the value of avoiding clinical inertia and the need for starting insulin early if multiple oral antidiabetic drugs are not effective. He begins to employ a dietician, whom he enrolls in a program to gain certification as a diabetes educator. The dietitian learns how to administer insulin, and how to teach patients about blood glucose and continuous glucose monitoring. She also prescribes healthy diets and increasing physical activity for patients. Together, Dr. Thomas and the dietitian develop specialized educational materials for patients with diabetes.

Dr. Thomas finds that, with the addition of the dietitian/diabetes educator to his clinic, his own time is freed up and he is under less pressure. Moreover, his patients benefit considerably from the extra attention that is given to them by the diabetes educator. Over time, Dr. Thomas finds that the general level of diabetes control in his patients improves considerably. Moreover, as he now starts seeing more patients with diabetes, he focuses his practice on diabetes and its associated comorbid conditions.

The lessons Dr. Thomas learns are as follows:

It is difficult for an individual physician to spend enough time to educate people with diabetes.

Addition of a dietitian/diabetes educator greatly enhanced his practice and improved the control of diabetes in his clinic.

His own self-improvement in knowledge of diabetes gave him the confidence to treat even difficult cases of diabetes.

Dr. Thomas does not hesitate anymore to use insulin whenever indicated. In fact, he has even started using a short course of insulin early in the treatment of those who present with infectious ketonemia, grossly elevated HbA1c, weight loss, or other symptoms of uncontrolled diabetes.

Case 8: Mrs. Karim, Ashulia, Bangladesh: Overcoming sudden stoppage of insulin

Mrs. Karim is a 45-year-old woman. Two years ago, she was experiencing typical symptoms such as polyuria and polydipsia. Mrs. Karim’s OGTT revealed her fasting blood glucose to be 14 mmol/l and her postprandial blood glucose to be 26 mmol/l. Regular pre-mixed insulin was initiated, as well as the introduction of dietary modifications and exercise.

As advised by a local village physician, Mrs. Karim stopped taking insulin after she experienced nocturnal hypoglycemia. Three months later, she developed the same symptoms of hyperglycemia that she experienced 2 years prior at the initial diabetes detection. Mrs. Karim then began to omit her nightly dose of insulin, taking it only in the morning.

Mrs. Karim experienced a recent non-healing ulcer on her left toe following a trauma. She was referred to BIRDEM, a tertiary care hospital. Mrs. Karim’s HbA1c levels were 11.3% with normal renal function.

The management plan for Mrs. Karim consisted of a split-mixed regimen, antibiotic prescription, and diabetes education. As patients may sometimes feel more comfortable with local physicians, education on future diabetic management, including insulin management, was provided to Mrs. Karim’s local physician.

The key features of the management plan were:

Split-mixed insulin regime of short-acting postprandial insulin, to keep postprandial blood glucose between 8 and 10 mmol/l and intermediate-acting insulin to keep pre-prandial blood glucose between 6 and 7 mmol/l.

Diabetes education including advice on self-adjustment of insulin and hypoglycemia.

Education on self-empowerment in Mrs. Karim’s diabetes management.

Dietary advice and adjustment, as well as frequent home monitoring.

Communication with Mrs. Karim’s local physician.

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Acknowledgements

Medical writing and editorial assistance.

Support for the development of this manuscript, under the direction of the authors, was provided by Edward Potts and Helen Marshall, of Ashfield MedComms, an Inizio company, and funded by Novo Nordisk. Drafts of the article were prepared by a medical writer, funded by the sponsor, and were circulated to all authors for review. The sponsor reviewed the final draft of the article for medical accuracy, with no input on the content of the article at any stage.

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University of New South Wales, Sydney, Australia

Department of Diabetes, Endocrinology and Metabolic Diseases, MTI Hayatabad Medical Complex, Peshawar, Pakistan

Azizul Hasan Aamir

Department of Endocrinology and Metabolic Disease, BIRDEM Hospital, Dhaka, Bangladesh

Mohammod Feroz Amin

Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Pongamorn Bunnag

Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia

Siew Pheng Chan

Department of Endocrinology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China

Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran

Mohammad E. Khamseh

Madras Diabetes Research Foundation and Dr. Mohan’s Diabetes Specialities Centre, Chennai, India

Viswanathan Mohan

Department of Biochemistry and Molecular Biology, University of the Philippines-College of Medicine, Manila, Philippines

Nemencio Nicodemus Jr.

South Australian Endocrine Clinical Research, Keswick, Adelaide, SA, Australia

Anthony Roberts

Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

Tri Juli Edi Tarigan

Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea

Kyu-Chang Won

Unidad de Investigación en Enfermedades Metabólicas, Departamento de Endocrinología y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico

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The concept for this review article was agreed on by all authors (Roger Chen, Azizul Hasan Aamir, Mohammod Feroz Amin, Pongamorn Bunnag, Siew Pheng Chan, Lixin Guo, Mohammad E. Khamseh, Viswanathan Mohan, Nemencio Nicodemus Jr., Anthony Roberts, Tri Juli Edi Tarigan, Kyu-Chang Won, and Roopa Mehta) and the sponsor. All authors (Roger Chen, Azizul Hasan Aamir, Mohammod Feroz Amin, Pongamorn Bunnag, Siew Pheng Chan, Lixin Guo, Mohammad E. Khamseh, Viswanathan Mohan, Nemencio Nicodemus Jr., Anthony Roberts, Tri Juli Edi Tarigan, Kyu-Chang Won, and Roopa Mehta) critically reviewed the article and approved the final version for submission.

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Roger Chen: was a speaker and/or attendee of advisory boards and has received research funding from: Abbott, Astra Zeneca, Boehringer Ingelheim, Eli Lilly and Novo Nordisk; Azizul Hasan Aamir: is a member of the speaker bureau for Sanofi, Novo Nordisk, Getz Pharma, Hilton Pharma and CCL Pharma; Mohammod Feroz Amin: has been a speaker and/or on advisory boards or a recipient of research funding for Eli Lilly, Novo Nordisk, Synovia ( Sanofi), ACI, Beximco and Incepta Pharmaceuticals Bangladesh; Pongamorn Bunnag: has acted as a speaker or advisor/consultant for AstraZeneca, Boehringer Ingelheim, Zuellig Pharma, Novo Nordisk, Sanofi, Abbott, LG Lifesciences, Bayer and Celltrion; Siew Pheng Chan: has received honoraria as speaker and advisory board member from: Abbott, AstraZeneca, Boerhinger-Ingelheim, Merck, Novo Nordisk, Servier, Zuellig Pharma Therapeutics; Lixin Guo: has participated as an advisory board member/consultant for Abbott, AstraZeneca, Bayer, Boehringer-Ingelheim, Dreisamtech, Dongbao, Eli Lilly, Gan & Lee, Hansoh, Hengrui, Huadong Medicine, Hua Medicine, Innovent, Janssen, Novartis, Novo Nordisk, Merck, Pfizer, Sanofi, Synapsor, Takeda, Zense and 3sbio, and has received research funding or grants from the National Natural Science Foundation of China, the Beijing Natural Science Foundation, Abbott, AstraZeneca, Bayer, Dreisamtech, Eli Lilly, Hansoh, Hengrui, Huadong Medicine, Hua Medicine, Innovent, Meitekanger tech, Novo Nordisk, Salubris, Sanofi, Synapsor and Zense; Mohammad E. Khamseh: has received honoraria and research grants from Novo Nordisk, Roche, Sanofi and Merck; Viswanathan Mohan: has received honoraria and research grants from Novo Nordisk, Eli Lilly, Sanofi, Boehringer Ingelheim and several Indian Pharma companies; Nemencio Nicodemus Jr.: has received speaker honoraria from Novo Nordisk and Sanofi; Anthony Roberts: has received research funding or honorarium from Eli Lilly, AstraZeneca, Novo Nordisk, MSD, Boehringer Ingelheim, Janssen, Novartis, Lexicon Pharmaceuticals and Inc., Sanofi; Tri Juli Edi Tarigan: has received honorarium as speaker/consultant, support for research/clinical trial/attendance at educational meetings from AstraZeneca, Sanofi, Novo Nordisk, Boehringer Ingelheim, Servier, Kalbe Pharma, Sanbe, ZP Pharma and more; Kyu-Chang Won: has received research grants and speaker honoraria from Novo Nordisk, Eli Lilly, and Sanofi; Roopa Mehta: has acted as a speaker or advisor/consultant for Abbott, Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Sanofi and Silanes. Mohammad E. Khamseh is an Editorial Board member of Diabetes Therapy. Mohammad E. Khamseh was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions.

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Chen, R., Aamir, A.H., Feroz Amin, M. et al. Barriers to the Use of Insulin Therapy and Potential Solutions: A Narrative Review of Perspectives from the Asia–Pacific Region. Diabetes Ther (2024). https://doi.org/10.1007/s13300-024-01568-9

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Diabetes & Primary Care
Vol:24 | No:06

Interactive case study: The elderly and type 2 diabetes

Share this article + Add to reading list – Remove from reading list ↓ Download pdf

Diabetes & Primary Care ’s series of interactive case studies is aimed at all healthcare professionals in primary and community care who would like to broaden their understanding of diabetes.

The care of older people with type 2 diabetes is complicated, as the prognosis and appropriate treatment goals vary greatly between individuals. The three mini-case studies developed for this issue of the journal take us through the basic considerations of managing type 2 diabetes in the elderly.

The format uses typical clinical scenarios as tools for learning. Information is provided in short sections, with most ending in a question to answer before moving on to the next section.

Working through the case studies will improve our knowledge and problem-solving skills in diabetes care by encouraging us to make evidence-based decisions in the context of individual cases.

Readers are invited to respond to the questions by typing in your answers. In this way, we are actively involved in the learning process, which is hopefully a much more effective way to learn.

By actively engaging with these case histories, I hope you will feel more confident and empowered to manage such presentations effectively in the future.

Marianne , who is 71 years old, has type 2 diabetes but lives a very active life, with little in the way of comorbidities. However, despite treatment with metformin 1000 mg twice daily, her glycaemic control has deteriorated in recent years.

Mike is 78 years old and has long-standing type 2 diabetes. Six years ago he suffered a myocardial infarction. He takes a range of medication to address his hyperglycaemia, hypertension and low mood. He lives alone, but uses a stick to walk and receives practical help from his daughter. Recently, he has been experiencing shakiness and sweating after gardening, and dizziness on standing. His BP is 117/58 mmHg and HbA 1c is 51 mmol/mol.

Claire is an 81-year-old who lives in a care-home. She has Alzheimer’s disease and long-standing type 2 diabetes. A stroke 4 years ago left her with unilateral weakness, and she has frequent lower urinary tract infections and episodes of urinary incontinence. For her hyperglycaemia, hypertension and various other health concerns, she is taking over a dozen medications. A review of her diabetes is due.

The health and care needs of each of these people differ greatly. By working through their case studies, we will consider the following issues, and more:

Agreeing glycaemic targets in the elderly.
Assessment of frailty and the importance of a holistic approach to managing diabetes in the elderly.
Choice of medications and concerns over hypoglycaemia.
Deintensification and simplification of medication regimens.

Click here to see the case study.

Interactive case study: Non-diabetic hyperglycaemia – Prediabetes

Diabetes distilled: smoking cessation cuts excess mortality rates after as little as 3 years, impact of freestyle libre 2 on diabetes distress and glycaemic control in people on twice-daily pre-mixed insulin, updated guidance from the pcds and abcd: managing the national glp-1 ra shortage, diabetes distilled: fib-4 – a diagnostic and prognostic marker for liver and cardiovascular events and mortality, at a glance factsheet: tirzepatide for management of type 2 diabetes, editorial: lipid management, tirzepatide and hybrid closed-loop: what does new nice guidance recommend.

Diagnosing and managing non-diabetic hyperglycaemia.

17 Apr 2024

The mortality benefits of smoking cessation may be greater and accrue more rapidly than previously understood.

Expanding CGM eligibility criteria to include this patient group may be beneficial.

27 Mar 2024

Advice on selecting alternative glucose-lowering therapies when GLP-1 RAs used in the management of type 2 diabetes in adults are unavailable.

22 Mar 2024

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This One Swap Might Help Those With Type 2 Diabetes Increase Longevity by 26%, a New Study Suggests

S wapping one serving of soda with unsweetened coffee, tea, milk or water may reduce risk for early death, according to this new health study.

According to the 2020 to 2025 Dietary Guidelines for Americans , we should aim to consume less than 10% of our total daily calories from added sugars. On a 2,000-calorie-per-day diet, that works out to about 12 teaspoons (about 48 grams) per day. Since the cardiologists at the American Heart Association (AHA) believe added sugars are so impactful on heart health (and overall health) they set even stricter guidelines and suggest that women aim for fewer than 6 teaspoons and men shoot for 9 teaspoons or fewer of added sugar per day.

Now that you know the goal, we have some not so sweet news: The average American consumes about 17 teaspoons of added sugars per day, according to USDA estimates. This is nearly three times as much as the AHA recommends, and about 50% more than the dietary guidelines' upper limit.

While you might guess that desserts, candy or sweet cereals might be the main culprits for the excess sugar, the most common source of added sugars in the typical American's diet is actually sugar-sweetened beverages . This category includes soft drinks, sports drinks, energy drinks, cocktails and fruit drinks (that aren't 100% juice), and the CDC reports that these make up about 24% of Americans' collective added sugar consumption.

If you sip on any sweetened beverage, you could inch a lot closer to—or even fall below—that upper added sugar limit if you start shifting your consumption to less-sugary beverage options. But one population in particular might want to consider making the switch sooner rather than later.

According to a new study published April 19, 2023 in the journal The BMJ , among people diagnosed with type 2 diabetes, those who drink the most sugar-sweetened beverages may be at a 20% higher risk for early mortality, including from conditions like heart disease. Drinking coffee, tea, water or low-fat milk instead slashed risk for all-cause mortality by 12% to 26% , they found.

Read on to learn more about this new research, plus how to make better beverage choices, whether you have prediabetes , have received a type 2 diabetes diagnosis or simply want to live a long, vital life.

Related: Why You Might Be Tested For Type 2 Diabetes at Your Next Physical, Even if You Don't Have Family History

What This Type 2 Diabetes Research Found

To land at this conclusion, a team of researchers from the U.S., Canada and China gathered insights from two long-term cohort studies that aggregate health data from large populations, the Nurses' Health Study and Health Professionals Follow-Up Study . These ran from the 1980s until 2018. The scientists selected 15,486 people (about 74% of these were women) who had been diagnosed with type 2 diabetes, and asked them to complete diet-related questionnaires every 2 to 4 years for an average of 18 ½ years. These surveys asked the participants what—and how often—they consumed foods and drinks. Anyone who skipped any questionnaires about their total drink consumption were excluded from the study, which left a total of 12,771 people.

By the end of the long follow-up period, 7,638 participants had died, which meant there was nearly a 50-50 split of those who were still living and those who had passed. This allowed the researchers to look at if there were any patterns among drink consumption in either party.

Related: 10 Starbucks Drinks That Have Less Than 10 Grams of Sugar

For each serving of sugar-sweetened drink consumed each day, an individual's risk of "all-cause mortality" (death from any cause) rose by 8%. Compared to those who drink none, those who consumed the most sugar-sweetened drinks were at 20% higher risk for early mortality.

If that same person swapped just one serving of a sugar-sweetened drink with a unsweetened beverage, their risk for death dropped significantly, the scientists found.

1 serving of coffee instead of a sweet drink: 26% lower risk for mortality
1 serving of plain water instead of a sweet drink: 23% lower risk for mortality
1 serving of tea instead of a sweet drink: 21% lower risk for mortality
1 serving of low-fat milk instead of a sweet drink: 12% lower risk for mortality

They also found that swapping in artificially-sweetened drinks, such as diet soda , did slightly lower overall risk of death compared to sugar-sweetened drinks. That said, the participants lowered their risk even more when they shifted from the artificially-sweetened option to water, tea or coffee.

While we certainly can't prove that the drink consumption played a large role in the death—this is likely more of a correlation than a causation— "choice of beverage clearly matters," writes Nita G Forouhi, Ph.D. , professor and program leader at the Medical Research Council Epidemiology Unit at the University of Cambridge School of Clinical Medicine in England in an accompanying editorial in The BM J . "Although the evidence is less clear for artificially-sweetened beverages and fruit juice, it is reasonable to shift the focus to drinks that are most likely to have positive health impacts: coffee, tea, plain water and low fat milk."

The Bottom Line

A new study suggests that, over the long-term, switching just one serving per day of a sugar-sweetened drink for a less-sugary option might be enough to lower risk for early death. This research included people who had been diagnosed with type 2 diabetes, a population among whom overall added sugar consumption matters a lot.

Still, the same moral of the story holds true for all humans: drinking water (still or sparkling ), unsweetened coffee or tea or low-fat milk (or an unsweetened plant-based alternative ) is a savvy move to reduce your overall calorie consumption and added sugar intake—while possibly playing a small role in longevity.

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Diabetes Spectr
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Case Study: Remission of Type 2 Diabetes After Outpatient Basal Insulin Therapy

Sierra c. schmidt.

1 Auburn University Harrison School of Pharmacy, Auburn, AL

Martha Ann Huey

Heather p. whitley.

2 Baptist Health System, Montgomery Family Medicine Residency Program, Montgomery, AL

Diabetes is a chronic, progressive disease with potentially serious sequelae. Treatment for type 2 diabetes often begins with oral agents and eventually requires insulin therapy. As the disease progresses, drug therapies are often intensified and rarely reduced to control glycemia. Conversely, in type 1 diabetes, some patients experience a “honeymoon period” shortly after diagnosis, wherein insulin needs decrease significantly before intensification is needed ( 1 ). No comparable honeymoon period has been widely described for type 2 diabetes. However, a few studies have demonstrated that drug-free glycemic control can be achieved in type 2 diabetes for 12 months on average after a 2-week continuous insulin infusion ( 2 – 4 ). Here, we describe an unusual case of a 26-month drug holiday induced with outpatient basal insulin in a patient newly diagnosed with type 2 diabetes.

Case Presentation

A 69-year-old white woman (weight 72.7 kg, height 59 inches, BMI 32.3 kg/m 2 ) was diagnosed with type 2 diabetes in June 2011. She presented with an A1C of 17.6% (target <7%) and a fasting blood glucose (FBG) of 452 mg/dL (target 70–130 mg/dL). Before diagnosis, the patient had not used any oral or parenteral steroids nor had she experienced any traumatic physical or emotional event or illness that could have abruptly increased her blood glucose. Metformin 500 mg twice daily was initiated at diagnosis, but was discontinued 9 days later to avoid risk of lactic acidosis, as her serum creatinine was 1.5 mg/dL. At that time, her fasting self-monitoring of blood glucose (SMBG) values ranged from 185 to 337 mg/dL. Treatment with 25 units of insulin detemir daily (0.34 units/kg/day) was initiated in place of metformin. The patient was counseled on diet modifications and encouraged to exercise.

One month later (July 2011), the patient’s fasting SMBG values had improved to a range of 71–212 mg/dL with a single hypoglycemic episode (58 mg/dL); her weight and BMI increased slightly to 74.1 kg and 32.9 kg/m 2 , respectively. Hypoglycemia education was reinforced, and insulin therapy was switched from 25 units of detemir delivered with the Levemir FlexPen to 28 units (0.38 units/kg/day) of insulin glargine delivered with the Lantus SoloStar due to the patient’s preference for this device. Two weeks later, the patient reported continued improvements in fasting SMBG (70–175 mg/dL) with one hypoglycemic episode (67 mg/dL). In response to the hypoglycemic episode, her insulin glargine dose was decreased to 25 units daily.

In September, the patient reported fasting SMBG values ranging between 71 and 149 mg/dL, and her A1C was 7.9%. On days when the patient skipped lunch, her midday blood glucose level would drop to <70 mg/dL (54–60 mg/dL). She was counseled not to skip meals, and her insulin glargine dose was maintained.

In October, the patient’s weight was 71.4 kg, and her BMI was 31.7 kg/m 2 . She reported recently initiating a cinnamon supplement and switching her beverage intake from sugar-sweetened products to water and diet soda. Although the majority of her fasting SMBG values were controlled (80–110 mg/dL), she had experienced six hypoglycemic episodes (FBG 13–64 mg/dL). All values were objectively confirmed in the patient’s glucose meter, and the meter was replaced in case of device error. Her daily insulin glargine dose was decreased to 20 units (0.28 units/kg/day).

In December, her SMBG values ranged between 70 and 106 mg/dL preprandially and 111 and 207 mg/dL postprandially, and she had had six additional hypoglycemic episodes (42–66 mg/dL). The patient’s weight remained stable at 71.4 kg (BMI 31.7 kg/m 2 ). At this follow-up visit, her daily insulin glargine dose was decreased further to 15 units (0.21 units/kg/day).

The patient self-discontinued daily insulin glargine in March 2012 but continued using the cinnamon supplements. She continued to perform SMBG 1–3 times/day, anticipating loss of glycemic control. During the next 2 years, her A1C remained stable (from 6.3% in January 2012 to 6.9% in May 2014) ( Figure 1 ).

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Object name is 50fig1.jpg

Daily basal insulin dose and A1C over time. Black triangle = insulin units; black square = A1C.

At a follow-up visit in May 2014, the patient’s SMBG indicated a need for resumed drug therapy (FBG 107–169 mg/dL, postprandial blood glucose 108–328 mg/dL). Her weight at this time was 65.5 kg (BMI 29.1 kg/m 2 ). Insulin glargine was reinitiated at 5 units daily (0.08 units/kg/day).

During the drug-free period of March 2012 to May 2014, the patient maintained her lack of sugar-sweetened beverage consumption. However, she reported having difficulties purchasing healthy food options because of financial constraints. In August 2013, she was specifically encouraged to incorporate physical activity (walking) into her daily routine. The patient’s weight during the drug-free interval declined from 70 kg in March 2012 to 65.5 kg in May 2014.

Hyperglycemia causes pancreatic β-cell toxicity, leading to decreased insulin release ( 3 ). In type 1 diabetes, the honeymoon period occurs when residual pancreatic β-cell function is partially restored for an average of 7.2 months, as hyperglycemic stress is removed before the β-cells are ultimately destroyed ( 1 , 3 ).

Past studies demonstrated induction of a drug-free period when patients newly diagnosed with type 2 diabetes were treated with 2–3 weeks of intensive insulin therapy ( 2 – 5 ). Ilkova et al. ( 2 ) induced a 12-month drug-free period in 46.2% ( n = 6) of patients using an insulin infusion averaging 0.61 units/kg/day. Three patients maintained glycemic control for 37–59 months. Li et al. ( 3 ) also induced a 12-month drug-free period in 47.1% ( n = 32) of patients with an insulin infusion of 0.7 units/kg. Additional studies indicate that basal-bolus insulin therapy (0.37–0.74 units/kg/day) using NPH and regular insulin can also induce a 12-month drug-free period in a similar percentage of patients (43.8–44.9%) ( 4 , 5 ).

The mechanism of remission appears to be related to resumption of endogenous insulin production after glucotoxicity is resolved. Glucotoxicity has been shown to inhibit first-phase insulin secretion from the pancreatic β-cells ( 3 ). Li et al. ( 3 ) theorized that an insulin infusion corrects hyperglycemia and removes stress from the β-cells, allowing them to produce insulin, resulting in euglycemia. Their study quantified an increase in secretion of endogenous insulin (44%) and C-peptide (26%) after 2 weeks of continuous insulin infusion. The mechanism through which insulin induces a period of drug-free glycemic control in type 2 diabetes appears to be similar to that causing the honeymoon period in type 1 diabetes.

To our knowledge, this is the first report of basal insulin monotherapy–induced remission of type 2 diabetes. Previous studies required multiple daily injections in a basal-bolus therapy regimen using NPH and regular insulin or hospitalization of patients administered a continuous insulin infusion ( 2 – 5 ).

Basal-only insulin therapy may be a slower method of achieving remission compared to more intensive insulin regimens. In this case, basal insulin was maintained for 9 months. However, according to the FBG trend, discontinuation could have occurred sooner. This report suggests that a trial of basal insulin dosed at 0.2–0.3 units/kg/day, with follow-up every 2–4 weeks in severely hyperglycemic patients with newly diagnosed type 2 diabetes, may be an alternative method to achieving temporary remission. Although this insulin regimen requires a longer timeframe compared to remission induced by basal-bolus therapy or continuous insulin infusion, it provides a more convenient outpatient therapeutic option at a lower cost.

Limitations of this case study include the patient’s use of cinnamon supplementation, which was continued throughout the drug-free period. Although reports are conflicting regarding its efficacy in type 2 diabetes, it is possible that cinnamon may have exerted a mild antidiabetic effect. Positive cinnamon studies have demonstrated a 0.36% A1C reduction after 3 months of use ( 6 ). Additionally, the patient’s weight declined by 3.75% during the 9 months of basal insulin therapy, which was likely in response to introducing dietary modifications related to beverage consumption. Most studies suggest that an A1C reduction of 0.36% ( 7 ) to 0.66% ( 8 ) can be achieved with intensive lifestyle interventions. Therefore, it is unlikely that cinnamon in combination with the mild lifestyle modifications accounted for a nearly 11% A1C reduction from baseline.

Eliminating the consumption of sugar-rich beverages alters the postprandial glycemic curve. In clinical practice, suppressing postprandial blood glucose excursions by adopting significant dietary improvements may postpone or obviate the need for bolus insulin therapy. Likewise, the remission of diabetes potentially may be achieved, as seen in this case, with monotherapy basal insulin when dietary modifications significantly alter the postprandial glycemic curve. However, it is unknown whether remission can be achieved using basal insulin administration alone in patients who choose not to incorporate lifestyle modifications or in patients with baseline healthy eating and exercise habits.

Although weight changes did not appear to contribute to disease remission, the moderate weight loss (6.5%) achieved during the drug-free interval and continued SMBG both may have contributed to maintaining and extending the remission period. The Diabetes Prevention Program ( 9 ) showed that lifestyle modifications aimed at achieving a 7% reduction of weight significantly delay the onset of diabetes compared to placebo and metformin. Finally, performing SMBG through the drug-free period may have empowered the patient by providing objective criteria necessary to validate the benefits of lifestyle modifications.

Based on this case, it is possible that initial type 2 diabetes management with basal insulin can temporarily restore β-cell function to a degree to which blood glucose control can be maintained without drug therapy. Although previous studies conducted with intensive insulin regimens have reported response rates nearing 50% for ∼12 months ( 2 – 5 ), future studies should investigate the ideal basal dose, percentage of patient responders, duration of drug-free glycemic control, and mechanism through which this phenomenon occurs. This case further highlights the need to educate every newly diagnosed patient about the treatment of hypoglycemic events.

The purposeful remission of diabetes is not widely attempted or generally considered possible. Although literature exists regarding the temporary honeymoon period experienced after insulin initiation in some people with type 1 diabetes ( 1 ), comparatively little research is available regarding the influence of insulin on the remission of type 2 diabetes. Current literature suggests benefit in nearly 50% of patients newly diagnosed with type 2 diabetes using one of the following strategies: a 2-week inpatient insulin infusion or multiple daily injections of basal-bolus therapy ( 2 – 5 ). However, there are disadvantages to these methods. A continuous insulin infusion requires inpatient admission, whereas a basal-bolus insulin regimen requires purchase of two products and administration of multiple subcutaneous injections daily. Unfortunately, both methods may be impractical, costly, and inconvenient for many patients newly diagnosed with type 2 diabetes.

This case outlines a third potential option for inducing remission of type 2 diabetes: basal insulin monotherapy. Using this approach avoids the costly and inconvenient hospital admission required for the continuous insulin infusion strategy. Furthermore, the cost of drug therapy is reduced with the purchase of one rather than two insulin products, as needed in a basal-bolus insulin regimen. Additionally, using basal insulin alone reduces the risk of hypoglycemic events that may occur with stacking of multiple insulin products. Finally, requiring only one injection of insulin each day offers a more manageable alternative for newly diagnosed patients compared to the multiple daily injections required with a basal-bolus insulin regimen.

By using this basal insulin strategy, the patient in this case was able to achieve drug-free glycemic control for 26 months. Early initiation of basal insulin monotherapy in patients newly diagnosed with type 2 diabetes is a more convenient and cost-effective approach than methods previously described and could potentially induce remission of type 2 diabetes in other patients.

Duality of Interest

No potential conflicts of interest relevant to this article were reported.

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Correlation of Platelet Indices in Patients With Type 2 Diabetes Mellitus and Associated Microvascular Complications: A Hospital-Based, Prospective, Case-Control Study

Barriers to the Use of Insulin Therapy and Potential Solutions: A Narrative Review of Perspectives from the Asia–Pacific Region

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Interactive case study: Non-diabetic hyperglycaemia – Prediabetes

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Case Study: Remission of Type 2 Diabetes After Outpatient Basal Insulin Therapy

Martha Ann Huey

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