Prevalence and correlation of glycemic control achievement in patients with type 2 diabetes in Iraq: A retrospective analysis of a tertiary care database over a 9-year period

BackgroundThis study was designed to assess the achievement of a glycated hemoglobin (HbA1c) target in Iraqi type 2 diabetes mellitus (T2DM) patients via retrospective analysis of a tertiary care database over a 9-year period.MethodsA total of 12,869 patients with T2DM with mean (SEM) age: 51.4(0.1) years, and 54.4% were females registered into Faiha Specialized Diabetes, Endocrine and Metabolism Center(FDEMC) database between August 2008 and July 2017 were included in this retrospective study. Data were recorded for each patient during routine follow-up visits performed at the center every 3–12 months.ResultsPatients were under oral antidiabetic drugs (OAD; 45.8%) or insulin+ OAD (54.2%) therapy. Hypertension was evident in 42.0% of patients, while dyslipidemia was noted in 70.5%. Glycemic control (HbA1c <7%) was achieved by 13.8% of patients. Multivariate analysis revealed <55 years of age, female gender, >3 years duration of diabetes, HbA1c >10% at the first visit, presence of dyslipidemia, and insulin treatment as significant determinants of an increased risk of poor glycemic control. BMI <25 kg/m² and presence of hypertension were associated with a decreased risk of poor glycemic control.ConclusionUsing data from the largest cohort of T2DM patients from Iraq to date, this tertiary care database analysis over a 9-year period indicated poor glycemic control. Younger patient age, female gender, longer disease duration, initially high HbA1c levels, dyslipidemia, insulin treatment, overweight and obesity, and lack of hypertension were associated with an increased risk of poor glycemic control in Iraqi T2DM patients.     

Cardiovascular risk factor management in patients with diabetes: Does management differ with disease duration?

AimsOur objective was to examine risk factor modification targets and treatment in relation to duration of diabetes.MethodsThe Diabetes Mellitus Status in Canada (DM-SCAN) study collected data on 5109 patients with type 2 diabetes mellitus (T2DM) in 2012 in primary care. We compared the prevalence of vascular complications, treatment targets, and interventions between patients with diagnosed diabetes duration ≤10 and > 10 years.ResultsPhysicians more frequently assigned HbA1c (glycated hemoglobin) targets of 7.1–8.5% (54–69 mmol/mol) to patients with longer duration of diabetes (n = 1647) (19.8% vs 9.5%, p < 0.001). Patients with longer duration of diabetes were less likely to achieve HbA1c targets of ≤7.0% (53 mmol/mol) (39% vs. 55%, p < 0.001), had similar likelihood of achieving blood pressure targets of ≤130/80 mmHg (38% vs. 36%, p = 0.26) and were more likely to achieve LDL-C targets of ≤2.0 mmol/L (≤77.3 mg/dL) (63% vs. 53%, p < 0.001) compared to patients with shorter duration of diabetes (n = 3462). Achievement of all three targets between both groups were similar (13% vs. 13%, p = 0.82). Overall, patients with longer duration of diabetes were more likely to be prescribed anti-hyperglycemic, anti-hypertensive, lipid-lowering medications and referred for diabetes education.ConclusionsOnly 13% of patients achieved glycemic, blood pressure, and LDL-C targets irrespective of duration of diabetes. Despite being managed with more medications, patients with longer duration of diabetes were less likely to achieve glycemic targets. More focus is needed on developing methods to bridge best care and real-world practice.     

Improvement of glycemic control in type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials

AimDifferent guidelines provide similar, but not identical, therapeutic targets for HbA1c in type 2 diabetes. These targets can also depend from the different pharmacological strategies adopted for intensifying glycemic control.Data synthesisThis meta-analysis includes randomized trials adopting any pharmacological regimen for intensifying glycemic control in T2DM (versus standard of care/placebo), with a trial duration ≥2 years and a between-group HbA1c difference≥0.5%. The primary outcome was to assess the effects of the improvement of glycemic control on major cardiovascular events (MACE), ocular and renal complications, and severe hypoglycemia. Mantel-Haenszel odds ratios (MH–OR) with 95% Confidence Intervals were calculated for all the outcomes considered.We included 13 trials fulfilling the inclusion criteria. The improvement of glycemic control was associated with a lower risk of MACE (MH–OR:0.89 [95%CI 0.85–0.94]) and renal adverse events (MH–OR 0.73 [0.65–0.82]), but not all-cause mortality (MH–OR 0.95 [0.88–1.01]) and ocular adverse complications (MH–OR 0.94 [0.72–1.22]). For glucose-lowering drugs inducing hypoglycemia, a protective effect on the risk of microvascular complications, but not of MACE and all-cause mortality, was observed only for HbA1c ≤ 48 mmol/mol, but with higher risk of severe hypoglycaemia (MH–OR 2.72 [1.79–4.13]). Drugs not inducing hypoglycaemia were associated with a reduction of MACE, renal adverse events, and all-cause mortality, for HbA1c< 7% (no data for lower targets).ConclusionsThe present meta-analysis show that the improvement of glycemic control with drugs not inducing hypoglycemia is associated with a reduction in the risk of long-term chronic vascular and renal complications, and all-cause mortality.     

Achievement of guideline targets of glycemic and non-glycemic parameters in North Indian type 2 diabetes mellitus patients: A retrospective analysis

Background and aimsThough, the prevalence of diabetes is increasing in the worldwide, achievement of glycemic and non-glycemic targets remain suboptimal. We conducted this retrospective cross-sectional study at two endocrine clinics of Aligarh (Uttar Pradesh) in north India.Materials and methodsAfter screening the records of 13800 patients, 12140 patients of type 2 diabetes mellitus who were attending the clinic regularly every three to four months, were included in the final analysis. The data regarding patient’s height, weight, body mass index, blood pressure, blood glucose, HbA1c, lipid profile and complications were obtained.ResultsMean age was 49.7 ± 11.3 years; males and females were almost equal in number. 2891 (23.8%) subjects were of age less than 40 years. 9614 (80%) patients had diabetes duration of less than 5 years. 3311 (27.3%) subjects were having an HbA1c of <7%, HbA1c 7–8% in 3711 (30.5%), HbA1c 8–9% in 2653 (21.9%) whereas HbA1c of >9% in 2465 (20.3%) subjects. The microvascular complications; diabetic nephropathy, diabetic neuropathy and diabetic retinopathy were present in 7.5%, 14.9% and 16.2% respectively. Hypertension was present in 25.8% and coronary artery disease was present in 15.5% of patients. Overall 27.3%, 41.7%, 44.1%, 45.3% and 67.7% of patients achieved their HbA1c, triglyceride, HDL, LDL and hypertension targets respectively, as per American Diabetes Association 2020 guidelines.ConclusionDespite availability of multiple drugs and guidelines, the attainment rates of glycemic and non-glycemic targets remain suboptimal. A more aggressive approach in the treatment of type 2 diabetes is required.     

A Project ECHO and Community Health Worker Intervention for Patients with Diabetes

BackgroundBoth community health workers and the Project ECHO model of specialist telementoring are innovative approaches to support primary care providers in the care of complex patients with diabetes. We studied the effect of an intervention that combined these 2 approaches on glycemic control.MethodsPatients with diabetes were recruited from 10 federally qualified health centers in New Mexico. We used electronic health record (EHR) data to compare HbA1c levels prior to intervention enrollment with HbA1c levels after 3 months (early follow-up) and 12 months (late follow-up) following enrollment. We propensity matched intervention patients to comparison patients from other sites within the same electronic health records databases to estimate the average treatment effect.ResultsAmong 557 intervention patients with HbA1c data, mean HbA1c decreased from 10.5% to 9.3% in the pre- versus postintervention periods (P < .001). As compared to the comparison group, the intervention was associated with a change in HbA1c of ?0.2% (95% confidence interval [CI] ?0.4%-0.5%) and ?0.3 (95% CI ?0.5–0.0) in the early and late follow-up cohorts, respectively. The intervention was associated with a significant increase in percentage of patients with HbA1c <8% in the late follow-up cohort (8.1%, 95% CI 2.2%?13.9%) but not the early follow-up cohort (3.6%, 95% CI ?1.5% to 8.7%)DiscussionThe intervention was associated with a substantial decrease in HbA1c in intervention patients, although this improvement was not different from matched comparison patients in early follow-up. Although combining community health workers with Project ECHO may hold promise for improving glycemic control, particularly in the longer term, further evaluations are needed.     

Diabetes care quality according to facility setting: A cross-sectional analysis in six Peruvian regions

ObjectiveTo characterize diabetes care across healthcare facilities in six Peruvian regions.MethodsCross-sectional study of patients with type 2 diabetes mellitus (T2DM), ranging from primary care facilities to hospital-based facilities, in six Peruvian regions. Data was collected by health staff trained between 2012 and 2016. We studied six diabetes care outcomes and four adequate diabetes care outcomes considering the healthcare facility as the exposure of interest. We estimated prevalence ratios (PR) and their 95% confidence intervals (95% CI) using Poisson regression with robust variance.ResultsData from 8879 patients with T2DM, mean age 59.1 years (SD ± 12.2), 53.6% males, was analyzed. Of these, 8096 (91.2%) were treated at primary care facilities. The proportions of patients who had HbA1c, LDL-c, and creatinine/microalbumin test performed increased with the setting of the healthcare facility. Overall, 39%–56% of patients had an adequate HbA1c control, being higher in hospital-based facilities with specialists in comparison to primary care facilities.ConclusionsWe observed that the higher the setting of the facility, the higher the rate of the assessed diabetes care outcomes and adequate diabetes care for four of the six targets (fasting glucose, HbA1c, LDL-c and creatinine or microalbumin) and for three of the four targets (glucose≤130 mg/dL, HbA1c ≤7%(53 mmol/mol) and LDL-c <100 mg/dL), respectively. Substantial gaps were observed at the primary care facilities, calling for the strengthening of diabetes care.     

Association of musculoskeletal pain with the achievement of treatment targets for type 2 diabetes among primary care patients

AimsTo assess the association of diagnosed musculoskeletal (MS) pain (low back, neck, shoulder, and knee pain; and the number of pain sites) with the achievement of targets for glycosylated haemoglobin A1c (HbA1c), low-density-lipoprotein cholesterol (LDL), and systolic blood pressure (SBP) among primary care patients with type 2 diabetes (T2D).MethodsThe cross-sectional study population consisted of 3478 patients with a registry-based T2D diagnosis and available registry-based data on MS pain diagnoses, covariates, and outcomes between 2016 and 2019. Logistic regression analysis was used to evaluate the study aims.ResultsOverall, 22% had at least one of the four types of MS pain, and 73%, 57%, and 51% achieved the treatment targets of HbA1c, LDL, and SBP, respectively. T2D patients with or without MS pain did not differ in their achievement of T2D treatment goals. Of pain locations, low back pain was associated with higher rates of achievement of the LDL target (OR 1.29, 95% CI 1.01–1.65), but the association was attenuated in the adjusted model.ConclusionsMS pain was relatively prevalent among primary care patients with T2D, but did not influence the achievement of T2D treatment goals.     

Pregnancy outcome and glycemic control in women with type 1 diabetes: A retrospective comparison between CSII and MDI treatment

AimPresent study was aimed to evaluate glycemic control and maternal–fetal outcome in pregnant type 1 diabetic patient treated with continuous subcutaneous insulin infusion (CSII) or multiple daily injections of insulin (MDI).Patients and methodsA retrospective observational study included thirty-four pregnant type 1 diabetic patients. Patients were divided into two group, CSII treated group (n = 14) and MDI treated group (n = 20). The HbA1c level and maternal–fetal outcome were evaluated in both the treatment group. Outcome parameters such as glycemic control (HbA1c), hypoglycemic events, time and mode of delivery and labor results (abortion, premature labor, perinatal mortality, neonatal weight, Apgar score, neonatal hypoglycaemia, presence of congenital abnormalities) were analyzed.ResultsPregnancy outcome and glycemic control in pregnant type 1 diabetic patients treated with CSII and MDI were evaluated and compared. Two groups were compared for their epidemiological parameters, although patients on CSII treatment had longer duration of diabetes compared to MDI treated group. Reduction in HbA1c level was higher in CSII treated patients at first (CSII: 0.9% vs MDI: 0.46%), second (CSII: 1.58% vs MDI: 0.78%) and third trimester (CSII: 1.74% vs MDI: 1.09%) of pregnancy compared to MDI treated patients. Duration of pregnancy and new born baby weight were founded similar in both group. Moreover, the rate of abortion, preterm labor, cesarean section and hypoglycemia in new born were founded less in CSII treated group compared to MDI treated group and Apgar score was significantly (p < 0.05) higher in CSII treated group compared to MDI treated group.ConclusionResults of present study revealed that the CSII gives better glycemic control and pregnancy outcome in pregnant type 1 diabetic patients compared to MDI treatment. CSII also decreases the daily insulin requirement compared MDI.     

Determinants of response to the glucagon-like peptide-1 receptor agonists in a type 2 diabetes population in the real-world

AimsTo identify clinical predictors associated with a response in terms of glycemic control and weight loss in patients with type 2 diabetes treated with glucagon-like peptide-1 receptor agonists (GLP-1RAs).MethodsA retrospective observational study was performed with real-world databases in primary care. Patients with type 2 diabetes-initiated treatment with GLP-1RAs during the study period, and response to GLP-1RAs were determined six months from treatment initiation. An optimal glycated hemoglobin (HbA1c) or weight response was defined as a reduction of ≥ 1% or ≥ 3%, respectively. A “great” response was defined as both an optimal HbA1c and weight response. Bivariate and multivariate analyses with intention-to-treat were performed.ResultsA sample of 2944 patients with type 2 diabetes was recruited. Higher HbA1c at baseline was the main clinical predictor of an optimal HbA1c response (odds ratio [OR]: 2.30, 95% confidence interval [CI]: 1.96–2.71 in men and OR: 2.03, 95% CI: 1.76–2.33 in women). Treatment without insulin at baseline was associated with a greater weight reduction in men (OR: 2.50, 95% CI: 1.41–4.44). Older age and a higher weight at baseline were related with this in women (OR: 1.02, 95% CI: 1.00–1.05 and OR: 1.01, 95% CI: 1.00–1.02, respectively).ConclusionsA high HbA1c at baseline and previous non-insulin therapy were the main predictors of a greater response (optimal HbA1c and weight response) to GLP1ra in both men and women. This may aid in treatment decision-making before initiating treatment with GLP-1RAs.     

Relation between diabetes related distress and glycemic control: The mediating effect of adherence to treatment

AimsDiabetes related distress (DRD) is a negative emotional reaction to stresses associated with diabetes mellitus (DM) and its management. This study estimated the burden of DRD and self-reported adherence to treatment (SRAT) among patients with DM and investigated their relationship with glycemic control.MethodsA cross sectional study of consented 157 diabetics was conducted using the17-item Diabetes Distress Scale (DDS). It measures distress at four subscales: Emotional Burden (EB), Physician-related (PD), Regimen-related (RD) and Interpersonal Distress (ID). SRAT was assessed using Morisky’s scale. Glycemic control was assessed using the most recent HbA1c results. Multivariable linear regression analysis was used for adjustment of confounders and bootstrap Confidence Interval was used to test for the occurrence of mediating effect.ResultsAverage age was 44.5 ± 16.0 years, 65% were females, 79% had type 2 DM and nearly 55% has had DM for more than 7 years and the average HbA1c was 8.9 ± 2.2%. Clinically significant DRD was reported by 37% of the participants, EB and RD in 40.8%, PD in 46.5%, and ID among 32.5%. Younger patients showed higher level of stress compared to older participants and patients with type 1 DM showed higher level of stress in all DRD domains. Only 46% of patients were defined as having satisfactory SRAT and improvement of SRAT significantly enhanced the glycemic control (r = ?0.32, p < 0.01). DRD and low SRAT negatively correlated with HbA1c; increasing the DRD by one point may increase the HbA1c on average by 0.41 (C.I. 0.02–0.80) and will indirectly raise the HbA1c by 0.24 (C.I. 0.04–0.47) through the mediating effect of low SRAT.ConclusionDRD and low SRAT are commonly reported among DM patients and both are indirectly correlated. The mediating effect of low SRAT highlights the clinical role of DRD and clarifies the process by which distress affect the outcome of DM management.     

Factors associated with poor glycemic control among patients with Type 2 diabetes

ObjectivesDetermine factors associated with poor glycemic control among Jordanian patients with Type 2 diabetes.MethodsA systematic random sample of 917 patients was selected from all patients with Type 2 diabetes over a period of 6 months in 2008. A prestructured questionnaire sought information about sociodemographic, clinical characteristics, self-care management behaviours, medication adherence, barriers to adherence, and attitude towards diabetes. Weight, height, and waist circumferences were measured. All available last readings of hemoglobin A1c (HbA1c), fasting blood sugar measurements and lipid were abstracted from patients' records. Poor glycemic control was defined as HbA1c ≥7%.ResultsOf the total 917 patients, 65.1% had HbA1c ≥7%. In the multivariate analysis, increased duration of diabetes (>7 years vs. ≤7years) (OR=1.99, P≤.0005), not following eating plan as recommended by dietitians (OR=2.98, P≤.0005), negative attitude towards diabetes, and increased barriers to adherence scale scores were significantly associated with increased odds of poor glycemic control.ConclusionThe proportion of patients with poor glycemic control was high, which was nearly comparable to that reported from many countries. Longer duration of diabetes and not adherent to diabetes self-care management behaviors were associated with poor glycemic control. An educational program that emphasizes lifestyle modification with importance of adherence to treatment regimen would be of great benefit in glycemic control.     

The relationship between glycemic control and platelet activity in type 2 diabetes mellitus

AimsPlatelet activity and aggregation potential, which are essential components of thrombogenesis and atherosclerosis, can be conveniently estimated by measuring mean platelet volume (MPV) as part of whole blood count. It has been shown that MPV was significantly higher in diabetes mellitus (DM); however, the effect of glycemic control on MPV has not been studied. The aim of this study was to investigate the relationship among MPV, glycemic control, and micro- and macrovascular complications in type 2 DM.MethodsSeventy patients with type 2 DM and 40 age- and sex-matched healthy individuals were enrolled. Diabetic patients were grouped into those with glycated hemoglobin (HbA1c) levels ≤7% (Group A, n=35 patients) and those with HbA1c >7% (Group B, n=35 patients). Initially, both groups were compared with regard to MPV, HbA1c, serum lipid levels, coronary artery disease, retinopathy, neuropathy, and nephropathy. Thereafter, Group B was called to monthly visits to obtain improved control glycemic control, which was defined as achievement of HbA1c ≤7%. At the end of 3 months of follow-up, Group B was reevaluated.ResultsMPV was significantly higher in patients with DM than in controls (8.7±0.8 fl vs. 8.2±0.7 fl, P=.002). In diabetic patients, there was a significant positive correlation between MPV and HbA1c levels (r=.39, P=.001) but not diabetic vascular complications. When we compared the two diabetic groups, Group B patients had significantly higher MPV than Group A (9.0±0.7 fl vs. 8.4±0.8 fl, P=.01). Thirty patients (86%) of Group B achieved improved glycemic control at the end of the 3 months. MPV of the patients with improved glycemic control were significantly decreased compared to baseline MPV (8.4±0.8 fl vs. 9.0±0.7 fl, P=.003).ConclusionsOur results suggested a close relationship between poor glycemic control and increased platelet activity in patients with type 2 DM. Furthermore, platelet activity recovered through improved glycemic control, which may prevent the possible role of platelets in cardiovascular events in these patients.     

Vitamin D status,determinants and relationship with biochemical profile in women with Type 2 Diabetes Mellitus in Delhi,India

ObjectiveTo determine the burden of vitamin D deficiency and its determinants and to assess the relationship of 25 hydroxycholecalciferol (25-OHD) levels with biochemical parameters linked to health outcomes in women with Type 2 Diabetes Mellitus (T2DM).Material and methodsThis was a hospital based cross-sectional study in the diabetes out-patient department clinic of a major tertiary care hospital in Delhi, India. Adult women with T2DM on treatment for at least 6 months were included in this study. The women who have been given Vitamin D supplementation during the past 6 months were excluded. We assessed Serum 25-OHD, HbA1c, lipid profile and fasting plasma glucose in the patients through standardized laboratory methods.ResultsOne hundred women with T2DM were enrolled of which 22 (22%) had good glycemic control (HbA1c < 7%). Vitamin D deficiency was seen among 77 (77%) and insufficiency among 16 (16%) of the recruited subjects. Younger age group (31–45 years) and illiteracy was significantly associated with vitamin D deficiency (p < 0.05). No association was found between Vitamin D deficiency and HbA1c levels.ConclusionVitamin D deficiency is highly prevalent among women with T2DM. Illiteracy and young age were major determinants of vitamin D deficiency indicating they need special attention and Vitamin D supplementation.     

Determinants of glycemic control in type 2 diabetes mellitus in Brazil: A sub-analysis of the longitudinal data from the BrazIian type 1 & 2 diabetes disease registry (BINDER)

BackgroundData on glycemic control and its determinants among Brazilian patients with type-2 diabetes (DM2) are scarce. The BrazIliaN Type 1 & 2 DiabetEs Disease Registry (BINDER) is a multicenter, longitudinal study, designed to investigate the glycemic control in a real-word scenario.Methods1142 patients participated in the five visits of the BINDER study between April/2017 and October/2019. For each visit, glycemic control was assessed using the last measure available for HbA1c. Sociodemographic and anthropometric characteristics were also analyzed.ResultsAt baseline, the median HbA1c level was 7.1% (4.1–15.0%); 259 (31.4%) participants had HbA1c ≤ 6.5% and 396 (48.2%) had HbA1c ≤ 7.0%. Younger age (p = 0.014), low educational level (p = 0.025) and the type of healthcare service (public sector; p = 0.0058) were independently associated with the elevated HbA1c. After 2 years, there were no statistically significant differences in HbA1c median values in relation to baseline.ConclusionsIn this sample of DM2 patients, younger age, low educational level and being treated at the public service were associated with worse glycemic control. Over a 2-year follow-up, there was no significant change in the median HbA1c. These findings suggest that strategies are needed to improve glycemic control, especially in those treated in the public service.     

Achievement of treatment targets predicts progression of vascular complications in type 1 diabetes

Background and aimTo study the association between achievement of guideline-defined treatment targets on HbA1c, low-density lipoproteins (LDL-C), and blood pressure with the progression of diabetic complications in patients with type 1 diabetes (T1D).MethodsThe study included 355 patients at baseline and 114 patients with follow-up data after 3–5 years. Outcome variables were the progression of diabetic kidney disease, retinopathy, or cardiovascular disease (CVD). We used logistic regression and other machine learning algorithms (MLA) to model the association of achievement of treatment targets and probability of progression of complications.ResultsAchievement of the target blood pressure was associated with 96% lower odds of a new CVD event (0.04 (95% CI 0.00, 0.53), p = 0.016), and 72% lower odds of progression of any complication (0.28 (95% CI 0.09, 0.89), p = 0.027. Achievement of HbA1c target was associated with lower odds of composite complication progression by 82% (0.18 (95% CI 0.04, 0.88), p = 0.034.) None of the patients who achieved HbA1c target progressed in CVD. MLA demonstrated good accuracy for the prediction of progression of CVD (AUC 0.824), and lower accuracy for other complications.ConclusionThe achievement of blood pressure and HbA1c treatment targets is associated with lower odds of vascular complication of T1D in a real life study.     

Relationship between glycemic control and chronic obstructive pulmonary disease in patients with type 2 diabetes: A nested case-control study

AimsTo evaluate the relationship between glycemic control and plasma glycated hemoglobin (HbA1c) levels in patients with type 2 diabetes mellitus (T2D) and the risk of chronic obstructive pulmonary disease (COPD).MethodsWe conducted a population-based, retrospective, nested, case-control study involving 124,876 patients with DM2 from the Canary Islands, Spain. From the cohort, we selected all COPD cases and, for each case, five control subjects who were COPD free. We analyzed the association between glycemic control, HbA1c level and incident COPD.ResultsA total of 1320 incidence cases of COPD (1.06%) were identified and matched individually with 6600 controls according to age and sex. After multivariate adjustment, the COPD risk increased among patients with poor glycemic control compared to patients with good glycemic control [HbA1c levels <7% (53 mmol/mol)] (OR 1.18; 95% CI: 1.03–1.36). In comparison with patients exhibiting HbA1c levels <7% (53 mmol/mol), the risk of COPD was higher among people with HbA1c levels of 7–8% (53–64 mmol/mol) (OR 1.24; 95% CI: 1.05–1.47) and 8–9% (64–75 mmol/mol) (OR 1.31; 95% CI: 1.04–1.66).ConclusionsPoor glycemic control reveals a weak association with increased risk of COPD in T2D patients.