NIHR: Call for ‘international efforts’ to examine link between COVID-19 and new-onset diabetes #Covid19RftLks

NIHR | October 2021 | Call for ‘international efforts’ to examine link between COVID-19 and new-onset diabetes 

A comprehensive review led by ARC East Midlands has explored ‘COVID-19, hyperglycemia and new-onset diabetes’.

An international team of researchers have been involved and have commented that early identification and treatment of people who fall into this category could improve their long-term outcomes.

Professor Kamlesh Khunti, Director of ARC East Midlands and Professor of Primary Care Diabetes and Vascular Medicine at the University of Leicester, said: “Given we are still in the midst of a global COVID-19 pandemic, we are likely to see even larger numbers of people globally with new-onset diabetes. International efforts need to be established to study COVID-19 associated new-onset diabetes with follow-up of large numbers of patients.”

Several studies conducted during the pandemic have reported that COVID-19 is associated with hyperglycaemia in people with and without known diabetes. The authors of this latest research also acknowledge that the phenomenon of new-onset diabetes following admission to hospital has been seen previously with other viral infections. 

The perspective, published in the American Diabetes Association’s journal, Diabetes Care, explores the possible reasons for the link between COVID-19 and new-onset diabetes.

The authors discuss four possible explanations:

  • Pre-existing undiagnosed diabetes. People admitted to hospital may have had undetected diabetes prior to admission, which could be a result of recent weight gain due to lifestyle changes and worsening of hyperglycaemia due to self-isolation; social distancing; reduced physical activity; and poor diet linked to mental health issues.
  • Stress hyperglycaemia and new-onset diabetes following acute illness. The phenomenon of hyperglycaemia and new-onset diabetes following admission to hospital with acute illness has previously been identified. In COVID-19, stress hyperglycaemia may be even more severe due to the cytokine storm – an inflammatory syndrome.
  • Viral infections and new-onset diabetes. Viral infections may have an effect on the pancreas. Previous studies have reported acute inflammation in the pancreas due to other viruses.
  • In hospital steroid-induced hyperglycaemia. Steroid-induced hyperglycaemia is common in hospitalised patients. Previous studies have shown that between 53 and 70 per cent of non-diabetic individuals develop steroid-induced hyperglycaemia(Source: NIHR).

Related:

COVID-19, Hyperglycemia, and New-Onset Diabetes

Impact of COVID-19 restrictions on diabetes health checks and prescribing for people with type 2 diabetes 

Carr, M.J. et al | 2021| Impact of COVID-19 restrictions on diabetes health checks and prescribing for people with type 2 diabetes: a UK-wide cohort study involving 618 161 people in primary care| BMJ Quality & Safety|  Published Online First: 12 October 2021. doi: 10.1136/bmjqs-2021-013613

The authors of this piece of research used a large primary care longitudinal dataset, broadly representative of the UK population, to compare the frequency of health checks and prescribing in people with type 2 diabetes (T2D), before and after the first nationwide COVID-19 lockdown in March 2020. In UK-wide data, they compared observed and predicted rates using data covering 10 years prior to the pandemic. Since older people, minority ethnic groups and more socially disadvantaged people have been disproportionally affected by COVID-19 infections, and since the same groups may be more adversely impacted by changes in healthcare delivery imposed by COVID-19, they aimed to study variation in outcomes by age, sex, ethnicity and deprivation level.

Abstract

Objective To compare rates of performing National Institute for Health and Care Excellence-recommended health checks and prescribing in people with type 2 diabetes (T2D), before and after the first COVID-19 peak in March 2020, and to assess whether trends varied by age, sex, ethnicity and deprivation.

Methods We studied 618 161 people with T2D followed between March and December 2020 from 1744 UK general practices registered with the Clinical Practice Research Datalink. We focused on six health checks: haemoglobin A1c, serum creatinine, cholesterol, urinary albumin excretion, blood pressure and body mass index assessment. Regression models compared observed rates in April 2020 and between March and December 2020 with trend-adjusted expected rates derived from 10-year historical data.

Results In April 2020, in English practices, rates of performing health checks were reduced by 76 per cent–88 per cent when compared with 10-year historical trends, with older people from deprived areas experiencing the greatest reductions. Between May and December 2020, the reduced rates recovered gradually but overall remained 28 per cent–47 per cent lower, with similar findings in other UK nations. Extrapolated to the UK population, there were approximately7.4 million fewer care processes undertaken March–December 2020. In England, rates for new medication fell during April with reductions varying from 10 per cent (95 per cent CI: 4 per cent to 16 per cent) for antiplatelet agents to 60 per cent (95 per cent CI: 58 per cent to 62 per cent) for antidiabetic medications. Overall, between March and December 2020, the rate of prescribing new diabetes medications fell by 19 per cent (95 per cent CI: 15 per cent to 22 per cent) and new antihypertensive medication prescribing fell by 22 per cent (95 per cent CI: 18 per cent to 26 per cent), but prescribing of new lipid-lowering or antiplatelet therapy was unchanged. Similar trends were observed across the UK, except for a reduction in new lipid-lowering therapy prescribing in the other UK nations (reduction: 16 per cent (95 per cent CI: 10 per cent to 21 per cent)). Extrapolated to the UK population, between March and December 2020, there were approximately 31 800 fewer people with T2D prescribed a new type of diabetes medication and approximately 14 600 fewer prescribed a new type of antihypertensive medication.

Conclusions Over the coming months, healthcare services will need to manage this backlog of testing and prescribing. We recommend effective communications to ensure patient engagement with diabetes services, monitoring and opportunities for prescribing, and when appropriate use of home monitoring, remote consultations and other innovations in care.

Impact of COVID-19 restrictions on diabetes health checks and prescribing for people with type 2 diabetes: a UK-wide cohort study involving 618 161 people in primary care [primary paper]

The Lancet: Obesity management as a primary treatment goal for type 2 diabetes: time to reframe the conversation

Lingvay, I., Sumithran, P., Cohen, R. V., & le Roux, C. W. | 2021 | Obesity management as a primary treatment goal for type 2 diabetes: time to reframe the conversation| The Lancet | https://doi.org/10.1016/S0140-6736(21)01919-X

Obesity is now recognised as a disease that is associated with serious morbidity and increased mortality. One of its main metabolic complications is type 2 diabetes, as the two conditions share key pathophysiological mechanisms. Weight loss is known to reverse the underlying metabolic abnormalities of type 2 diabetes and, as such, improve glucose control; loss of 15 per cent or more of bodyweight can have a disease-modifying effect in people with type 2 diabetes, an outcome that is not attainable by any other glucose-lowering intervention. Furthermore, weight loss in this population exerts benefits that extend beyond glycaemic control to improve risk factors for cardiometabolic disease and quality of life. We review the evidence supporting the role of weight loss in the management of type 2 diabetes and propose that many patients with type 2 diabetes would benefit from having a primary weight-centric approach to diabetes treatment. We discuss the logistical challenges to implementing a new weight-centric primary treatment goal in people with type 2 diabetes.

Interested in the full article? Rotherham NHS staff can request this article from their Library & Knowledge Service  

Providers of the Diabetes Prevention Programme need to be more consistent, and offer flexibility and equality of access

NIHR | September 2021 | Providers of the Diabetes Prevention Programme need to be more consistent, and offer flexibility and equality of access

This NIHR Alert summarises the research findings of a cohort study that followed participants in the the NHS Diabetes Prevention Programme (DPP). The DPP was set up by NHS England, Public Health England, and Diabetes UK. Its aim is to identify people at high risk of developing type 2 diabetes and help them change lifestyle behaviours to prevent progression to the disease.

The cohort study provides the first independent assessment of participation in the English DPP and the first study internationally to examine the impact of DPP service delivery on participation.

The authors report that measures to improve uptake and retention among younger and deprived groups, and retention among minority ethnic groups, those with a disability, and people at work, may be needed.

‘Going the distance’: an independent cohort study of engagement and dropout among the first 100,000 referrals into a large-scale diabetes prevention programme [primary paper]

Howarth, E. et al | 2020| Going the distance’: an independent cohort study of engagement and dropout among the first 100 000 referrals into a large-scale diabetes prevention program| BMJ Open Diabetes Research and Care | 8| e001835|  doi: 10.1136/bmjdrc-2020-001835

Abstract

Introduction 

Diabetes prevention programs (DPPs) are effective, in a pre-diabetic population, in reducing weight, lowering glycated hemoglobin and slowing the progression to diabetes. Little is known about the relationship between participation in DPPsand participant characteristics or service delivery. We investigated uptake and retention in England’s NHS DPP, reporting on variability among patient subgroups, providers, and sites.

Research design and methods 

This prospective cohort study included 99 473 adults with non-diabetic hyperglycemia referred to the English DPP between 2016 and 2017. The program seeks to change health behaviors by offering at least 16 hours of group education and exercise. Multilevel logistic regression models were used to analyze variation in uptake, retention, and completion.

Results 

Uptake among 99 473 adults referred to the program was 56 per cent (55 275). Among 55 275 who started the program, 34 per cent (18 562) achieved the required dose and 22 per cent (12 127) completed the full course. After adjustment for variation in case mix, substantial heterogeneity in uptake and retention was seen across four service providers (uptake OR 1.77 (1.33, 2.34), 4.30 (3.01, 6.15), and 1.45 (1.07, 1.97) compared with the reference provider) and between sites (uptake for typical individuals ranged from 0.32 to 0.78 across the middle 95 per cent of sites, intraclass correlation coefficient (ICC) 0.07). Higher levels of retention and completion were seen where some out-of-hours provision was offered (retention OR 1.32 (1.25, 1.39)).

Conclusions 

This study provides the first independent assessment of participation in the English DPP and the first study internationally to examine the impact of DPP service delivery on participation. When implementing a large-scale DPP, heterogeneity in service provision between different providers and sites can result in variable participation beyond that attributable to case mix, with potential consequences for effectiveness and health inequalities. Extending out-of-hours provision may improve participation in prevention programs.

Going the distance’: an independent cohort study of engagement and dropout among the first 100 000 referrals into a large-scale diabetes prevention program

COVID-19 and Type 1 Diabetes: Addressing Concerns and Maintaining Control

DiMeglio,L.A. | 2021 | COVID-19 and Type 1 Diabetes: Addressing Concerns and Maintaining Control | Diabetes Care | https://doi.org/10.2337/dci21-0002

Abstract

The worldwide outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been an unprecedented pandemic. Early on, even as the signs and symptoms of coronavirus disease 2019 (COVID-19) were first characterized, significant concerns were articulated regarding its potential impact on people with chronic disease, including type 1 diabetes. Information about the basic and clinical interrelationships between COVID-19 and diabetes has rapidly emerged. Initial rapid reports were useful to provide alerts and guide health care responses and initial policies. Some of these have proven subsequently to have durable findings, whereas others lacked scientific rigor/reproducibility. Many publications that report on COVID-19 and “diabetes” also have not distinguished between type 1 and type 2 (1). Available evidence now demonstrates that people with type 1 diabetes have been acutely affected by COVID-19 in multiple ways. This includes effects from limited access to health care, particularly during lockdown periods, and increased morbidity/mortality in infected adults with type 1 diabetes compared with peers without diabetes.

Rotherham NHS staff can request this article here 

Patients with type 1 diabetes to get artificial pancreas on the NHS

NHS England | June 2021 | Patients with type 1 diabetes to get artificial pancreas on the NHS

Up to 1 000 patients with type 1 diabetes from 25 specialist diabetes centres in England will benefit from a pilot of the innovative ‘closed loop technology’, which continually monitors blood glucose and automatically adjusts the amount of insulin given through a pump. Sir Simon Stevens, Chief Executive of the NHS announced the pilot programme earlier today at the NHS Confederation conference

The technology can eliminate finger prick tests and prevent life-threatening hypoglycaemic attacks. It uses hHybrid closed-loop insulin delivery systems automatically balance blood sugar levels by constantly measuring glucose and delivering insulin directly to the bloodstream when needed. Not only does this offer better glucose control and significantly reduce the risk of hypoglycaemia, it can also relieve some of the mental burden on patients and caregivers, who otherwise must remain constantly vigilant to blood sugar levels.Up to 1 000 patients from around 25 specialist diabetes centres in England will benefit from the pilot programme.

Participating centres will submit data via the NHS’s world-leading National Diabetes Audit and the results will feed into the evidence assessment undertaken by the National Institute for Health and Care Excellence (NICE).

Professor Partha Kar, NHS national speciality advisor for diabetes, said: “One hundred years after the discovery of insulin, the ‘artificial pancreas’ is a potentially revolutionary development in the treatment of diabetes.

“The NHS has long been at the forefront of clinical advances in care for major diseases, including diabetes, which have allowed patients to live longer and healthier lives.

“We have already outperformed the goals in the NHS Long Term Plan for better diabetes care, and this new technology is an extension of the fantastic work achieved by the NHS, third sector and industry partners who are working together to improve the lives of patients.”

Further details are available from NHS England

A lower-carb diet is an effective short-term option for type 2 diabetes

Public Health England | May 2021 | A lower-carb diet is an effective short-term option for type 2 diabetes

The Scientific Advisory Committee on Nutrition (SACN) in conjunction with Diabetes UK and other stakeholders who formed part of a joint working group have published their report: lower carbohydrate diets for type 2 diabetes. The report was commissioned by Public Health England whom requested a systematic assessment of evidence in relation ‘low’ carbohydrate diets, in recognition that such diets are gaining attention and are increasingly being promoted. However, since there is no agreed definition of a ‘low’ carbohydrate diet, comparisons in this report were between lower and higher carbohydrate diets.

Adults living with type 2 diabetes and overweight or obesity, there are beneficial effects of a lower carbohydrate diet for up to 6 months for some of the outcomes considered, including improving blood sugar management.

People on lower carbohydrate diets lost more weight than those on higher carbohydrate diets in the first 3 months but not after, so it’s unclear if the benefits of a lower carbohydrate diet are due to this early weight loss.

Overall, the quality of the evidence wasn’t strong enough to recommend a lower carbohydrate diet for longer than 6 months (Source: Public Health England).


Lower carbohydrate diets for adults with type 2 diabetes: SACN report

Public Health England A lower-carb diet is an effective short-term option for type 2 diabetes

The state of diabetes treatment coverage in 55 low-income and middle-income countries

Flood, D. et al | 2021| The state of diabetes treatment coverage in 55 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 680 102 adults | The Lancet Healthy Longevity | https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(21)00089-1/fulltext

This cross-sectional cohort study is the largest assessment of comprehensive diabetes treatment using individual-level data from nationally representative samples of adults across low-income and middle-income countries (LMICs) of diverse income groups and geographical regions. 

Key points:

  1. Less than one in ten people with diabetes in LMICs receive comprehensive diabetes treatment as recommended by WHO; scaling up the capacity of health systems to deliver treatment not only to lower glucose but also to address cardiovascular disease risk factors, such as hypertension and high cholesterol, are urgent global diabetes priorities.
  2. The authors make cross-country estimates of diabetes treatment that could be used by health systems in LMICs to benchmark current and future performance
  3. They report individual characteristics such as young age and lower body-mass index that are associated with low coverage of diabetes treatment; these individual-level findings can be used by health systems to direct care to underserved groups.

The authors findings suggest that improving access to comprehensive treatment not only to lower glucose but also to address cardiovascular disease risk factors such as hypertension and elevated cholesterol are global diabetes priorities.

Paper available in full from The Lancet Healthy Longevity

Continuous subcutaneous insulin infusion therapy is associated with reduced retinopathy progression compared with multiple daily injections of insulin

Reid, L.J., et al | 2021|  Continuous subcutaneous insulin infusion therapy is associated with reduced retinopathy progression compared with multiple daily injections of insulin| Diabetologia | https://doi.org/10.1007/s00125-021-05456-w

The authors of this study set out to address the research question: Is the introduction of continuous subcutaneous insulin infusion (CSII) therapy associated with early diabetic retinopathy worsening or long term benefits in diabetic retinopathy progression vs continued MDI therapy in adults with type 1 diabetes?

The researchers used the Scottish Care Information Diabetes database for retinal screening outcomes and HbA1c changes in 204 adults commenced on CSII therapy between 2013 and 2016, and 211 adults eligible for CSII during the same period but who continued on MDI therapy.  Their results show that no evidence of early diabetic retinopathy worsening following the introduction of CSII therapy in those with no or mild baseline diabetic retinopathy.

Image source: Reid et al, 2021 Image description: graphical abstract outlining the study design, its outcomes, results and providing a summary of the research.

Abstract

Aims/hypothesis

We aimed to compare diabetic retinopathy outcomes in people with type 1 diabetes following introduction of continuous subcutaneous insulin infusion (CSII) therapy with outcomes in people receiving continuing therapy with multiple daily insulin injections (MDI).

Methods

This is a retrospective cohort study using the Scottish Care Information – Diabetes database for retinal screening outcomes and HbA1c changes in 204 adults commenced on CSII therapy between 2013 and 2016, and 211 adults eligible for CSII during the same period but who continued on MDI therapy. Diabetic retinopathy progression (time to minimum one-grade worsening in diabetic retinopathy from baseline grading) was plotted for CSII and MDI cohorts using Kaplan–Meier curves, and outcomes were compared using multivariate Cox regression analysis adjusting for age, sex, baseline HbA1c, blood pressure, cholesterol, smoking status and socioeconomic quintile. Impact of baseline HbA1c and change in HbA1c on diabetic retinopathy progression was assessed within CSII and MDI cohorts.

Results

CSII participants were significantly younger, were from less socially deprived areas, and had lower HbA1c and higher diastolic BP at baseline. There was a larger reduction in HbA1c at 1 year in those on CSII vs MDI (−6 mmol/mol [−0.6%] vs −2 mmol/mol [−0.2%], p < 0.01). Diabetic retinopathy progression occurred in a smaller proportion of adults following commencement of CSII vs continued MDI therapy over mean 2.3 year follow-up (26.5% vs 18.6%, p = 0.0097). High baseline HbA1c (75 mmol/mol [9%]) was associated with diabetic retinopathy progression in the MDI group (p = 0.0049) but not the CSII group (p = 0.93). Change in HbA1c at follow-up, irrespective of baseline glycaemic status, did not significantly affect diabetic retinopathy progression in either group.

Conclusions/interpretation

CSII was associated with reduced diabetic retinopathy progression compared with continued MDI therapy, and may be protective against diabetic retinopathy progression for those with high baseline HbA1c. Progression of diabetic retinopathy over 3 years was not associated with a change in HbA1c.

Continuous subcutaneous insulin infusion therapy is associated with reduced retinopathy progression compared with multiple daily injections of insulin

Impact of COVID-19 on diagnoses, monitoring, and mortality in people with type 2 diabetes in the UK #covid19rftlks

Carr, M.J. et al | 2021| Impact of COVID-19 on diagnoses, monitoring, and mortality in people with type 2 diabetes in the UK | The Lancet Diabetes & Endocrinology | https://doi.org/10.1016/S2213-8587(21)00116-9

New correspondence published in The Lancet Diabetes & Endocrinology underlines how almost 60 000 missed/delayed type 2 (TD2) diabetes diagnosis between March and December 2020 & mortality, which increased two-fold in people with diabetes.

The original paper Risk factors for COVID-19-related mortality in people with type 1 and type 2 diabetes in England: a population-based cohort study (2020). The authors of this paper highlight that as Type 2 diabetes develops over many years; therefore, it seems unlikely that people’s behaviour during the pandemic has reduced the true incidence of this condition.

They emphasise how reductions in the diagnosis and monitoring of type 2 diabetes during the COVID-19 pandemic, which have important clinical and public health implications. Over the coming months, health-care services will need to manage this predicted backlog, and the anticipated deterioration of blood glucose levels and cardiovascular risk factors due to delayed diagnoses and reduced monitoring of patients with established diabetes. Their data showed that older individuals, men, and people from areas of high deprivation were most adversely affected and could represent specific groups to target for early intervention. Moving forward, during and beyond the pandemic, effective public health communication should ensure that patients remain engaged with diabetes services and make use of HbA1c monitoring and remote consultations (Source: Carr et al, 2021)

Impact of COVID-19 on diagnoses, monitoring, and mortality in people with type 2 diabetes in the UK

Risk factors for COVID-19-related mortality in people with type 1 and type 2 diabetes in England: a population-based cohort study [original paper]