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Treatment of Type 2 Diabetes: From "Guidelines" to "Position Statements" and Back: Recommendations of the Israel National Diabetes Council

Ofri Mosenzon
Aug 1, 2016; 39:S146-S153
II. Diabetes Treatment Options




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Table 1-Systeme International (SI) units for plasma, serum, or blood concentrations


Aug 1, 1995; 18:1223-1224
Syst[egrave]me International (SI) Units




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Effects of Gender-Affirming Hormone Therapy on Insulin Sensitivity and Incretin Responses in Transgender People

OBJECTIVE

The long-term influences of sex hormone administration on insulin sensitivity and incretin hormones are controversial. We investigated these effects in 35 transgender men (TM) and 55 transgender women (TW) from the European Network for the Investigation of Gender Incongruence (ENIGI) study.

RESEARCH DESIGN AND METHODS

Before and after 1 year of gender-affirming hormone therapy, body composition and oral glucose tolerance tests (OGTTs) were evaluated.

RESULTS

In TM, body weight (2.8 ± 1.0 kg; P < 0.01), fat-free mass (FFM) (3.1 ± 0.9 kg; P < 0.01), and waist-to-hip ratio (–0.03 ± 0.01; P < 0.01) increased. Fasting insulin (–1.4 ± 0.8 mU/L; P = 0.08) and HOMA of insulin resistance (HOMA-IR) (2.2 ± 0.3 vs. 1.8 ± 0.2; P = 0.06) tended to decrease, whereas fasting glucose (–1.6 ± 1.6 mg/dL), glucose-dependent insulinotropic polypeptide (GIP) (–1.8 ± 1.0 pmol/L), and glucagon-like peptide 1 (GLP-1) (–0.2 ± 1.1 pmol/L) were statistically unchanged. Post-OGTT areas under the curve (AUCs) for GIP (2,068 ± 1,134 vs. 2,645 ± 1,248 [pmol/L] x min; P < 0.01) and GLP-1 (2,352 ± 796 vs. 2,712 ± 1,015 [pmol/L] x min; P < 0.01) increased. In TW, body weight tended to increase (1.4 ± 0.8 kg; P = 0.07) with decreasing FFM (–2.3 ± 0.4 kg; P < 0.01) and waist-to-hip ratio (–0.03 ± 0.01; P < 0.01). Insulin (3.4 ± 0.8 mU/L; P < 0.01) and HOMA-IR (1.7 ± 0.1 vs. 2.4 ± 0.2; P < 0.01) rose, fasting GIP (–1.4 ± 0.8 pmol/L; P < 0.01) and AUC GIP dropped (2,524 ± 178 vs. 1,911 ± 162 [pmol/L] x min; P < 0.01), but fasting glucose (–0.3 ± 1.4 mg/dL), GLP-1 (1.3 ± 0.8 pmol/L), and AUC GLP-1 (2,956 ± 180 vs. 2,864 ± 93 [pmol/L] x min) remained unchanged.

CONCLUSIONS

In this cohort of transgender persons, insulin sensitivity but also post-OGTT incretin responses tend to increase with masculinization and to decrease with feminization.




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Steroid Metabolomic Signature of Insulin Resistance in Childhood Obesity

OBJECTIVE

On the basis of urinary steroidal gas chromatography-mass spectrometry (GC-MS), we previously defined a novel concept of a disease-specific "steroid metabolomic signature" and reclassified childhood obesity into five groups with distinctive signatures. The objective of the current study was to delineate the steroidal signature of insulin resistance (IR) in obese children.

RESEARCH DESIGN AND METHODS

Urinary samples of 87 children (44 girls) aged 8.5–17.9 years with obesity (BMI >97th percentile) were quantified for 31 steroid metabolites by GC-MS. Defined as HOMA-IR >95th percentile and fasting glucose-to-insulin ratio >0.3, IR was diagnosed in 20 (of 87 [23%]) of the examined patients. The steroidal fingerprints of subjects with IR were compared with those of obese children without IR (non-IR). The steroidal signature of IR was created from the product of IR – non-IR for each of the 31 steroids.

RESULTS

IR and non-IR groups of children had comparable mean age (13.7 ± 1.9 and 14.6 ± 2.4 years, respectively) and z score BMI (2.7 ± 0.5 and 2.7 ± 0.5, respectively). The steroidal signature of IR was characterized by high adrenal androgens, glucocorticoids, and mineralocorticoid metabolites; higher 5α-reductase (An/Et) (P = 0.007) and 21-hydroxylase [(THE + THF + αTHF)/PT] activity (P = 0.006); and lower 11βHSD1 [(THF + αTHF)/THE] activity (P = 0.012).

CONCLUSIONS

The steroidal metabolomic signature of IR in obese children is characterized by enhanced secretion of steroids from all three adrenal pathways. As only the fasciculata and reticularis are stimulated by ACTH, these findings suggest that IR directly affects the adrenals. We suggest a vicious cycle model, whereby glucocorticoids induce IR, which could further stimulate steroidogenesis, even directly. We do not know whether obese children with IR and the new signature may benefit from amelioration of their hyperadrenalism.




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Vasodilatory Actions of Glucagon-Like Peptide 1 Are Preserved in Skeletal and Cardiac Muscle Microvasculature but Not in Conduit Artery in Obese Humans With Vascular Insulin Resistance

OBJECTIVE

Obesity is associated with microvascular insulin resistance, which is characterized by impaired insulin-mediated microvascular recruitment. Glucagon-like peptide 1 (GLP-1) recruits skeletal and cardiac muscle microvasculature, and this action is preserved in insulin-resistant rodents. We aimed to examine whether GLP-1 recruits microvasculature and improves the action of insulin in obese humans.

RESEARCH DESIGN AND METHODS

Fifteen obese adults received intravenous infusion of either saline or GLP-1 (1.2 pmol/kg/min) for 150 min with or without a euglycemic insulin clamp (1 mU/kg/min) superimposed over the last 120 min. Skeletal and cardiac muscle microvascular blood volume (MBV), flow velocity and blood flow, brachial artery diameter and blood flow, and pulse wave velocity (PWV) were determined.

RESULTS

Insulin failed to change MBV or flow in either skeletal or cardiac muscle, confirming the presence of microvascular insulin resistance. GLP-1 infusion alone increased MBV by ~30% and ~40% in skeletal and cardiac muscle, respectively, with no change in flow velocity, leading to a significant increase in microvascular blood flow in both skeletal and cardiac muscle. Superimposition of insulin to GLP-1 infusion did not further increase MBV or flow in either skeletal or cardiac muscle but raised the steady-state glucose infusion rate by ~20%. Insulin, GLP-1, and GLP-1 + insulin infusion did not alter brachial artery diameter and blood flow or PWV. The vasodilatory actions of GLP-1 are preserved in both skeletal and cardiac muscle microvasculature, which may contribute to improving metabolic insulin responses and cardiovascular outcomes.

CONCLUSIONS

In obese humans with microvascular insulin resistance, GLP-1’s vasodilatory actions are preserved in both skeletal and cardiac muscle microvasculature, which may contribute to improving metabolic insulin responses and cardiovascular outcomes.




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Time Course of Normalization of Functional {beta}-Cell Capacity in the Diabetes Remission Clinical Trial After Weight Loss in Type 2 Diabetes

OBJECTIVE

To assess functional β-cell capacity in type 2 diabetes during 2 years of remission induced by dietary weight loss.

RESEARCH DESIGN AND METHODS

A Stepped Insulin Secretion Test with Arginine was used to quantify functional β-cell capacity by hyperglycemia and arginine stimulation. Thirty-nine of 57 participants initially achieved remission (HbA1c <6.5% [<48 mmol/mol] and fasting plasma glucose <7 mmol/L on no antidiabetic drug therapy) with a 16.4 ± 7.7 kg weight loss and were followed up with supportive advice on avoidance of weight regain. At 2 years, 20 participants remained in remission in the study. A nondiabetic control (NDC) group, matched for age, sex, and weight after weight loss with the intervention group, was studied once.

RESULTS

During remission, median (interquartile range) maximal rate of insulin secretion increased from 581 (480–811) pmol/min/m2 at baseline to 736 (542–998) pmol/min/m2 at 5 months, 942 (565–1,240) pmol/min/m2 at 12 months (P = 0.028 from baseline), and 936 (635–1,435) pmol/min/m2 at 24 months (P = 0.023 from baseline; n = 20 of 39 of those initially in remission). This was comparable to the NDC group (1,016 [857–1,507] pmol/min/m2) by 12 (P = 0.064) and 24 (P = 0.244) months. Median first-phase insulin response increased from baseline to 5 months (42 [4–67] to 107 [59–163] pmol/min/m2; P < 0.0001) and then remained stable at 12 and 24 months (110 [59–201] and 125 [65–166] pmol/min/m2, respectively; P < 0.0001 vs. baseline) but lower than that of the NDC group (250 [226–429] pmol/min/m2; P < 0.0001).

CONCLUSIONS

A gradual increase in assessed functional β-cell capacity occurred after weight loss, becoming similar to that of NDC group participants by 12 months. This result was unchanged at 2 years with continuing remission of type 2 diabetes.




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The Contemporary Prevalence of Diabetic Neuropathy in Type 1 Diabetes: Findings From the T1D Exchange

OBJECTIVE

To evaluate the contemporary prevalence of diabetic peripheral neuropathy (DPN) in participants with type 1 diabetes in the T1D Exchange Clinic Registry throughout the U.S.

RESEARCH DESIGN AND METHODS

DPN was assessed with the Michigan Neuropathy Screening Instrument Questionnaire (MNSIQ) in adults with ≥5 years of type 1 diabetes duration. A score of ≥4 defined DPN. Associations of demographic, clinical, and laboratory factors with DPN were assessed.

RESULTS

Among 5,936 T1D Exchange participants (mean ± SD age 39 ± 18 years, median type 1 diabetes duration 18 years [interquartile range 11, 31], 55% female, 88% non-Hispanic white, mean glycated hemoglobin [HbA1c] 8.1 ± 1.6% [65.3 ± 17.5 mmol/mol]), DPN prevalence was 11%. Compared with those without DPN, DPN participants were older, had higher HbA1c, had longer duration of diabetes, were more likely to be female, and were less likely to have a college education and private insurance (all P < 0.001). DPN participants also were more likely to have cardiovascular disease (CVD) (P < 0.001), worse CVD risk factors of smoking (P = 0.008), hypertriglyceridemia (P = 0.002), higher BMI (P = 0.009), retinopathy (P = 0.004), reduced estimated glomerular filtration rate (P = 0.02), and Charcot neuroarthropathy (P = 0.002). There were no differences in insulin pump or continuous glucose monitor use, although DPN participants were more likely to have had severe hypoglycemia (P = 0.04) and/or diabetic ketoacidosis (P < 0.001) in the past 3 months.

CONCLUSIONS

The prevalence of DPN in this national cohort with type 1 diabetes is lower than in prior published reports but is reflective of current clinical care practices. These data also highlight that nonglycemic risk factors, such as CVD risk factors, severe hypoglycemia, diabetic ketoacidosis, and lower socioeconomic status, may also play a role in DPN development.




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As Governments Build Advanced Surveillance Systems to Push Borders Out, Will Travel and Migration Become Unequal for Some Groups?

As governments seek to push their borders out by amassing ever more data on travelers and migrants, their creation of increasingly complex border surveillance systems and use of risk-assessment technologies could ease mobility for some while rendering other groups immobile based on hypothetical risk profiles and decisions that are not publicly known and cannot be challenged, as this article explores.




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International Experience Suggests Safe Third-Country Agreement Would Not Solve the U.S.-Mexico Border Crisis

While safe third-country agreements appear to hold the potential of deterring new asylum claims, experience suggests this may be a false promise. As the Trump administration explores the possibility of such agreements with Mexico and Guatemala, this commentary examines the evidence of safe third-country arrangements in Europe, finding them difficult to enforce and playing little role in deterring new claims.




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USCIS Fee Increase Proposed Rule Could Represent the Latest Step in Reshaping Immigration to United States

While much attention has been given to the move by U.S. Citizenship and Immigration Services to raise its application fees—including an 83 percent hike to apply for U.S. citizenship—the policy changes embedded in the proposed rule have been less scrutinized. The changes, including the elimination of most fee waivers for lower-income applicants, would likely reduce the number and shift the profile of those getting a green card or other immigration status.




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A New Migration Policy for A New Era: A Conversation with Mexico&#039;s Interior Secretary Olga Sánchez Cordero

On her first official trip to Washington, DC, Secretary of the Interior Olga Sánchez Cordero offered a public address on Mexico’s new approach to migration policy at MPI. Her remarks and the event discussion were mostly conducted in Spanish, and this recording is of the simultaneous English interpretation. 




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Una nueva política migratoria para una nueva era: Una conversación con la Secretaria de Gobernación Olga Sánchez Cordero

Durante su primera visita oficial a Washington, DC, la Secretaria de Gobierno Olga Sánchez Cordero presento un discurso público sobre la nueva política migratoria de México en el Instituto de Políticas Migratorias.




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ADA seeks nominations for representation on Dental Quality Alliance

The ADA is calling for nominations for two seats to represent the Association in the Dental Quality Alliance.




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Alliance of the ADA offers education, entertainment at Conference 2020

From courses on burnout, vaping and more to golf and a low-country boil, the Alliance of the American Dental Association's upcoming Conference 2020 in Charleston, South Carolina, will offer a variety of educational and entertainment opportunities.




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ADA House rescinds The Dentist’s Prayer, amends recognition of religious diversity policy to be more inclusive

In an effort to advance the Association’s diversity and inclusion efforts, the ADA House of Delegates voted at its meeting in September to rescind the policy titled “The Dentist’s Prayer,” used by some state and local dental societies during their meetings, and amend its policy on recognition of religious diversity.




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Tufts University program provides homeless veterans with advanced dental care

Service With A Smile was among 10 programs from nine universities to receive funding this year through the ADA Foundation’s E. “Bud” Tarrson Dental School Student Community Leadership Awards.




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Dental Quality Alliance to help dentists make connection between everyday dentistry, quality measures

The Dental Quality Alliance will help dentists learn more about how quality measure domains can be best used to drive quality improvement at the practice level through a free webinar in March.




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Study clubs ‘enhance the level of care provided’

The Duluth Dental Forum in northeastern Minnesota celebrated its 75th anniversary in late 2019, stating that it was the second-oldest study club of its kind in the United States.




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CDC to offer coronavirus guidance during webinar Jan. 31

The Centers for Disease Control and Prevention will provide interim guidance to clinicians regarding the coronavirus outbreak during a webinar at 2 p.m. EST Jan. 31.




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Looking back: ADA annual meeting welcomes more than 200,000 attendees since 2010

The last decade brought 236,658 attendees to the American Dental Association's annual meeting. The ADA will continue to build on that momentum with the ADA FDC Annual Meeting from Oct. 15-18 in Orlando, Florida.




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ADA opposes CMS’ Medicaid block grant guidance

The ADA said it believes a new policy from the Centers for Medicare and Medicaid could be “detrimental” to the millions of adults who rely on Medicaid for dental care.




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Dental plan transparency continues to drive advocacy efforts

A new California law is requiring dental benefit companies to be more transparent about the leasing of dental networks, making California the 20th state to pass or amend such legislation.




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March JADA finds past incarceration associated with oral health issues

Formerly incarcerated people in the U.S. have worse oral health outcomes than those who have never been in prison, according to a study published in the March issue of The Journal of the American Dental Association.




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ADA to stream dental insurance webinar in April

Trying to navigate the world of dental benefits can be full of choppy seas, and the ADA is holding a free webinar in April to help dentists and their staff find a safe harbor full of information.




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Study: Evidence does not support classifying fluoride as cognitive neurodevelopmental hazard

The National Academies of Sciences, Engineering, and Medicine announced March 5 that it does not find that the National Toxicology Program adequately supported its conclusion that fluoride is “presumed” to be a cognitive neurodevelopmental hazard to humans.




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ADEA cancels annual session due to coronavirus concerns

The American Dental Education Association announced March 9 it has cancelled its annual session due to the coronavirus disease, now named COVID-19.




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Connecticut Foundation for Dental Outreach postpones Mission of Mercy dental clinic amid coronavirus concerns

The Connecticut Foundation for Dental Outreach has postponed the Connecticut Mission of Mercy Free Dental Clinic scheduled for March 20-21 in Danbury, Connecticut, "out of abundant caution" amid the coronavirus disease outbreak.




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IADR, AADR cancel general session in light of coronavirus

The International Association for Dental Research and American Association for Dental Research have canceled their general session scheduled for March 18-21 in Washington, D.C., in light of the coronavirus disease outbreak.




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Association launches new ADA Science & Research Institute

The American Dental Association launched the new ADA Science & Research Institute LLC on Jan. 1, bringing together the Science Institute in Chicago and research group in Gaithersburg, Maryland, that previously reported to the ADA Foundation.




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ADA to Congress: Include dentists, patients in coronavirus legislation

The American Dental Association is urging Congress to include oral health care providers and their patients in any legislation proposed to confront the coronavirus disease outbreak.




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OSHA issues coronavirus guidance

The Occupational Safety and Health Administration has issued new guidance for health care providers to prepare workplaces for COVID-19.




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ADA develops guidance on dental emergency, nonemergency care

The ADA provided its members and their patients detailed guidance on March 18 on what to consider dental emergencies and nonemergencies dental care as part of an effort to curb the spread of the coronavirus disease, COVID-19, and alleviate the burden on hospital and emergency departments.




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ADA urges Congress to increase relief for small businesses, dentist owners

As Congress works on a third legislation package in response to the coronavirus pandemic, the ADA is asking lawmakers to include provisions on how to assist dental practices and other small businesses facing economic burdens.




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Dental Trade Alliance appoints new CEO

Arlington, Va. — The Dental Trade Alliance announced March 10 that it appointed Gregory Chavez as CEO. Mr. Chavez, formerly the executive vice president of operations and membership at The Vision Council, will be taking over for Gary Price.




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ADA urges CDC to provide ‘immediate guidance’ on protecting dental patients, staff from COVID-19 during emergency treatments

The American Dental Association is urging the Centers for Disease Control and Prevention to provide immediate guidance on the best way to protect dental patients and staff from the transmission of COVID-19 during emergency and urgent care situations.




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FDI World Dental Congress canceled

This year’s FDI World Dental Congress, scheduled for September in Shanghai, China, is canceled due to the global COVID-19 outbreak, according to a March 26 news release.




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Two March 27 webinars focus on surviving financial storm caused by pandemic

The ADA is presenting two free webinars March 27, aiming to help dentists financially weather the economic downturn during the COVID-19 outbreak and illustrate how ADA advocacy has helped turn the tide.




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Labor Dept. releases new guidance in response to Families First Coronavirus Response Act

The U.S. Department of Labor Wage and Hour Division released new guidance March 26 to help workers and employers understand provisions included in the Families First Coronavirus Response Act.




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Delta Dental member companies begin offering financial assistance during pandemic

The ADA is calling on third-party payers to support dental practices in the midst of the COVID-19 pandemic.




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ADA releases interim guidance on minimizing COVID-19 transmission risk when treating dental emergencies

The American Dental Association has released interim guidance for dentists on how to minimize the risk of COVID-19 transmission before, during and after treating dental emergencies.




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Code Maintenance Committee approves new codes associated with vaping, teledentistry

On the heels of the ADA’s December interim policy on vaping comes a new CDT code that references counseling services about high-risk substance use including vaping.




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New clinical dental licensure examination to launch in June

The Dental Licensure Objective Structured Clinical Examination, or DLOSCE, is expected to launch in June, the Joint Commission on National Dental Examinations announced April 2.




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ADA offers free e-books on managing finances, HIPAA training April 8-14

As part of its ongoing efforts to support dentists during the COVID-19 pandemic, the ADA is offering members two free e-books the week of April 8-14: “Managing Finances: Best Practices” and “The ADA Practical Guide to HIPAA Training.”




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ADA council affirms importance of code of ethics during COVID-19 pandemic

The ADA Council on Ethics, Bylaws and Judicial Affairs’ ethics subcommittee authored an online essay as part of its Ethical Moment series in the May issue of The Journal of the American Dental Association, affirming that the ADA Principles of Ethics and Code of Professional Conduct is just as important as ever when making the difficult decisions they encounter on a daily basis.




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ADA asks Congress to increase funding, extend dates for Small Business Administration loans

The ADA is urging Congress to continue supporting small businesses during the COVID-19 pandemic by increasing funding and streamlining the application process for Small Business Administration loans.




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Homeland Security issues alert on cybercriminals increasingly exploiting COVID-19 pandemic

The U.S. Department of Homeland Security issued an alert April 8 warning that cybercriminals are increasingly exploiting the COVID-19 pandemic to target individuals, small and medium businesses and large organizations.




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North Carolina interactive map launches to help public find emergency dental treatment during pandemic

A North Carolina oral health coalition, in collaboration with multiple state partners, has developed an interactive map to help guide the public to sites where emergency dental services are available throughout the Tar Heel State both during and after the COVID-19 outbreak.




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SBA announces funding no longer available for Economic Injury Disaster Loans, Paycheck Protection Program

The Small Business Administration said that as of April 16, the agency is unable to accept any new applications for the Paycheck Protection Program or the Economic Injury Disaster Loans due to a lack of funding.




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ADA advises dentists to follow science-backed guidance regarding COVID-19 testing, avoid 'gray market'

The ADA is urging dentists to be cautious about using novel coronavirus diagnostic tests before they have been properly evaluated and made available for dentists.




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ADA antibiotics guideline authors to discuss C. diff infections in dentistry during Peggy Lillis Foundation conference

Two of the authors of the American Dental Association's antibiotics guideline will discuss C. diff infections and antibiotic stewardship in dentistry April 21 as part of a free, online conference organized by the Peggy Lillis Foundation.