Diabetes

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The remote care approach improved therapy adherence and uptake in patients with type 2 diabetes.

Mass General Brigham study found earlier and greater uptake of medication when a remote care team delivered simultaneous education and medication management compared to a period of education before medication management
Mass General Brigham study found earlier and greater medication uptake when a remote care team delivered simultaneous education and medication management compared to a period of education before medication management.
  • Researchers at Mass General Brigham tested a remote patient education and navigation program with 200 patients who had type 2 diabetes and elevated cardiovascular/kidney risk.
  • Patients who received education simultaneously with treatment were more likely to begin and adhere to treatment while a period of education before therapy initiation was inferior for prescription acceptance and therapy uptake.
  • The study highlights the importance of “striking while the iron is hot” and the potential for remote, team-based care to bridge healthcare gaps and enhance patient outcomes.

A new study by investigators from Mass General Brigham demonstrated that a remote team focused on identifying, educating and prescribing therapy can improve guideline-directed-medical-therapy (GDMT) adherence in patients with type 2 diabetes and high cardiovascular and/or kidney risk. The research team observed that patients who received education simultaneously with medication management demonstrated a higher rate of medication uptake and initiated treatment earlier compared to patients who received education over two months before medication management. Their results were presented at the 2024 American College of Cardiology’s Annual Scientific Session and simultaneously published in Circulation.

“Our results suggest that patients are more inclined to adhere to therapy when approached with education and treatment simultaneously and immediately,” said corresponding author Alexander J. Blood, MD, MSc, who presented the results. Blood serves as an attending physician in the Division of Cardiovascular Medicine and the Heart and Vascular Center at Brigham and Women’s Hospital, a founding member of the Mass General Brigham healthcare system. “Providers should ‘strike while the iron is hot.’ If a patient is already interested in investing in their health and willing to meet with you, that’s the time to initiate treatment while providing educational resources.”

Type 2 diabetes, which increases an individual’s risk of cardiovascular and kidney events, affects millions of adults in the United States. Medications such as SGLT2 inhibitors and GLP-1 receptor agonists can improve cardiovascular and kidney outcomes in patients with type 2 diabetes, but data from clinical trials and society recommendations have not led to widespread adoption and utilization of these therapies.

To investigate the impact of patient education on prescription acceptance and therapy uptake, the research team conducted a parallel, randomized, open-label clinical trial. The study was funded by the Novo Nordisk Foundation. They enrolled 200 adult patients with type 2 diabetes at Mass General Brigham, who were at elevated risk of cardiac and/or kidney complications. Patients were randomly assigned to one of two groups. The “education-first” group received a dedicated two-month period of education, consisting of curated patient-centric videos on disease management and medication, prior to treatment initiation via an online portal. The second “simultaneous” group had access to the educational videos but received patient education concurrently with the initiation of their treatment.

Both groups received treatment through a research and clinical care management platform designed and created by the Accelerator for Clinical Transformation at Brigham and Women’s Hospital and Mass General Brigham, which facilitated care coordination among patient navigators, pharmacists, nurse practitioners and physicians. These healthcare professionals guided patients through every step of their engagement with health care and streamlined communication. The platform is part of Mass General Brigham’s larger efforts to transform healthcare delivery by helping patients access services and monitor health from home, especially at a time when hospitals are regularly operating over capacity.

Patients were followed for six months from enrollment or one month after medication initiation, whichever duration was longer.

While patients in both groups experienced benefits such as weight loss and reductions in blood glucose levels by the end of the study, those who received simultaneous education demonstrated a higher retention rate. Specifically, 60 percent of patients in this group were confirmed to have taken their prescribed therapy, compared to 44 percent in the “education-first” group. Additionally, contrary to initial predictions, patients in the “education-first” group did not engage more with the educational platform than those in the simultaneous group.

While the findings suggest that a pre-treatment education period may not be the solution to medication adherence issues, they underscore the potential of remote, team-based care delivery. This approach holds promise in facilitating the implementation of new therapies, bridging care quality disparities, and enhancing healthcare outcomes across diverse populations. The authors describe how the flexibility inherent in remote treatment may extend access to care, particularly benefiting traditionally underserved populations or individuals with busy schedules. Moreover, the inclusion of a patient navigation team fosters ongoing patient-provider communication, providing the personalized support necessary for sustained patient engagement in their care.

“We strongly believe that remote care programs that leverage non-licensed navigators, clinical pharmacists, and team-based care, together with a care delivery platform, will improve operational efficiencies and communication and thereby address many of the persistent problems in health care,” said Benjamin M. Scirica, MD, MPH, principal investigator of the DRIVE study and director of the Accelerator for Clinical Transformation. “On a broader scale, programs like this enhance access, elevate patient outcomes, reduce physician burden, and promote the appropriate utilization of guideline-recommended medications.”

Posted on Diabetes

Chinese Medical Journal review identifies disrupted mitochondrial metabolism as a trigger for diabetic cardiomyopathy.

Overview of altered fuel preference and cardiac energetics in diabetic cardiomyopathy

In diabetic hearts, ATP production fails to meet demands due to altered mitochondria and substrate utilization. Early diabetes triggers metabolic issues, exacerbating myocardial injury and contributing to cardiac dysfunction in conjunction with damaged mitochondria CREDIT Chinese Medical Journal

Diabetes is a global health burden. A whopping 536 million people worldwide struggle with diabetes. Diabetic cardiomyopathy (DC) is a serious condition characterized by impaired heart function due to diabetes-related metabolic abnormalities. It is a complex, multi-faceted condition where the heart fails to efficiently pump blood into the body. Insulin resistance, abnormal mitochondrial dynamics, oxidative stress, and impaired calcium handling are some of the underlying mechanisms that contribute to DC.

Traditional treatment strategies have often focused on controlling blood glucose levels and managing cardiovascular risk factors. However, recent advancements in understanding the intricate mechanisms underlying DC have paved the way for targeted therapeutic interventions.

Dr. Tao Li from West China Hospital, Sichuan University, China, and his team conducted a review to understand various aspects of metabolic dysregulation in diabetic cardiomyopathy. Their study was published online on March 25, 2024 in the Chinese Medical Journal. “We reviewed the current knowledge of the reprogrammed mitochondrial energy metabolism in diabetic cardiomyopathy by elaborating how the changed catabolism of glucose, FAs, lactate, ketone bodies, and branched-chain amino acids (BCAAs) participates or counteracts the pathogenesis, and highlighting the emerging mitochondrial metabolism targeted therapies,” explains Dr. Li.

Maintaining mitochondrial integrity and activity is crucial for energy production. However, in diabetes, the processes of mitochondrial formation (fusion) and mitochondrial fragmentation (fission) are both dysregulated. “In DC, mitochondrial fusion decreases, as indicated by a significant decrease in mitofusion 2 (MFN2) expression. The overexpression of MFN2 in diabetic hearts has been shown to reduce reactive oxygen species (ROS) production and normalize fission. And MFN2 expression can be regulated via the peroxisome proliferator-activated receptor (PPARa),” explains Dr. Li. Mitophagy is an important step involved in the elimination of damaged mitochondria. Imbalance in mitochondrial dynamics and dysregulation of mitophagy are precursors to the development of DC. In diabetic hearts, inefficient energy compensation leads to excessive electron and ROS production, which play a significant role in DC. Mitochondrial calcium regulates pumping of the heart, and its dysregulation affects multiple functions. Increased levels of mitochondrial calcium can damage cardiomyocytes, whereas decreased levels can decrease glucose utilization, increase fatty acid utilization, and impair adenosine triphosphate (ATP) production.

The heart consumes approximately 8% of the body’s total energy, derived from ATP. The diabetic heart struggles to meet the ATP demands of myocardial activities, leading to the initiation of abnormal metabolic pathways and a shift in substrate preferences. Fatty acids and lactic acid, chosen to compensate for the ATP deficit, prove to be less efficient substrates, resulting in oxidative stress and subsequent myocardial damage. Additionally, BCAAs, such as leucine, isoleucine, and valine, contribute to inefficient ATP production, and their accumulation is associated with reduced glucose metabolism, rendering the heart vulnerable to ischemic injury. Altered metabolites with damaged mitochondria further promote myocardial injury and contribute to cardiac dysfunction. In contrast, ketone bodies are proposed as an alternative metabolic fuel in diabetic cardiomyopathy as they serve as efficient substrates. “Recently, in streptozotocin-induced diabetic rats, a ketogenic diet was demonstrated to enhance cardiac function by increasing ketone utilization, suppressing fatty acid metabolism, and reducing inflammation. Ketone bodies may play a regulatory role in modulating other energy substrates,” elaborates Dr. Li.

Considering the complex interplay of mitochondria, insulin, glucose, calcium, and metabolic pathways, there is no specific treatment for DC. The gold standard strategies focus on maintaining optimum blood glucose levels, managing the progression of associated comorbidities, and treating heart failure. GLP-1 RA and sodium-glucose transporter are clinically proven anti-hyperglycemic agents that are clinically well-established. Statins, such as atorvastatin and fluvastatin, have cardioprotective effects as they reduce low-density lipoprotein cholesterol levels. Ketogenic therapies involve the consumption of low-glycemic foods where the energy source shifts from glucose to ketones, thereby reducing the burden on insulin. The study offers insights into the key role of mitochondrial energy dysregulation and mitochondrial oxidative stress in DC. Mitochondria-oriented therapies, including antioxidants such as MitoTEMPO, have emerged that offer cardioprotection.

Posted on Diabetes

Low-fat vegan diet reduces insulin requirements and improves insulin sensitivity for people with type 1 diabetes, finds groundbreaking new study

Researchers find adding a banana decreased the level of flavanols in smoothies

A low-fat vegan diet rich in fruits, vegetables, grains, and beans reduces insulin needs. It improves insulin sensitivity and glycemic control in people with type 1 diabetes, according to a first-of-its-kind study by the Physicians Committee for Responsible Medicine published in Clinical Diabetes. The study also found that a vegan diet improved cholesterol levels, kidney function, and weight.

Type 1 diabetes is thought to be caused by an autoimmune reaction that destroys the beta cells in the pancreas that make insulin. Insulin is a hormone that helps move glucose (sugar) from the blood into muscle and liver cells for energy. People with type 1 diabetes must take insulin because their body doesn’t produce enough. Some people with type 1 diabetes may also have insulin resistance, a condition in which cells don’t respond well to insulin, and glucose remains in the blood. Dietary fat strongly influences insulin resistance, which can inhibit glucose from entering the cells. Over time, high blood glucose levels can lead to health complications.

In the 12-week study, which is the first randomized clinical trial to look at a vegan diet in people with type 1 diabetes, 58 adults with type 1 diabetes were randomly assigned to either a low-fat vegan group with no limits on calories or carbohydrates, or a portion-controlled group that reduced daily calorie intake for overweight participants and kept carbohydrate intake stable over time.

Those in the low-fat vegan diet group reduced the amount of insulin they needed to take by 28% and increased insulin sensitivity (how well the body responds to insulin) by 127%, compared with those following the portion-controlled diet. This was associated with changes in body weight. Body weight decreased by about 11 pounds on average in the vegan group, compared with a nonsignificant change in body weight in the portion-controlled group. Changes in insulin sensitivity were also associated with increased carbohydrate and fibre intake. Previous research shows that reducing fat and protein intake is also associated with reduced insulin requirements and improved insulin sensitivity in people with type 1 diabetes.

In the vegan group, total cholesterol decreased by 32.3 mg/dL compared to 10.9 mg/dL in the portion-controlled group. LDL cholesterol decreased by approximately 18.6 mg/dL in the vegan group and did not change significantly in the portion-controlled group.

Type 1 diabetes is associated with an increased risk of cardiovascular disease and death. In this study, the reduction in insulin use on the vegan diet corresponds to a 9% reduction in cardiovascular risk; the decrease in HbA1c corresponds to a 12% and 8.8-12% reduced risk of heart attack and cardiovascular disease, respectively; and the reduction in LDL cholesterol corresponds to an approximate 20% reduced risk for a major cardiac event, including heart attack and stroke.

Approximately 40,000 new cases of type 1 diabetes are diagnosed each year. Recent analyses project up to a 107% increase in prevalence of type 1 diabetes by 2040. The annual cost of type 1 diabetes care increased by more than 50% from 2012 and 2016, primarily due to rising costs of insulin and diabetes monitoring equipment.

“With the cost of insulin remaining a concern for many, our groundbreaking research shows that a low-fat vegan diet that doesn’t restrict carbs may be the prescription for reducing insulin needs, managing blood sugar levels, and improving heart health in people with type 1 diabetes,” says Hana Kahleova, MD, PhD, the lead author of the study and director of clinical research at the Physicians Committee for Responsible Medicine.

Posted on Diabetes, Diet

Eggs may not be bad for your heart after all

Subgroup analyses signal a possible benefit among older adults and those with diabetes
Subgroup analyses signal a possible benefit among older adults and those with diabetes

Whether you like your eggs sunny-side up, hard boiled or scrambled, many hesitate to eat them amid concerns that eggs may raise cholesterol levels and be bad for heart health. However, results from a prospective, controlled trial presented at the American College of Cardiology’s Annual Scientific Session show that over a four-month period cholesterol levels were similar among people who ate fortified eggs most days of the week compared with those who didn’t eat eggs.

A total of 140 patients with or at high risk for cardiovascular disease were enrolled in the PROSPERITY trial, which aimed to assess the effects of eating 12 or more fortified eggs a week versus a non-egg diet (consuming less than two eggs a week) on HDL- and LDL-cholesterol, as well as other key markers of cardiovascular health over a four-month study period.

“We know that cardiovascular disease is, to some extent, mediated through risk factors like high blood pressure, high cholesterol and increased BMI and diabetes. Dietary patterns and habits can have a notable influence on these and there’s been a lot of conflicting information about whether or not eggs are safe to eat, especially for people who have or are at risk for heart disease,” said Nina Nouhravesh, MD, a research fellow at the Duke Clinical Research Institute in Durham, North Carolina, and the study’s lead author. “This is a small study, but it gives us reassurance that eating fortified eggs is OK with regard to lipid effects over four months, even among a more high-risk population.”

Eggs are a common and relatively inexpensive source of protein and dietary cholesterol. Nouhravesh and her team wanted to look specifically at fortified eggs as they contain less saturated fat and additional vitamins and minerals, such as iodine, vitamin D, selenium, vitamin B2, 5 and 12, and omega-3 fatty acids.

For this study, patients were randomly assigned to eat 12 fortified eggs a week (cooked in whatever manner they chose) or to eat fewer than two eggs of any kind (fortified or not) per week.  All patients were 50 years of age or older (the average age was 66 years), half were female and 27% were Black. All patients had experienced one prior cardiovascular event or had two cardiovascular risk factors, such as high blood pressure, high cholesterol, increased BMI or diabetes. The co-primary endpoint was LDL and HDL cholesterol at four months. Secondary endpoints included lipid, cardiometabolic and inflammatory biomarkers and levels of vitamin and minerals. 

Patients had in-person clinic visits at the start of the study and visits at one and four months to take vital signs and have bloodwork done. Phone check-ins occurred at two and three months and patients in the fortified egg group were asked about their weekly egg consumption. Those with low adherence were provided additional education materials.

Results showed a -0.64 mg/dL and a -3.14 mg/dL reduction in HDL-cholesterol (“good” cholesterol) and LDL cholesterol (“bad” cholesterol), respectively, in the fortified egg group. While these differences weren’t statistically significant, the researchers said the differences suggest that eating 12 fortified eggs each week had no adverse effect on blood cholesterol. In terms of secondary endpoints, researchers observed a numerical reduction in total cholesterol, LDL particle number, another lipid biomarker called apoB, high-sensitivity troponin (a marker of heart damage), and insulin resistance scores in the fortified egg group, while vitamin B increased.

“While this is a neutral study, we did not observe adverse effects on biomarkers of cardiovascular health and there were signals of potential benefits of eating fortified eggs that warrant further investigation in larger studies as they are more hypothesis generating here,” Nouhravesh said, explaining that subgroup analyses revealed numerical increases in HDL cholesterol and reductions in LDL cholesterol in patients 65 years or older and those with diabetes in the fortified egg group compared with those eating fewer than two eggs.

So why have eggs gotten a bad rap? Some of the confusion stems from the fact that egg yolks contain cholesterol. Experts said a more important consideration, especially in the context of these findings, might be what people are eating alongside their eggs, such as buttered toast, bacon and other processed meats, which are not heart healthy choices. As always, Nouhravesh said it’s a good idea for people with heart disease to talk with their doctor about a heart healthy diet.

This single-center study is limited by its small size and reliance on patients’ self-reporting of their egg consumption and other dietary patterns. It was also an unblinded study, which means patients knew what study group they were in, which can influence their health behaviors.

Posted on Diabetes, Diet

With so many types of diets being promoted online and on social media, a leading dietitian says flexibility is more sustainable than a rigid diet plan.

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Joyce Patterson, MPH, RDN, BC-ADM, CPT is a registered dietitian and a diabetes care and education specialist at Michigan Medicine in Ann Arbor, U.S., and she says the science points to a balanced approach.

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“We live in a world full of messages to restrict, eliminate, and fast, and misconceptions related to diet trends are common, such as macronutrient or supplement needs,” she explains. For example, the war wages over fats versus carbs, or eggs come in and out of favor every couple of years, and the media and food manufacturers exploit such information to drive what people think about nutrition and increase sales.

“The sheer number of products and programs claiming to ‘reset your metabolism’ or ‘cleanse’ your system indicates that many people are interested in the science. However, few receive comprehensive and reliable nutrition education and cannot discern between marketing ploys and good science. They make food choices and purchase decisions based on minimal or misleading information.”

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What are some diet trends?

In her new book, Think Like A Dietitian, Patterson reviews various diet trends, unpacking the myths around each and where the barriers to success lie.

“For many, diet culture has shaped their relationship with food. From the parental influences of their childhood to the virality of social media today, these beliefs can be deeply ingrained.”

Patterson highlights that many popular diets are based on minimal scientific evidence, but the ketogenic diet and intermittent fasting are highly studied and debated among nutrition researchers and clinicians.

Research cited in the book has shown the ketogenic diet offers short term benefits in rapid weight loss and metabolic disorders including diabetes, but Patterson says there are not enough long‑term studies to determine the long‑term safety of the regimen.

Similarly, the various forms of intermittent fasting have also shown potential as treatments for obesity and cardiometabolic disorders, but for alternate‑day fasting or prolonged fasts, more studies are needed to assess its long‑term safety.

“When certain diets show promising findings in research, many well‑meaning, non‑nutrition clinicians will be quick to recommend these approaches,” Patterson explains. “From low fat to low carb to fasting, the most popular diets are ironically the most restrictive. It is no wonder they tend to be the most unsustainable.”

In ketogenic diets, the initial water loss in the first week alone can show changes on the scale. However, studies also repeatedly show evidence of weight loss in various other eating patterns—regardless of macronutrient composition—without one proving to be more superior to others. In regard to weight loss maintenance, Patterson explains that “research continues to show little difference when comparing various dietary patterns for long-term weight loss.”

What are the issues with diet trends?

“A common practice is that people will apply certain features of a diet, instead of the actual dietary pattern that was researched. Without proper guidance, people may end up practicing unhealthy behaviors that put their health at risk.”

Patterson points out that diet culture can also push people down a path of overly-restrictive eating.

“Not all people push nutrition down the priority list,” she explains. “In fact, some are so aware of their choices that they control themselves straight into hunger. They know their way around a grocery store and leave no package unturned, scanning and comparing nutrition labels.

“While mindfulness is a key tenet in healthy eating, calories and certain food groups have been vilified by diet culture. Whether people are counting calories, carbs, fat, sodium, or other nutrients, the interpretation is often ‘less is more’. Instead of focusing on healthy food choices and overall balance, some people get caught up in the minutiae of nutrients. They feel food is something to be avoided, as opposed to being the fuel that provides power, strength, and protection.”

Following diet trends can also create an attitude which Patterson calls ‘all-or-nothing’. She explains: “Many people are pretty savvy when it comes to diet trends. They keep up with the latest trends and are willing to try new things. They become familiar with terms like ‘macros’ or ‘alkalinity’ or ‘ketones’. When they put their minds to it, they are able to lose weight rather quickly. They know how to slim down for a wedding or a cruise or a beach vacation. When they’re ready, they dive right in and see results.”

However, Patterson explains that when something unexpected happens, such as a social event, a family issue, a health concern, or a stressful event, often these ‘all or nothing’ dieters hit an inevitable plateau, become frustrated, and give up.

“Life happens. And it will happen again and again. These are perhaps the most impactful challenges that people encounter because they are recurring and inevitable. They may be accompanied by an emotional burden such as stress or worry. Or the episode may be followed by feelings of guilt or failure, especially for those whose self‑efficacy was low in the first place. If it happens repeatedly, the cost of the effort may seem to outweigh the benefit, leading to a complete cessation of action. All too often, this cycle of regression repeats itself,” she explains.

What should we do instead?

“In my experience, I find that many diet trends are effective not because they are novel, but because they are similar,” Patterson says.

Research and Patterson’s experience both suggest that most diets work because regardless of whether it monitors calories, carbs, fat, protein or points, it usually follows that some of these basics are applied: added sugar and ultra‑processed foods are limited; plant foods increase; portions are controlled.

“With every new study, there is a new headline, causing whiplash among patients and health professionals alike,” she explains. “Therefore, erring on the side of balance and variety can be a safe way to maneuver some of these controversial and ever‑changing topics.”

Patterson suggests that following an ‘80/20’ rule is more sustainable, acknowledging that dietary perfection is an impractical approach.

“Specifically, this rule of thumb suggests that people follow dietary recommendations 80% of the time, and not to worry about the other 20%, factoring in convenience, enjoyment, and social interactions.

“One of the most important experiences that a dietitian can share is that perfection is not only unattainable but also unnecessary. Even centenarians often admit to some lifelong indulgences.

“A healthy diet does not have to be all-or-nothing. The occasional treat is not harmful. However poor choices in excess can increase risk for nutrition-related disease,” she explains.