Edited by Helaine E. Resnick, PhD, MPH
Telephone-Based Behavioral Intervention Yields Modest Effect
This issue of Diabetes Care (p. 2177) includes results of a long-term behavioral intervention that suggests that a telephone-based intervention aimed at improving weight, physical activity, and dietary intake in patients with type 2 diabetes had a limited impact. The new study randomized 302 patients with diabetes to either usual care or receipt of an 18-month intervention consisting of up to 27 motivational phone calls (4 weekly calls in the first month, every 2 weeks for the following 5 months, and monthly for the next year). The intervention focused on behavior change strategies, goal setting, self-monitoring, problem solving, and use of available supports. The primary outcomes were weight, level of physical activity, and HbA1c. Secondary outcomes included energy intake, waist circumference, lipids, and blood pressure. At 18 months, participants who received the telephone counseling intervention had significantly more weight loss and higher physical activity relative to people in usual care, but these differences were quite modest. The difference in weight loss between the two groups was only 1.42% of baseline body weight, and the difference in physical activity was about 43 min/week, favoring the intervention group. Similarly, modest improvements were observed at 18 months for diet quality and waist circumference but not for HbA1c or any of the other secondary outcomes. At 24 months—6 months after the intervention ended—physical activity was the only effect that persisted in the intervention group, and this remained about 39 min higher per week compared to usual care. Overall, these modest results suggest that telephone-based interventions with a relatively “light touch” may not be sufficient to generate changes in key cardiometabolic risk factors—particularly HbA1c—at levels that are likely to have a clinical impact on the trajectory of diabetes complications. — Helaine E. Resnick, PhD, MPH
New Data on Interrelationships Among Diabetes, Inflammation, and Depression
A study in this issue of Diabetes Care (p. 2186) shows that not only is depression present in a significant proportion of people with newly diagnosed type 2 diabetes, but that at the point of diagnosis, these individuals have higher levels of six inflammatory markers. The newly published findings support the idea that depression is prevalent even in the early stages of diabetes and that activation of certain aspects of the innate immune system in these individuals may explain the higher rates of unfavorable health outcomes that have long been observed among diabetic people with depression. The study was based on data from more than 1,200 people with newly diagnosed type 2 diabetes who also had stored blood samples that were used for biochemical analysis. Depressive symptoms were assessed in these patients with a validated instrument, and the results were related to levels of 12 inflammatory markers. The investigators found that depression was present in nearly 15% of the sample and that even after adjustment for potential confounders, depression was associated with 6 of the 12 inflammatory markers that were measured in the study. Although the cross-sectional design precluded an examination of the temporal association between depression and elevated inflammatory makers among these newly diagnosed patients, the data are consistent with the idea that inflammation may be associated with the development of depression in diabetic patients and that these processes may also explain why diabetic patients with depression have particularly unfavorable clinical outcomes. A prospective study that sheds light on whether baseline levels of these inflammatory markers predict the development of depressive symptoms in diabetes would help clarify the interrelationships among these factors, potentially informing on interventions that could simultaneously treat depression and depression-associated morbidity. — Helaine E. Resnick, PhD, MPH
Twice-Daily Insulin Degludec/Insulin Aspart Performs Well Versus Biphasic Insulin Aspart 30
Although the progressive nature of type 2 diabetes often results in patients requiring insulin during the course of their treatment, new research in this issue of Diabetes Care (p. 2084) suggests that these frequently demanding insulin regimens may become easier to manage in the future. Often, patients find that effective self-management with insulin is hindered by the frequency of required injections. For some patients, this challenge is exacerbated by the complexity associated with separate bolus and basal injections and the fear of hypoglycemia associated with premix insulin. Responding to the need for more streamlined approaches to insulin administration, the newly published study tested a combination of basal and rapid-acting insulin that can be administered in a single injection (IDegAsp) against the more conventional biphasic insulin aspart (BIAsp 30). In a 26-week trial, patients who were not adequately controlled on pre- or self-mixed insulin (with or without oral medication) were randomized to receive one of the two types of insulin. The primary outcome was HbA1c, with additional interest focused on fasting glucose and hypoglycemic episodes. At study end, HbA1c was similar in the two groups, suggesting that the combination insulin provided a similar glucose-lowering benefit as the conventional insulin regimen. However, patients who were randomized to IDegAsp had significantly lower fasting glucose, required a lower daily insulin dose, and had fewer confirmed episodes of hypoglycemia than the BIAsp 30 group. The findings from this trial support the efficacy and safety of IDegAsp and may offer a streamlined approach to insulin administration for diabetic patients who are not able to achieve control with conventional insulin regimens. Beyond the positive findings concerning HbA1c, glucose, and hypoglycemia, these results have potentially far-reaching implications for improving convenience and reducing complexity for insulin-requiring patients. — Helaine E. Resnick, PhD, MPH
Review and Recommendations for High-Altitude Physical Activity Among People With Diabetes
Promotion of physical activity among people with diabetes has resulted in increased numbers of diabetic patients taking part in activities at high altitude. The impact of diabetes on people who engage in activities such as skiing and mountain climbing is the topic of a review in this issue of Diabetes Care (p. 2404). The report summarizes the impact of hypobaric hypoxia on various physiological processes and how this environment influences diabetes-specific factors such as glucose regulation, insulin action, the function of glucose monitors, and insulin storage. In nondiabetic people, acute hypoxia is associated with decreased insulin-stimulated glucose uptake and a state of relative hyperglycemia. However, there is also evidence supporting the ability of normal subjects to acclimatize after extended periods at elevation—an observation suggesting that glucose disposal normalizes over time. However, in people with type 1 diabetes, there is research indicating that although insulin requirements are reduced at lower altitudes, these patients require higher levels of insulin as elevation increases. The risk of hypoglycemia may be increased due to a number of factors including increased insulin requirements and the difficulty of distinguishing hypoglycemia symptoms from those of acute mountain sickness. Studies in patients with type 2 diabetes compared with their diabetic counterparts who exercise under normal conditions have suggested that exercise at low oxygen levels is associated with greater glucose disposal and larger reductions in blood glucose. Overall, current research suggests that high-altitude exercise does not result in unfavorable glycemic changes in patients with type 2 diabetes, and it may even result in modest improvements in insulin sensitivity. However, the new report cautions that blood glucose monitors tend to overestimate glucose values at very cold temperatures and that insulin’s potency can also be lost in extreme cold and in response to sunlight. The report offers a number of practical recommendations for people with diabetes who enjoy outdoor activities at high altitude. These include monitoring glucose six times per day and keeping test strips, monitors, batteries, and insulin in pouches close to the skin to avoid freezing. — Helaine E. Resnick, PhD, MPH
