In This Issue of Diabetes Care

Intermittent fasting for 12 weeks is safe and effective in reducing HbA_1c and body weight in individuals with insulin-treated type 2 diabetes, according to Obermayer et al. (p. 463). The dietary pattern involved 3 days per week with a maximum of one-quarter of an individual’s usual dietary intake as breakfast/lunch only and 4 days of usual, unrestricted intake. According to the authors, individuals with insulin-treated type 2 diabetes often struggle with weight gain, yet concerns around dieting, and particularly the risk of hypoglycemia, often act as a barrier to weight loss, motivating the study. Using a randomized controlled trial design, the authors assigned 46 individuals to either an intermittent fasting group (n = 22) or control group (n = 24). All participants also received dietary advice and continuous glucose monitoring. Coprimary end points were change in HbA_1c over 12 weeks and a composite end point combining measures of reductions in weight, insulin use, and HbA_1c. At baseline, mean HbA_1c across both groups was 67 ± 11 mmol/mol (8.3% ± 1.1). The intermittent fasting group saw a reduction of 7.3 ± 12.0 mmol/mol over 12 weeks, while for the control group the level increased 0.1 ± 6.1 mmol/mol. The difference between groups also remained after adjustment for a series of factors. In terms of continuous glucose monitoring, the intermittent fasting group had less time above range and more time in range than the control group. Forty percent of the intermittent fasting group achieved the weight, HbA_1c, and insulin dose reduction targets, while none in the control group managed to do so. Weight reduction in the intermittent fasting group was about 5 kg over the 12 weeks, while the control group largely did not change weight. Commenting further, author Harald Sourij said, “Intermittent fasting can safely and effectively reduce body weight and improve glycemic control in insulin-treated people with type 2 diabetes. For some people, time-restricted eating appears to be an easier-to-follow dietary regimen than a continuous caloric restriction approach—our data can help personalize future lifestyle intervention counseling in people with type 2 diabetes.”

One in five youth and young adults with diabetes in the U.S. potentially lives in a household that has limited or uncertain availability of nutritionally adequate food, according to Malik et al. (p. 278). An additional 13% of households were found to be marginally food secure. According to the authors, policy-level interventions that address underlying causes of food insecurity are needed, and medical teams should take food security status into consideration when making decisions about treatment (as recommended by the American Diabetes Association). “To date, most diabetes studies examining food insecurity have focused on middle-aged and older adults,” said author Faisal S. Malik. “Our large population-based multicenter study confirms that household food insecurity is an important health consideration in youth and young adults living with diabetes as well.” The findings come from an analysis of participants in the SEARCH for Diabetes in Youth study with food insecurity, which was assessed with the 18-item U.S. Household Food Security Survey Module. Most of the young respondents had type 1 diabetes (∼2,500) while just over 380 had type 2 diabetes, and the overall prevalence of food insecurity was just under 20%. Prevalence was higher in the type 2 diabetes group at just under 31% compared with just under 18% in participants with type 1 diabetes. Factors influencing the odds of food insecurity included having Medicare/ Medicaid or no insurance, level of parental education, and perhaps not surprisingly, level of household income. Only 14% reported they had used the Supplemental Nutrition Assistance Program, or SNAP, with the burden of requirements cited as a possible reason for the low participation rate. Dr. Malik added, “Given our finding that youth and young adults with diabetes experience food insecurity at a substantially higher rate than the general U.S. population, diabetes care teams can play an important role in ameliorating the potential impact of food insecurity in this population by connecting patients to local and community resources.”

Young adults with either type 1 or type 2 diabetes who lived in households with food insecurity experienced more fear of hypoglycemia than similar individuals who were food secure, according to Reid et al. (p. 262). The fears also extended to parents of adolescents with type 1 diabetes and were much greater when they were food insecure compared with the fears of individuals who had food security. The authors say the findings suggest that more research is warranted on how to help young adults with diabetes manage their fears of hypoglycemia. They also suggest that providers take food insecurity into account, particularly when conventional methods, such as carrying snacks, might not work because of food insecurity. The findings come from further analysis of the SEARCH for Diabetes in Youth study and included 1,676 young adults with youth-onset diabetes. Most (84%) had type 1 diabetes, while the balance had type 2 diabetes. A total of 568 adolescents with type 1 diabetes were also included. Overall, 16% of adolescents with type 1 diabetes were from households with food insecurity, while 19% of young adults with type 1 diabetes and 35% with type 2 diabetes experienced food insecurity. Young adults with type 1 or type 2 diabetes and food insecurity had higher fear scores than those with food security. Parents of adolescents with type 1 diabetes generally had the highest fear scores, but as with adolescents with type 1 diabetes, food security, or lack of it, did not appear to affect fear levels. Modeling to adjust for a series of factors suggested the associations between hypoglycemia fear and food insecurity remained for young adults with either type of diabetes. “Food-insecure young adults with diabetes are in a real bind when it comes to managing their glucose,” said author Angela D. Liese. “Our study documents that the limited or unreliable availability of food correlates with markedly higher levels of fear of having abnormally low blood sugar.”

Severe hypoglycemia in the context of type 2 diabetes may double the risk of later dementia, according to Alkabbani et al. (p. 331). The increased risk was approximately the same whether the severe hypoglycemia event occurred in mid-life or later life and did not seem altered in men versus women or according to socioeconomic status. Accordingly, the authors suggest it underlines the importance of preventing hypoglycemia “throughout the life course of patients with type 2 diabetes.” The findings come from a retrospective population-based cohort study based on over 20 years of health care data from British Columbia, Canada. The base cohort consisted of patients with incident type 2 diabetes aged older than 40 years, and the exposure of interest was the first occurrence of severe hypoglycemia (i.e., requiring hospitalization or physician assistance). The authors then defined two cohorts consisting of individuals aged either 45–64 years or 65–84 years and used modeling (with adjustments for many hundreds of confounding factors) to assess the relationship between hypoglycemia and later dementia. For the middle-aged cohort, which consisted of just under 222,000 individuals, approximately 1,800 experienced their first severe hypoglycemia event, and over a median of about 9 years 3,117 individuals developed dementia. Thirty-two individuals who had severe hypoglycemia also developed dementia. In the later-life cohort, there were approximately 224,000 equivalent individuals, of whom 2,466 had a severe hypoglycemia event and just under 16,000 developed dementia. Another 158 individuals both had hypoglycemia and developed dementia. Modeling with full adjustment indicated risks for dementia were about 2–3 times higher in both cohorts following hypoglycemia (compared with levels for participants with no severe hypoglycemia). Commenting further, author Wajd Alkabbani said, “These novel findings highlight the importance of minimizing hypoglycemic episodes for patients irrespective of age. Our article provides a signal directing future research to understand the potential long-lasting damage of severe hypoglycemic episodes on cognitive functions.”