Utilising continuous glucose monitoring for glycemic control in diabetic kidney disease

In this editorial,we comment on the article by Zhang et al.Chronic kidney disease(CKD)presents a significant challenge in managing glycemic control,especially in diabetic patients with diabetic kidney disease undergoing dialysis or kidney transplantation.Conventional markers like glycated haemoglobin(HbA1c)may not accurately reflect glycemic fluctuations in these populations due to factors such as anaemia and kidney dysfunction.This comprehensive review discusses the limitations of HbA1c and explores alternative methods,such as continuous glucose monitoring(CGM)in CKD patients.CGM emerges as a promising technology offering real-time or retrospective glucose concentration measure-ments and overcoming the limitations of HbA1c.Key studies demonstrate the utility of CGM in different CKD settings,including hemodialysis and peritoneal dialysis patients,as well as kidney transplant recipients.Despite challenges like sensor accuracy fluctuation,CGM proves valuable in monitoring glycemic trends and mitigating the risk of hypo-and hyperglycemia,to which CKD patients are prone.The review also addresses the limitations of CGM in CKD patients,emphasizing the need for further research to optimize its utilization in clinical practice.Altogether,this review advocates for integrating CGM into managing glycemia in CKD patients,highlighting its superiority over traditional markers and urging clinicians to consider CGM a valuable tool in their armamentarium.

Glucagon-like peptide-1 receptor agonists:Exploring the mechanisms from glycemic control to treatment of multisystemic diseases

This editorial takes a deeper look at the insights provided by Soresi and Giannitrapani,which examined the therapeutic potential of glucagon-like peptide-1 receptor agonists(GLP-1RAs)for metabolic dysfunction-associated fatty liver disease.We provide supplementary insights to their research,highlighting the broader systemic implications of GLP-1RAs,synthesizing the current understanding of their mechanisms and the trajectory of research in this field.GLP-1RAs are revolutionizing the treatment of type 2 diabetes mellitus and beyond.Beyond glycemic control,GLP-1RAs demonstrate cardiovascular and renal protective effects,offering potential in managing diabetic kidney disease alongside renin–angiotensin–aldosterone system inhibitors.Their role in bone metabolism hints at benefits for diabetic osteoporosis,while the neuroprotective properties of GLP-1RAs show promise in Alzheimer's disease treatment by modulating neuronal insulin signaling.Additionally,they improve hormonal and metabolic profiles in polycystic ovary syndrome.This editorial highlights the multifaceted mechanisms of GLP-1RAs,emphasizing the need for ongoing research to fully realize their therapeutic potential across a range of multisystemic diseases.

Efficacy of a Diabetes Specific Nutrition Supplement on Glycemic, Anthropometric, Dietary and Gut Health Markers in Adults with Type 2 Diabetes: An RCT

With increasing incidence of diabetes, use of diabetes specific nutrition supplements (DSNS) is common for better management of the disease. To study effect of 12-week DSNS supplementation on glycemic markers, anthropometry, lipid profile, SCFAs, and gut microbiome in individuals with diabetes. Markers studied were glycemic [Fasting Blood Glucose (FBG), Post Prandial Glucose (PPG), HbA1c, Incremental Area under curve (iAUC), Mean Amplitude of Glycemic Excursions (MAGE), Time in/above Range (TIR/TAR)], anthropometry [weight, Body Mass Index (BMI), waist circumference (WC)], lipid profile, diet and gut health [plasma short chain fatty acids (SCFAs)]. N = 210 adults were randomized to receive either DSNS with standard care (DSNS + SC;n = 105) or standard care alone (SC alone;n = 105). After 12 weeks, significant differences between DSNS + SC versus SC alone was observed in FBG [−3 ± 6 vs 14 ± 6 mg/dl;p = 0.03], PPG [−35 ± 9 vs −3 ± 9 mg/dl;p = 0.01], weight [−0.6 ± 0.1 vs 0.2 ± 0.1 kg;p = 0.0001], BMI [−0.3 ± 0.1 vs 0.1 ± 0.1 kg/m2;p = 0.0001] and WC [−0.3 ± 0.2 vs 0.2 ± 0.2 cm;p = 0.01]. HbA1C and low-density lipoprotein (LDL) were significantly reduced in DSNS + SC [−0.2 ± 0.9;p = 0.04 and −5 mg/dl;p = 0.03] respectively with no change in control. Continuous Glucose Monitoring (CGM) reported significant differences between DSNS + SC versus SC alone for mean glucose [−12 ± 65 vs 28 ± 93 mg/dl;p < 0.01], TAR 180 [−9 ± 42 vs 7 ± 45 mg/dl;p = 0.04], TAR 250 [−3 ± 27 vs 9 ± 38 mg/dl;p = 0.05], iAUC [−192 (1.1) vs −48 (1.1) mg/dl;p = 0.03]. MAGE was significantly reduced for both DSNS + SC (−19 ± 67;p < 0.001) and SC alone (−8 ± 70;p = 0.04), with reduction being more pronounced for DSNS + SC. DSNS + SC reported a decrease in carbohydrate energy % [−9.4 (−11.3, −7.6) %;p < 0.0001] and amount [−47.4 (−67.1, −27.7) g;p < 0.0001], increased dietary fiber [9.5 (7.2, 11.8) g;p < 0.0001] and protein energy % [0.9 (0.5, 1.3) %;p < 0.0001] versus SC alone. DSNS + SC reported significant increases versus SC alone in total (0.3 ng/ml;p = 0.03) and individual plasma SCFAs. The consumption of DSNS significantly improves the glycemic, anthropometric, dietary, and gut health markers in diabetes.

Blood Pressure Profile and Glycemic Control of Type 2 Diabetics and Hypertensives at the Yalgado Ouedraogo University Hospital: A Review of 116 Cases

Objective: The association hypertension and diabetes is important. The two pathologies may influence each other. The aim was to study the correlation between glycemic control and blood pressure control and to determine the factors associated with blood pressure control. Methodology: This was a descriptive cross-sectional study with an analytical focus over 7 months. Patients were recruited as outpatients and all underwent ambulatory blood pressure measure, glycated hemoglobin and creatinine measurements, and assessment of compliance with treatment. Results: During this period 116 patients were collected. The predominance was female 69%. The mean age of the patients was 62 ± 7 years with a peak between 60 and 70 years. The average age of hypertension was 12 years and that of diabetes 6 1/2 years. The most frequently associated cardiovascular risk factor was a sedentary lifestyle (71.5%) after age. 57.8% of patients were not controlled at the office, with a predominance of systolic hypertension (58.2%). 61.6% of patients were controlled by ambulatory blood pressure measure, a rate of 47.8% of white coat hypertension. Glycemic control was observed in 42.2% of cases and 87% of patients had good renal function (glomerular filter rate ≥ 60 ml/mn). Therapeutic compliance was good in 53.4% of cases and dual therapy was the most used therapeutic modality 44.8% (52 patients) followed by triple therapy. The factors associated with poor blood pressure control were glycemic imbalance, non-compliance and monotherapy. Dual therapy had a protective effect. Conclusion: The association of hypertension and type 2 diabetes is frequent. The risk of occurrence increases with age. Ambulatory blood pressure measure is the best method to assess blood pressure control. Optimization of blood pressure control should also include optimization of glycemic control.

Recent Advances in Glycemic Management for Hospitalized Diabetic Patients

With the increase in the number of diabetic patients,hospitalized diabetes management has become very important.During hospitalization,diabetic patients are prone to high or low blood glucose levels,which pose significant risks and challenges for treatment and recovery.Therefore,glycemic management of diabetic patients during hospitalization is critical.This article reviews the latest research progress in glycemic management of hospitalized diabetic patients from several aspects,develops individualized treatment plans,and uses various methods to manage and control blood glucose in hospitalized diabetic patients.

Utility of different glycemic control metrics for optimizing management of diabetes

The benchmark for assessing quality of long-term glycemic control and adjustment of therapy is currently glycated hemoglobin(Hb A1c). Despite its importance as an indicator for the development of diabeticcomplications, recent studies have revealed that this metric has some limitations; it conveys a rather complex message, which has to be taken into consideration for diabetes screening and treatment. On the basis of recent clinical trials, the relationship between Hb A1 c and cardiovascular outcomes in long-standing diabetes has been called into question. It becomes obvious that other surrogate and biomarkers are needed to better predict cardiovascular diabetes complications and assess efficiency of therapy. Glycated albumin, fructosamin, and 1,5-anhydroglucitol have received growing interest as alternative markers of glycemic control. In addition to measures of hyperglycemia, advanced glucose monitoring methods became available. An indispensible adjunct to Hb A1 c in routine diabetes care is selfmonitoring of blood glucose. This monitoring method is now widely used, as it provides immediate feedback to patients on short-term changes, involving fasting, preprandial, and postprandial glucose levels. Beyond the traditional metrics, glycemic variability has been identified as a predictor of hypoglycemia, and it might also be implicated in the pathogenesis of vascular diabetes complications. Assessment of glycemic variability is thus important, but exact quantification requires frequently sampled glucose measurements. In order to optimize diabetes treatment, there is a need for both key metrics of glycemic control on a day-to-day basis and for more advanced, user-friendly monitoring methods. In addition to traditional discontinuous glucose testing, continuous glucose sensing has become a useful tool to reveal insufficient glycemic management. This new technology is particularly effective in patients with complicated diabetes and provides the opportunity to characterize glucose dynamics. Several continuous glucose monitoring(CGM) systems, which have shown usefulness in clinical practice, are presently on the market. They can broadly be divided into systems providing retrospective or real-time information on glucose patterns. The widespread clinical application of CGM is still hampered by the lack of generallyaccepted measures for assessment of glucose profiles and standardized reporting of glucose data. In this article, we will discuss advantages and limitations of various metrics for glycemic control as well as possibilities for evaluation of glucose data with the special focus on glycemic variability and application of CGM to improve individual diabetes management.

Glycemic index and glycemic load of selected Chinese traditional foods

AIM:To determine the glycemic index(GI)and glycemic load(GL)values of Chinese traditional foods in Hong Kong.METHODS:Fifteen healthy subjects(8 males and 7 females)volunteered to consume either glucose or one of 23 test foods after 10-14 h overnight fast.The blood glucose concentrations were analyzed immediately before,15,30,45,60,90 and 120 min after food consumption using capillary blood samples.The GI value of each test food was calculated by expressing the incremental area under the blood glucose response curve(IAUC)value for the test food as a percentage of each subject's average IAUC value for the glucose.The GL value of each test food was calculated as the GI value of the food multiplied by the amount of the available carbohydrate in a usual portion size,divided by 100.RESULTS:Among all the 23 Chinese traditional foods tested,6 of them belonged to low GI foods(Tuna Fish Bun,Egg Tart,Green Bean Dessert,Chinese Herbal Jelly,Fried Rice Vermicelli in Singapore-style,and Spring Roll),10 of them belonged to moderate GI foods(Baked Barbecued Pork Puff,Fried Fritter,"Mai-Lai"Cake,"Pineapple"Bun,Fried Rice Noodles with Sliced Beef,Barbecue Pork Bun,Moon Cakes,Glutinous Rice Ball,Instant Sweet Milky Bun,and Salted Meat Rice Dumpling),the others belonged to high GI foods(Fried Rice in Yangzhou-Style,Sticky Rice Wrapped in Lotus Leaf,Steamed Glutinous Rice Roll,Jam and Peanut Butter Toast,Plain Steamed Vermicelli Roll,Red Bean Dessert,and Frozen Sweet Milky Bun).CONCLUSION:The GI and GL values for these Chinese traditional foods will provide some valuable information to both researchers and public on their food preference.

Inverted U-Shaped Associations between Glycemic Indices and Serum Uric Acid Levels in the General Chinese Population:Findings from the China Cardiometabolic Disease and Cancer Cohort(4C)Study

Objective The relationship between serum uric acid(SUA)levels and glycemic indices,including plasma glucose(FPG),2-hour postload glucose(2 h-PG),and glycated hemoglobin(HbA1 c),remains inconclusive.We aimed to explore the associations between glycemic indices and SUA levels in the general Chinese population.Methods The current study was a cross-sectional analysis using the first follow-up survey data from The China Cardiometabolic Disease and Cancer Cohort Study.A total of 105,922 community-dwelling adults aged≥40 years underwent the oral glucose tolerance test and uric acid assessment.The nonlinear relationships between glycemic indices and SUA levels were explored using generalized additive models.Results A total of 30,941 men and 62,361 women were eligible for the current analysis.Generalized additive models verified the inverted U-shaped association between glycemic indices and SUA levels,but with different inflection points in men and women.The thresholds for FPG,2 h-PG,and HbA1 c for men and women were 6.5/8.0 mmol/L,11.0/14.0 mmol/L,and 6.1/6.5,respectively(SUA levels increased with increasing glycemic indices before the inflection points and then eventually decreased with further increases in the glycemic indices).Conclusion An inverted U-shaped association was observed between major glycemic indices and uric acid levels in both sexes,while the inflection points were reached earlier in men than in women.

Effect of Incorporation of Yam Flour and Moringa Powder in Wheat Bread on Glycemic Response

This study aimed to investigate the effect of yam flour substitution (Dioscorea alata L.) and moringa powder in wheat bread on glycemic response. Glycemic index (GI) and glycemic load (GL) of pieces of bread were determined. A mixture plan design was used to determine the optimal formulation of bread made of yam flour, wheat flour and moringa powder. The mixture of 79.4% soft wheat flour, 20% yam flour and 0.6% moringa leaves powder has a good potential in bread preparation and was used in this study. 100% wheat bread was used as control. Postprandial blood glucose response (glycemic response) was evaluated with the glucose used as a reference food. Blood glucose responses were measured at different intervals for 2 hours. The results indicated that composite bread had low GI and GL values than wheat bread. Values are GI = 80 and GL = 61.2 for wheat bread and GI = 37.78 and GL = 29.65 for the composite bread. This study demonstrated that the inclusion of yam flour of moringa leaves powder in bread production might not pose a threat to blood glucose response compared to wheat bread. These pieces of bread could be included easily in diabetics’ and non-diabetics diet.

Glycemic responses to glycemia-targeted specialized-nutrition beverages with varying carbohydrates compared to a standard nutritional beverage in adults with type 2 diabetes

Background: Postprandial plasma glucose concentration is an important diabetes management target. Glycemia-targeted specialized-nutrition (GTSN) beverages, containing various quantities and types of carbohydrates (CHO), have been formulated to blunt postprandial hyperglycemia. The objective of this research was to evaluate the effectiveness of these products on postprandial glycemic and hormonal responses based on comparisons of GTSN with differing carbohydrate quantities or types. Methods: In two randomized, double-blind, crossover studies, participants (mean age 61 years) with type 2 diabetes consumed GTSN in a meal tolerance test. In the CHO Quantity Study, a standard nutritional beverage (STD) was compared to a low carbohydrate nutritional beverage with tapioca dextrin (GTSN-TDX) and a balanced carbohydrate nutritional beverage containing a blend of the slowly-digesting carbohydrates maltodextrin and sucromalt (GTSN-SDC). In the CHO Type Study, the GTSN beverages had similar carbohydrate quantities but varied in carbohydrate composition with GTSN-SDC compared to a formula with tapioca starch and fructose (GTSN-TS&F), and one with isomaltulose and resistant starch (GTSN-I&RS). Postprandial (0-240 min) concentrations of blood glucose, insulin (CHO Quantity Study only) and glucagon-like-peptide (GLP)-1 (CHO Quantity Study only) were measured. Results: Despite having substantially different carbohydrate quantities, the GTSN blunted the glucose positive area under the curve (AUC0-240 min) by 65% to 82% compared to the STD formulation (p < 0.001). GTSN also elicited ~50% lower insulin positive AUC0-240 min (p < 0.05), while postprandial GLP-1 responses were increased (p = 0.018) vs. STD. In the CHO Type Study, glucose positive AUC0-240 min tended to be lower for GTSN-SDC (1477 ± 460) than GTSN-TS&F (2203 ± 412;p = 0.062) and GTSN-I&RS (2190 ± 412;p = 0.076). No differences were observed between GTSN-TS&F and GTSN-I&RS. Conclusions: These results demonstrate the effectiveness of several GTSN products and suggest that both CHO quantity and type play important roles in postprandial glycemic response in men and women with type 2 diabetes. Furthermore, GTSN products containing slow-digesting carbohydrates can blunt postmeal glucose and insulin concentration despite delivering greater total grams of CHO, which provides a dietary benefit for people with diabetes.

Glycemic Index and Glycemic Load of Selected Staples Based on Rice,Yam and Cassava Commonly Consumed in Cote d’Ivoire

Integrating information on the glycemic index (GI) and the glycemic load (GL) of diet is limited in C?te d’Ivoire because of the lack of data. Thus, this study was undertaking for the local management and prevention of diabetes mellitus and its complications based on nutritional data (GI and GL values). The study included ten healthy subjects with 7 males, 3 females (28 ± 2 years on average age and 20.5 ± 1.7 on average BMI). Participants tested three different meals with equal carbohydrate load (50 g). Blood samples were obtained at 0, 15, 30, 45, 60, 90 and 120 min before and after consumption for glucose levels determination. GIs were determined using a standard method with glucose as reference food and data were used for GLs calculating. Data showed that GIs value of pounded yam with eggplant sauce and cassava paste with granulates palm nut sauce were high ranging to 94 to 86 respectively while rice with groundnut sauce, have a low GI (GI = 45). Nevertheless, the GLs of the all the test foods are high with the values of 47, 43 and 23 (g) for pounded yam with eggplant sauce, cassava paste with granulates palm nut sauce and rice with groundnut sauce respectively. According to GIs and GLs data, the three test foods must be consumed moderately in a diet. So, it is important to associate GL data to GI data of Ivorian traditional foods for the management and the prevention of diabetes mellitus in C?te d’Ivoire and in others countries sharing the same food tradition.

Glycemic Index, Glycemic Load, and Glycemic Response to Pomelo in Patients with Type 2 Diabetes

Food intake has a great influence on blood glucose in patients with diabetes. This study was to determine the glycemic index（GI） and glycemic load（GL） of a particular pomelo named Majia pomelo and its effects on postprandial glucose（PPG） in patients with type 2 diabetes（T2D）. Twenty healthy subjects and 20 T2D patients（controlled on lifestyle measures and/or metformin） were tested on 2 separate days with 50 g of glucose and 50 g equivalent of carbohydrates from Majia pomelo for GI measurement. To test effects of Majia pomelo on PPG, 19 hospitalized T2D patients（controlled on insulin therapy） were selected for a 9-day study. The dose of insulin for each patient was adjusted on the first 3 days. A total of 100 g Majia pomelo was consumed per meal in the last 3 tested days. Blood glucose was measured to evaluate the glycemic excursions. The GIs for Majia pomelo in healthy individuals and T2D patients were 78.34±1.88 and 72.15±1.95 respectively. The value of GL was as low as 4.23 in diabetic patients with serving size of 100 g pomelo, indicting Majia pomelo as a high GI but low GL fruit. Consumption of Majia pomelo in hospitalized T2D patients did not cause significant glucose fluctuation. It was concluded that high GI pomelo can serve as a low GL fruit if it is consumed with a limited daily amount and thus can be supplied to diabetic patients. These results may mean more varieties of food choices for T2D patients.

The Effect of Potato Varieties and Processing Methods on Glycemic Response

In order to identify those potatoes which exert a low glycemic impact after processing, eight early potato varieties and four processing methods were evaluated for their total starch content, amylose content, rapidly digestible starch (RDS), slowly digestible starch (SDS), and resistant starch (RS), estimated glycemic index (eGI), glycemic load (eGL) as well as their relationship among each other. While all these profiles were highly dependent on the potato variety and processing methods, all the eight varieties were classified as low GL foods (p ≤ 0.05). A strong positive correlation was observed between eGI and RDS (r = 0.84, 0.79, and 0.74) for retrograded and reheated, baked and microwaved varieties, respectively), whereas a moderate negative correlation was observed between eGI and RS for retrograded and reheated (r = -0.39) and microwaved (-0.37) varieties (p ≤ 0.05). On the basis of these findings, it can be concluded that potato variety, processing methods, and starch characteristics define the eGI and eGL. Furthermore, for the varieties examined, the present study identified RDS as a major starch factor contributing to eGI.

Glycemic Index and Glycemic Load of Juice from Edible Wild Fruits (Adansonia digitata, Tamarindus indica and Parkia biglobosa) Consumed in Cote d’Ivoire

The diabetes mellitus is a public health problem in C?te d’Ivoire. The Glycemic index (GI) and the Glycemic load (GL) determination of commonly consumed foods such as juice fruits is an alternative to prevent metabolic diseases. This study carried out three wild fruits locally named Baobab (Adansonia digitata), Tomi (Tamarindus indica) and Néré (Parkia biglobosa) collected at maturity stage. The juices from the pulp of fruits have been elaborated, pasteurized, submitted to microbiological and physicochemical analysis before GIs/GLs determination. Ten healthy subjects with body mass index and age average respectively 21.57 ± 1.06 and 28 ± 2 years old tested the three juices and glucose (50 g) as reference food. Blood samples have been collected at 0, 15, 30, 45, 60, 90 and 120 min after foods consumption. The GIs/GLs has been determined according to ISO/FDI 26642:2010 protocol. Data showed that pasteurized juices has a weak microbiologic load (1.0102 - 2.4102 of Mesophylls Aerobic Germs) and not contain pathogen germs. The GI and GL of Néré juice are high with respective values of 89.54 ± 1.63 and 29.22 ± 4.09 whereas those of Baobab and Tomi juice are moderate with respective GI/GL values of 66.48 ± 2.12/13.24 ± 1.99 and 60.41 ± 2.63/12.87 ± 1.67. The juice of Néré should be consumed occasionally when those of Baobab and Tomi should be consumed with moderation. It would be suitable to know more about the GI and GL of all the juice fruits produced locally so as to prevent efficiently diabetes mellitus in the country.

Rice and Bean:Glycemic Index and Glycemic Load of the“Baiao de Dois”

The “bai?o de dois” is a typical Brazilian dish and a rich combination of rice and beans. This preparation has a high nutritional value but its effect on glycemic response is not yet studied. To determine the glycemic index and glycemic load of foods can help prescribing diets and as a result, improving the treatment and prevention of chronic diseases. This study aimed to access the glycemic index (GI) and glycemic load (GL) of “bai?o de dois”. Following the protocol recommended by the Food and Agriculture Organization, 6 volunteers were recruited to perform blood glucose tests. Each volunteer performed three glucose tolerance tests and a test with “bai?o de dois”. All tests were undertaken in separate weeks. Through the calculation of the areas under each of the curves, it was possible to access the GI of “bai?o de dois” by the average values of six GIs found for each volunteer. It was calculated that the GL of each portion tested and recommended servings per capita. It was found that “bai?o de dois” had low GI (44) and GL (6) at the recommended per capita, but high GL (22) at the portion tested (bigger than the recommended). The “bai?o de dois” do not present a potential risk for developing chronic diseases, but it is recommended consumption to be monitored.

Glycemic index,glycemic load and insulinemic index of Chinese starchy foods

AIM:To determine the glycemic index(GI),glycemic load(GL)and insulinemic index(Ⅱ)of five starchy foods that are commonly used in Chinese diets.METHODS:Ten healthy subjects aged between 20-30 years were recruited.Each subject was asked to consume 50 g of available carbohydrate portions of test foods and reference food.Finger capillary blood samples were collected at the start of eating and 15,30,45,60,90 and 120 min after consumption.The GI and Ⅱ of foods were calculated from the ratio of incremental area under the glucose/insulin response curves of test and reference foods.The GL for each test food was determined from its GI value and carbohydrate content.RESULTS:The results showed that brown rice elicited the highest postprandial glucose and insulin responses,followed by taro,adlay,yam and mung bean noodles,which produced the lowest.Among the five starchy foods,brown rice evoked the highest GI and GL at 82±0.2 and 18±0.2,followed by taro(69±0.4,12±0.2),adlay(55±0.4,10±0.2),yam(52±0.3,9±0.0)and mung bean noodles(28±0.5,7±0.2),respectively.The Ⅱ values of the test foods corresponded with GI values.Similarly,brown rice gave the highest Ⅱ at 81±0.1,followed by taro(73±0.3),adlay(67±0.3),yam(64±0.5) and mung bean noodles(38±0.3).All five starchy foods had lower GI,GL and Ⅱ than reference bread(P<0.05).CONCLUSION:The GI,GL and Ⅱ values of starchy foods provide important information for the public to manage their diet and could be useful for the prevention of lifestyle-related diseases such as diabetes mellitus.

Birth defects in pregestational diabetes:Defect range,glycemic threshold and pathogenesis

Currently,60 million women of reproductive age(18-44 years old) worldwide,and approximately 3 million American women have diabetes mellitus,and it has been estimated that this number will double by 2030.Pregestational diabetes mellitus(PGD) is a significant public health problem that increases the risk for structural birth defects affecting both maternal and neonatal pregnancy outcome.The most common types of human structural birth defects associated with PGD are congenital heart defects and central nervous system defects.However,diabetes can induce birth defects in any other fetal organ.In general,the rate of birth defects increases linearly with the degree of maternal hyperglycemia,which is the major factor that mediates teratogenicity of PGD.Stringent prenatal care and glycemic control are effective means to reduce birth defects in PGD pregnancies,but cannot reduce the incidence of birth defects to the rate of that is seen in the nondiabetic population.Studies in animal models have revealed that PGD induces oxidative stress,which activates cellular stress signalling leading to dysregulation of gene expression and excess apoptosis in the target organs,including the neural tube and embryonic heart.Activation of the apoptosis signalregulating kinase 1(ASK1)-forkhead transcription factor 3a(Fox O3a)-caspase 8 pathway causes apoptosis in the developing neural tube leading to neural tube defects(NTDs).ASK1 activates the c-Jun-N-Terminal kinase 1/2(JNK1/2),which leads to activation of the unfolded protein response and endoplasmic reticulum(ER) stress.Deletion of the ASK1 gene,the JNK1 gene,or the JNK2 gene,or inhibition of ER stress by 4-Phenylbutyric acid abrogates diabetes-induced apoptosis and reduces the formation of NTDs.Antioxidants,such as thioredoxin,which inhibits the ASK1-Fox O3a-caspase 8 pathway or ER stress inhibitors,may prevent PGD-induced birth defects.

Relationship between perioperative glycemic control and postoperative infections

Perioperative hyperglycemia in critically ill surgery patients increases the risk of postoperative infection (POI), which is a common, and often costly, surgical complication. Hyperglycemia is associated with abnormalities in leukocyte function, including granulocyte adherence, impaired phagocytosis, delayed chemotaxis, and depressed bactericidal capacity. These leukocyte deficiencies are the cause ofinfection and improve with tight glycemic control, which leads to fewer POIs in critically ill surgical patients. Tight glycemic control, such as intensive insulin therapy, has a risk of hypoglycemia. In addition, the optimal targeted blood glucose range to reduce POI remains unknown. Since 2006, we have investigated tight perioperative blood glucose control using a closed-loop artificial endocrine pancreas system, to reduce POI and to avoid hypoglycemia. In this Topic Highlight, we review the relationship between perioperative glycemic control and POI, including the use of the artificial pancreas.

Impact of postoperative glycemic control and nutritional status on clinical outcomes after total pancreatectomy

AIM To evaluate the impact of glycemic control and nutritional status after total pancreatectomy(TP) on complications, tumor recurrence and overall survival.METHODS Retrospective records of 52 patients with pancreatic tumors who underwent TP were collected from 2007 to 2015. A series of clinical parameters collected before and after surgery, and during the follow-up were evaluated. The associations of glycemic control and nutritional status with complications, tumor recurrence and long-term survival were determined. Risk factors for postoperative glycemic control and nutritional status were identified.RESULTS High early postoperative fasting blood glucose(FBG) levels(OR = 4.074, 95%CI: 1.188-13.965, P = 0.025) and low early postoperative prealbumin levels(OR = 3.816, 95%CI: 1.110-13.122, P = 0.034) were significantly associated with complications after TP. Postoperative Hb A1 c levels over 7%(HR = 2.655, 95%CI: 1.299-5.425, P = 0.007) were identified as one of the independent risk factors for tumor recurrence. Patients with postoperative Hb A1 c levels over 7% had much poorer overall survival than those with Hb A1 c levels less than 7%(9.3 mo vs 27.6 mo, HR = 3.212, 95%CI: 1.147-8.999, P = 0.026). Patients with long-term diabetes mellitus(HR = 15.019, 95%CI: 1.278-176.211, P= 0.031) and alcohol history(B = 1.985, SE = 0.860, P = 0.025) tended to have poor glycemic control and lower body mass index levels after TP, respectively.CONCLUSION At least 3 mo are required after TP to adapt to diabetes and recover nutritional status. Glycemic control appears to have more influence over nutritional status on longterm outcomes after TP. Improvement in glycemic control and nutritional status after TP is important to prevent early complications and tumor recurrence, and improve survival.

Indicators of glycemic control in patients with gestational diabetes mellitus and pregnant women with diabetes mellitus

Recently, it has become clear that mild abnormal glucose tolerance increases the incidence of perinatal maternalinfant complications, and so the definition and diagnostic criteria of gestational diabetes mellitus(GDM) have been changed. Therefore, in patients with GDM and pregnant women with diabetes mellitus, even stricter glycemic control than before is required to reduce the incidence of perinatal maternal-infant complications. Strict glycemic control cannot be attained without an indicator of glycemic control; this review proposes a reliable indicator. The gold standard indicator of glycemic control in patients with diabetes mellitus is hemoglobin A1c(Hb A1c); however, we have demonstrated that Hb A1 c does not reflect glycemic control accurately during pregnancy because of iron deficiency. It has also become clear that glycated albumin, another indicator of glycemic control, is not influenced by iron deficiency and therefore might be a better indicator of glycemic control in patients with GDM and pregnant women with diabetes mellitus. However, largepopulation epidemiological studies are necessary in order to confirm our proposal. Here, we outline the most recent findings about the indicators of glycemic control during pregnancy including fructosamine and 1,5-anhydroglucitol.