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A severe earthquake/hurricane has caused devastation to a wide area. Nearly all local infrastructure was damaged, and it will take time to restore function. Several patients arrive days into the deployment to the area. At your medical tent, a pair of patients arrive with complaints of hyperglycemia due to not being able to take their medication and use their insulin, as well as not being able to contact their primary care doctor. One patient is mildly hyperglycemic and can be treated and released. The other patient has developed DKA and must be managed. The patient with DKA is treated with insulin and transferred to a local hospital for ongoing care.
The rapidly growing burden of non-communicable diseases (NCDs) in sub-Saharan Africa necessitates a better understanding of access gaps along the care continuum. This study assessed the prevalence and inequality in unmet need for hypertension and diabetes care in Tanzania, South Africa, and Lesotho using a care cascade framework.
Methods:
We conducted a cross-sectional analysis of nationally representative Demographic Health Survey (DHS) datasets from Tanzania (2022), South Africa (2016), and Lesotho (2023/24), focusing on adults aged 15 years and older. The study estimated the proportion of adults with hypertension or diabetes who had not been screened, diagnosed, treated, or achieved disease control. Inequality was assessed using Erreygers Normalized Concentration Indices (ENCI), stratified by sex and residence.
Results:
Hypertension prevalence was 12.6% (95% CI: 11.7–13.4) in Tanzania, 46.7% (95% CI: 45.0–48.4) in South Africa, and 15.4% (95% CI: 13.8–17.2) in Lesotho. In Lesotho, 9.1% (95% CI: 7.8–10.6) of adults had diabetes. Unmet need was substantial across all countries: 96.5% for hypertension in Tanzania, 84.2% in South Africa, 65.8% in Lesotho, and 84.2% for diabetes in Lesotho. The care cascade framework revealed critical bottle-necks at screening and treatment stages. Inequality analyses revealed strong pro-poor gradients, particularly in screening (ENCIs: Tanzania −0.19, South Africa −0.17, Lesotho hypertension −0.15, Lesotho diabetes −0.24; all p < 0.01), with poor men experiencing the most disparities.
Conclusion:
Substantial and inequitable gaps exist in hypertension and diabetes care. Policy strategies should prioritize community-based screening, primary care integration, and equity-focused interventions targeting poor men to improve NCD outcomes in the region.
Medical care treatments can cause harm or even death. Healthcare workers assess vital signs of individuals to gauge their health. Medical care treats cells and organs while ignoring the plight of that person. Improvements in sanitation and standard of living over the last century are responsible for having longer lives. Economic growth leads to longer lives, but after a plateau of around $10,000 per person, more growth does not lead to better health. The US is an outlier with a high GDP but considerably lower health measures than many other countries. Recently, when comparing Americans with their counterparts in other rich nations, Americans demonstrate worse disease outcomes, no matter their skin color or wealth. US life expectancy declines result in almost 800 excess deaths per day here that aren’t present in comparable countries. US well-being and happiness similarly rank behind those of many other nations, despite the happiness industry telling Americans that they can make themselves happy
Greater consumption of red meat has been linked to a higher risk of mortality and chronic diseases, including diabetes. We aim to examine the associations between total, processed, and unprocessed red meat intake and diabetes, and to evaluate the substitution effects of other protein sources for red meat on diabetes. This population-based cross-sectional study utilized data from the National Health and Nutrition Examination Survey (NHANES) 2003-2016. Diabetes was defined as being diagnosed by a physician or other health professional, having a fasting plasma glucose of 126 mg/dL or higher, an HbA1c level of 6.5% or higher, or the use of antidiabetic drugs. Multivariable logistic regression models were conducted. The study included 34,737 adult participants (mean (SD) age of 45.8 (17.5) years) from NHANES 2003-2016. After adjusting for major confounders, compared to the first quintile, higher intakes of total, processed, and unprocessed red meat were positively associated with higher odds of diabetes, with adjusted odds ratios of 1.49 (95% CI, 1.22-1.81), 1.47 (95% CI, 1.17-1.84), and 1.24 (95% CI, 1.06-1.44), respectively (P- trend for all < 0. 001). In this nationally representative sample of U.S. adults, participants in the highest quintiles of total, processed, and unprocessed red meat intake had higher odds of diabetes than those in the lowest quintile. Substituting 1 serving/day of dietary protein from foods of plant origin (including nuts, seeds, legumes, and soy) for total, processed, or unprocessed red meat was associated with 9% to 14% lower odds of diabetes.
Eating duration and shift work can both influence metabolic regulation, but their joint associations with diabetes are unknown. We aimed to examine the independent and joint associations of eating duration and shift work with diabetes in a cross-sectional study using a nationally representative sample of US workers. We included 14852 eligible participants from the National Health and Nutrition Examination Survey, 2005–2010 and 2017–2020. Eating duration was calculated based on first and last eating occasions from 24-h dietary recalls. Long eating duration (LED: ≥ 13 h) v. short eating duration (SED: < 13 h) was defined based on the median. Workers were classified as engaging in shift work (SW, n 5140) v. non-shift work (NSW, n 8945) based on self-report. Logistic regressions were used to examine the associations of LED and SW with diabetes, independently and jointly with stratification by age. LED was associated with higher odds of diabetes among workers aged < 45 years (OR, 1·51; 95 % CI, 1·05–2·19) but not among workers aged ≥ 45 years (OR, 0·98; 95 % CI, 0·79–1·20). SW was associated with higher odds of diabetes among both younger (OR, 1·28; 95 % CI, 0·88–1·85) and older workers (OR, 1·28; 95 % CI, 1·04–1·58). There was suggestive evidence that workers with both LED and SW had higher odds of diabetes compared with those with SED and NSW, but the association was stronger among younger (OR, 1·40; 95 % CI, 0·85–2·28) than older workers (OR, 1·28; 95 % CI, 0·99–1·66). LED and SW were independently associated with increased odds of diabetes with suggestive evidence on their joint associations, but associations varied by workers’ age.
White potatoes are a major contributor to energy and nutrient intake in the USA, which supports investigating their relationship with cardiometabolic health. This cross-sectional analysis assessed relationships of total white potato intake and dietary patterns containing white potatoes prepared by various methods with markers of cardiometabolic health in adults categorised by diabetes status. The dietary intake assessment component of the National Health and Nutrition Examination Survey (2001–2018), What We Eat in America (WWEIA), was linked with the Food and Nutrient Database for Dietary Studies and Food Patterns Equivalents Database to rank the consumption of white potato-containing foods. Dietary patterns were determined by percent calories from white potatoes and main food groups in WWEIA using cluster analysis. Regression analysis assessed trends in individuals with (n 5467) and without (n 38 159) diagnosed diabetes. P < 0·01 was significant. The most consumed white potato-containing foods were French fries, potato chips and home fries. In adults without diagnosed diabetes, total white potato intake was positively associated with glucose, insulin, Homeostatic Model Assessment for Insulin Resistance and waist circumference. Glycated Hb was lower in those who primarily consumed dietary patterns with baked/boiled potatoes, and waist circumference was higher in those who primarily consumed dietary patterns with chips, fried potatoes or mashed potatoes compared with adults with no white potato intake. In adults without diagnosed diabetes, total white potato intake was associated with greater cardiometabolic risk, which may be due, in part, to frying as the predominate preparation method of white potatoes in the USA.
The aim of this study was to explore the acceptability of an educational video among primary care clinicians as a tool to promote the use of stigma-free language in interactions with individuals with type 2 diabetes (T2D).
Background:
The language used by primary care clinicians in interactions with adults living with T2D can contribute to perceptions and experiences of diabetes-related stigma and be a barrier to achieving and sustaining glycaemic targets. In 2017, the American Diabetes Association (ADA) and the Association for Diabetes Care & Education Specialists (ADCES) issued a guidance paper with recommendations to promote stigma-free communication about diabetes.
Methods:
The educational video, developed by the research team, presents two versions of a vignette in which a nurse practitioner interacts with an adult with T2D in a primary care setting. The first version of the vignette features the nurse practitioner using stigmatizing language as outlined in the ADA and ADCES guidance paper; the second demonstrates the use of stigma-free language by the nurse practitioner. A narrator highlights the linguistic differences. The study participants, comprising physicians (n = 8), nurse practitioners (n = 9), and physician assistants (n = 1), were recruited through professional networks and via online forums and listservs for healthcare professionals. Participants viewed the educational video and were interviewed via Zoom by a research team member using a semi-structured interview guide. The transcripts of the interviews were analysed using a qualitative descriptive approach.
Findings:
Three main themes emerged from the data: aligning video content with existing attitudes and beliefs, reducing the use of stigmatizing language, and increasing the use of stigma-free language. Findings suggest that an educational video promoting the use of stigma-free language in interactions with adults with T2D is acceptable among primary care clinicians.
Alpha-ketoglutarate (AKG) is a well-known intermediate of the tricarboxylic acid cycle and plays an important role in the catabolism of branched-chain amino acids (BCAAs: leucine, isoleucine, and valine). While previous study suggested that AKG enhances glucose metabolism, its effect on the adaptation of muscles and adipocytes has not been well studied in diabetic condition. This study aimed to determine whether AKG improves glucose metabolism in the skeletal muscles and adipose tissues in diabetic mice. Male institute of cancer research mice were divided into control, diabetic, and diabetic + AKG groups. Diabetes (DM) was induced by a high fat diet consumption and streptozotocin (STZ) injection. Mice in the DM + AKG group were administered 1% AKG in drinking water for 6 weeks. The non-fasting plasma glucose level was significantly higher in the diabetic group than that in the control and DM + AKG groups (P < 0.05). No significant difference was observed in glucose transporter 4 (GLUT4) protein levels in the muscles between the DM and DM + AKG groups. AKG supplementation attenuated the decrease in peroxisome proliferator-activated receptor γ coactivator 1 alpha and GLUT4 protein levels in inguinal and epididymal adipose tissues in diabetic condition. In conclusion, the study findings suggested that AKG supplementation increased protein levels related to mitochondrial biogenesis and glucose transporters in adipocyte tissue accompanied with improved whole-body glucose metabolism in STZ and high-fat diet-induced diabetic mice.
Evidence regarding the association between dietary choline intake and mortality in individuals with diabetes remains limited. This study aimed to evaluate the relationship between dietary choline intake and all-cause, CVD and cancer-related mortality among adults with diabetes. A total of 4712 participants with diabetes were included from the National Health and Nutrition Examination Survey 2007–2018 cycles. Dietary choline intake was estimated using two 24-h dietary recalls, and mortality outcomes were ascertained via linkage to National Death Index records through 31 December 2019. Cox proportional hazards models and Kaplan-Meier analyses were employed to assess the associations between choline intake and mortality. Restricted cubic spline models were used to examine potential non-linear relationships, and threshold analyses were conducted to identify inflection points. Over a median follow-up of 6·42 years, 805 deaths were documented, including 267 from CVD and 126 from cancer. A U-shaped association was observed between dietary choline intake and all-cause mortality (Pfor non-linearity < 0·0001). Compared with the lowest quartile, multivariable-adjusted hazard ratios for all-cause mortality were 0·64 (95 % CI 0·47, 0·88) for the second quartile, 0·59 (0·43, 0·82) for the third and 0·69 (0·43, 1·09) for the highest quartile. No significant associations were found between choline intake and either CVD or cancer mortality. These findings indicate a U-shaped relationship between dietary choline intake and all-cause mortality in individuals with diabetes, with intakes between 286·77 and 538·86 mg/d associated with the lowest risk – providing potential implications for dietary guidance in diabetes management.
Labour and delivery are associated with changes in maternal physiology which can impact on women with medical disorders and need to be taken into consideration when managing medications, considering mode of birth and the use of analgesia. There are relatively few conditions where caesarean section is recommended for medical indications and most women with medical problems can deliver vaginally safely at full term. Some conditions may deteriorate around delivery, such as sickle cell disease, diabetes, epilepsy, critical heart disease and restrictive lung disease requiring specific management. Others, such as asthma and arrhythmias, are not affected by delivery. Women on anticoagulation pose specific risks of haemorrhage at delivery, versus thrombosis from halting anticoagulation. Clear management plans for delivery, postnatal care and contraception should be made and agreed by both the multidisciplinary team and the woman in advance of delivery. Several medical conditions requiring multidisciplinary management plans are discussed in this chapter.
Tamil immigrants in Canada face high rates of Type II Diabetes Mellitus (T2DM) and significant barriers in accessing T2DM-related services. These barriers are often amplified for older adults, whose age-related needs intersect with cultural, linguistic, and socioeconomic factors. This study explored the lived experiences of Tamil older adults accessing T2DM-related health care services in the Greater Toronto Area. A qualitative interpretive description approach was used, involving in-depth semi-structured interviews with nine Tamil older adults. Participants were recruited through purposive and snowball sampling. Thematic analysis was applied, with findings organized using Levesque et al.’s framework (2013). Five key themes were identified: (1) timely and informed diabetes management, (2) reliance on trusted health service providers, (3) reliance on others for transportation, (4) financial factors, and (5) navigating health care through cultural and communication factors. Identified themes can inform potential solutions to improve access including centralized resource hubs, culturally tailored education programs, affordable transportation options, and an integrated health care approach.
Type 2 diabetes (T2D) incidence has been steadily increasing over the past few decades. Several studies have evaluated the effect of plant-based, vegetarian or vegan diets on the risk of T2D, although their potential benefits need to be confirmed and characterised. We performed a literature search up to 10 July 2025, using the terms/keywords related to plant-based index (PDI), vegetarian/vegan diets and T2D. We included observational non-experimental studies evaluating adherence to such diets in adult subjects assessing T2D risk. We specifically considered overall PDI and related healthy PDI (hPDI) and unhealthy PDI (uPDI), assessing intake of different food groups. We included 36 studies published between 1999 and 2025. We found an inverse association between adherence to vegetarian/plant-based dietary patterns and T2D risk. This association was stronger, though statistically imprecise, for the vegan diet (RR = 0·65, 95 % CI 0·42, 1·00) and for lacto-ovo-vegetarian diet (RR = 0·68, 0·57, 0·82). For studies using plant-based indices, the RR were 0·82 (0·69, 0·82), 0·76 (0·69, 0·82) and 1·13 (0·98, 1·30) for overall PDI, hPDI and uPDI, respectively. In the dose–response meta-analysis, overall PDI and hPDI showed an inverse and almost linear association with T2D risk. Conversely, adherence to uPDI directly correlated with T2D risk. Overall, adherence to vegan/vegetarian diets may reduce T2D risk, while an unhealthy plant-based diet appears to linearly increase disease risk, indicating caution in the consumption of such unhealthy foods even if of plant origin. The beneficial association between vegetarian and healthy plant-based diets may have major public health implications.
This research aimed to explore the perspectives of primary and community care providers on the challenges that hinder the delivery and uptake of personalized type 2 diabetes (T2D) care, with a focus on the integration of mental health support and care.
Background:
The day-to-day burden and demand of self-managing T2D can negatively impact quality of life and take a toll on mental health and psychological well-being. As a result, there is a need for personalized T2D self-management education and support that integrates mental health care. Despite the need for this personalized care, existing systems remain siloed, hindering access and uptake. In response, innovative, comprehensive, and collaborative models of care have been developed to address fragmentations in care. As individuals living with T2D often receive their care in primary care settings, linking mental health care to existing teams and networks in primary care settings is required. However, there is a need to understand how best to support access, adoption, and engagement with these models in these unique contexts.
Methods:
A cross-sectional survey was distributed to primary and community providers of an Ontario-based smoking cessation network. Survey data were analyzed descriptively with free text responses thematically reported.
Findings:
Survey respondents (n = 85) represented a broad mix of health professions across primary and community care settings. Addressing challenges to the delivery and uptake of personalized T2D care requires comprehensive strategies to address patient-, practice-, and system-level challenges. Findings from this survey identify the need to tailor these models of care to individual needs, clearly addressing mental health needs, and building strong partnership as means of enhancing accessibility and sustainability of integrated care delivery in primary care settings.
Immune dysregulation contributes to the pathophysiology of depression and is a potential link between depression and comorbid medical conditions. DNA methylation is a dynamic transcriptional regulator of the immune system.
Aims
To study changes in DNA methylation of disease- and comorbidity-associated immune genes in patients with and without depression diagnoses from the German BiDirect Study.
Method
We performed a cross-sectional (baseline, y0) and longitudinal (consecutive assessments at 3-year intervals, y0, y3, y6) differential methylation analyses of 382 immune-related genes associated with depression, obesity, diabetes and/or gout in 276 patients with depression and in 207 individuals without a lifetime depression diagnosis from the BiDirect Study. In addition, we applied unsupervised clustering to identify subgroups of individuals with depression based on longitudinal methylation patterns.
Results
There were no significant methylation changes between individuals with depression and controls at baseline. Follow-up analyses used to assess the top (P < 0.05) 151 methylation probes longitudinally identified 42 CpG sites that showed time-dependent changes associated with depression, and defined 3 depression clusters with differential profiles of serum inflammation markers at baseline. The implicated genes corresponded in the majority to those associated with diabetes risk, and were enriched in processes relevant for haematopoiesis.
Conclusions
Our results suggest that immune dysregulation associated with DNA methylation profiles contributes to the pathophysiology of depression and is a plausible link to chronic medical conditions such as diabetes.
Impaired glycaemic control is a major risk factor for developing type 2 diabetes (T2D), a worldwide health epidemic intrinsically linked to diet and obesity. Whey proteins (WP) are increasingly popular supplements that are a rich source of branched-chain amino acids (BCAA), essential for muscle protein synthesis and metabolic regulation. In humans, fasting plasma concentrations of BCAA are maintained around 350 µM but become chronically elevated by 10–25% in persons with T2D. Little is known about whether BCAA from WP impacts circulating BCAA concentrations and contributes to this phenomenon. This narrative review used a systematic search approach with relevant keywords to identify evidence from randomised controlled trials in normoglycaemic humans and those with insulin resistance or T2D, on the effects of WP intake on plasma BCAA and glycaemic control. This review is, to the authors’ knowledge, the first to specifically examine the effects of WP intake on plasma BCAA concentrations in relation to glycaemic control. Whilst the majority of acute studies identified (n = 6) reported that WP consumption between 10 and 50 g significantly elevates postprandial BCAA and insulin responses (as evidenced by peak concentration and/or area under the curve), evidence from chronic studies (n = 3) report inconsistent findings on the impact of 9–51 g of WP/d on fasting BCAA and glycaemic control (for example, fasting glucose and insulin, insulin clearance). Findings from this literature review highlight the need for further studies that investigate the relationship between WP consumption with BCAA and glycaemic control, and to determine underlying mechanisms of action.
Edited by
Rebecca Leslie, Royal United Hospitals NHS Foundation Trust, Bath,Emily Johnson, Worcester Acute Hospitals NHS Trust, Worcester,Alex Goodwin, Royal United Hospitals NHS Foundation Trust, Bath,Samuel Nava, Severn Deanery, Bristol
Chapter 2.9 covers drugs acting on the gastro-intestinal tract that are relevant to anaesthesia. We include antiemetic drugs, with detail on the vomiting centre and the mechanisms of action of commonly used antiemetics. We then discuss gastric acid secretion and drugs used to control this. Finally we discuss drugs used in diabetes – oral hypoglycaemic agents. Here we include detail on the diagnosis of diabetes mellitus, commonly used drugs and the perioperative management of such drugs.
Hypoglycemic patients are often hospitalized for further management. Most of these patients can be successfully managed in an observation unit (OU). OU management includes determining the cause of the hypoglycemia, lab tests (basic metabolic panel and renal function, other tests as indicated), correction of the hypoglycemia, frequent monitoring of serum glucose, administration of medications including dextrose, glucagon, and occasionally octreotide, patient education, and at discharge adjustment of daily medications if needed.
Hyperglycemia ranges from new onset diabetes to nonketotic hyperglycemia (hyperosmolar hyperglycemic state [HHS]) and diabetic ketoacidosis (DKA). The treatment goals in selected patients with DKA and HHS can be achieved in the observation unit (OU) and include frequent monitoring, IV fluids and insulin to correct hypovolemia, hyperglycemia, hyperosmolality, electrolyte abnormalities and in the case of DKA, correct the metabolic acidosis. For new-onset diabetics, medications can be started and education can be provided. The OU provides an opportunity to address related lifestyle and health issues that affect patient outcomes in diabetes; including diet, exercise, weight loss, and smoking cessation. Patients with elevated lipids can be started on statin therapy and those with established cardiovascular risk factors begin a daily aspirin. An OU stay allows for expedited consultation with endocrinology in select patients with poorly controlled diabetes, which has shown to improve quality of care.
Parkinson’s disease (PD) is a severe neurodegenerative disorder characterized by prominent motor and non-motor (e.g., cognitive) abnormalities. Notwithstanding Food and Drug Administration (FDA)-approved treatments (e.g., L-dopa), most persons with PD do not adequately benefit from the FDA-approved treatments and treatment emergent adverse events are often reasons for discontinuation. To date, no current therapy for PD is disease modifying or curative. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are central nervous system (CNS) penetrant and have shown to be neuroprotective against oxidative stress, neuroinflammation, and insulin resistance, as well as promoting neuroplasticity. Preclinical evidence suggests that GLP-1RAs also attenuate the accumulation of α-synuclein. The cellular and molecular effects of GLP-1RAs provide a basis to hypothesize putative therapeutic benefit in individuals with PD. Extant preclinical and clinical trial evidence in PD provide preliminary evidence of clinically meaningful benefit in the cardinal features of PD. Herein, we synthesize extant preclinical and early-phase clinical evidence, suggesting that GLP-1RAs may be beneficial as a treatment and/or illness progression modification therapeutic in PD.