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USA: The American Diabetes Association (ADA) has released new screening and obesity management recommendations for diabetes patients. The updated Standards of Care in Diabetes—2024 is available online and is published as a supplement to the January 2024 issue of Diabetes Care.

The ADA’s Standards of Care for 2024 include new recommendations to screen for heart failure, type 1 diabetes risk, and peripheral arterial disease (PAD), along with new obesity management guidance. It also includes new recommendations related to bone health and liver disease. The Standards of Care are essentially the global guidelines for the care of individuals with diabetes and those at risk.

The ADA’s Professional Practice Committee developed the document via a scientific literature review. The panel comprised 21 professionals, including physicians from many specialities, certified diabetes care and education specialists, nurse practitioners, pharmacists, and dieticians.

This article will mainly focus on the ADA’s updates in obesity and weight management for the prevention and treatment of type 2 diabetes.

Obesity is a chronic, often relapsing disease with several physical, metabolic, and psychosocial complications, including a substantially increased type 2 diabetes risk. There is strong and consistent evidence that obesity management can delay the progression of prediabetes to type 2 diabetes (T2D) and is highly beneficial in T2D treatment.

The ADA aimed to provide evidence-based recommendations for obesity management, including pharmacologic, behavioural, and surgical intervention in people with, or at high risk of, type 2 diabetes.

Assessment and Monitoring of the Individuals with Overweight and Obesity

The use of person-centred, nonjudgmental language is recommended to foster collaboration between individuals and health care professionals, including person-first language.

To support the diagnosis of obesity, measure height and weight to calculate BMI and perform additional measurements of body fat distribution, like waist circumference, waist-to-hip ratio, and/or waist-to-height ratio.

At least annual monitoring of obesity-related anthropometric measurements is recommended to inform treatment considerations.

Accommodations should be made to provide privacy during anthropometric measurements.

In people with type 2 diabetes and overweight or obesity, weight management should represent a primary goal of treatment along with glycemic management.

People with diabetes and overweight or obese may benefit from any magnitude of weight loss. Weight loss of 3–7% of baseline weight improves glycemia and other intermediate cardiovascular risk factors.

Initial treatment approaches for obesity should be individualized.

Nutrition, Physical Activity, and Behavioral Therapy

Physical activity, nutrition, and behavioural therapy to achieve and maintain ≥5% weight loss are recommended for people with type 2 diabetes and overweight or obese.

Interventions including high frequency of counselling (≥16 sessions in 6 months) with a focus on nutrition changes, physical activity, and behavioural strategies to achieve a 500–750 kcal/day energy deficit be beneficial for weight loss and should be considered when available.

Structured programs delivering behavioural counselling (face-to-face or remote) to address barriers to access should be considered.

Nutrition recommendations should be individualized to the person’s preferences and nutritional needs.

When developing a plan of care, systemic, structural, and socioeconomic factors that may impact nutrition patterns and food choices should be considered, such as food access to healthful food options, insecurity and hunger, cultural circumstances, and other social determinants of health.

For those who achieve weight loss goals, long-term (≥1 year) weight maintenance programs are recommended, when available.

When short-term nutrition intervention using structured, very low-calorie meals (800–1,000 kcal/day) is considered.

Nutritional supplements are not effective for weight loss and are not recommended.

Pharmacotherapy

Whenever possible, minimizing medications for comorbid conditions that are associated with weight gain is recommended.

When choosing glucose-lowering medications for people with type 2 diabetes and overweight or obesity, prioritize medications with beneficial effects on weight.

Obesity pharmacotherapy should be considered for people with diabetes and overweight or obesity along with lifestyle changes. Potential benefits and risks must be considered.

In people with diabetes and overweight or obesity, the preferred pharmacotherapy should be a glucagon-like peptide 1 receptor agonist or dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide 1 receptor agonist with greater weight loss efficacy (i.e., semaglutide or tirzepatide), especially considering their added weight-independent benefits.

To prevent therapeutic inertia, for those not reaching goals, reevaluate weight management therapies and intensify treatment with additional approaches.

Metabolic Surgery

Metabolic surgery should be considered as a weight and glycemic management approach in people with diabetes with BMI ≥30.0 kg/m2 who are otherwise good surgical candidates.

Metabolic surgery should be performed in high-volume centres with interprofessional teams knowledgeable about and experienced in managing obesity, diabetes, and gastrointestinal surgery.

People who undergo metabolic surgery should receive long-term medical and behavioural support and routine micronutrient, nutritional, and metabolic status monitoring.

In people who undergo metabolic surgery, routinely screen for psychosocial and behavioural health changes and refer to a qualified behavioural health professional as needed.

To sum up, new updates in managing obesity in people with diabetes, include approaches to reduce therapeutic inertia, support more personalization, and incorporate additional obesity measurements beyond body mass index (i.e., waist circumference, waist-to-hip ratio, and/or waist-to-height ratio).

Reference:

American Diabetes Association Professional Practice Committee; 8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Care in Diabetes–2024. Diabetes Care 1 January 2024; 47 (Supplement_1): S145–S157. https://doi.org/10.2337/dc24-S008

China: Findings from a prospective cohort study have shown an association between serum glycated haemoglobin (HbA1c) levels at early gestation and the risk of subsequent pregnancy loss in pregnant women without diabetes mellitus.

USA: Warfarin use after bioprosthetic surgical aortic valve replacement (sAVR) was tied to lower all-cause mortality and decreased thromboembolism risk compared with not receiving warfarin, a recent retrospective study has revealed. The findings were published online in Mayo Clinic Proceedings. 

The use of bioprosthetic aortic valve replacement has increased significantly during the past decade. Among its advantages is that most patients can avoid warfarin for anticoagulation treatment. Even so, research has been conflicting on whether patients would benefit from more aggressive early postoperative anticoagulation treatment.

The researchers compared thromboembolic events and all-cause mortality in patients undergoing surgical aortic valve replacement receiving anticoagulation with warfarin versus patients with no systemic anticoagulation.

Mayo Clinic researchers analyzed nationwide data on more than 10,000 patients who underwent bioprosthetic aortic valve replacement. Warfarin use was associated with a 32% reduction in mortality risk. Patients treated with warfarin early postoperatively also had an increased risk of major bleeding events. 

“The findings support early warfarin use in appropriately selected patients, such as patients with low bleeding risk,” says Hartzell Schaff, M.D., a Mayo Clinic cardiovascular surgeon who contributed to the study. “There’s often reluctance to prescribe anticoagulant treatment early after surgery due to concerns about bleeding and uncertainty about benefits. Our research finds that the small increased hazard of bleeding (4% versus 2.3%) may be an acceptable risk given the benefits in terms of mortality risk as well as reduced risk of thromboembolism.”

The Mayo Clinic study analyzed deidentified patient data from 2007 to 2019 using OptumLabs Data Warehouse, which contains claims data of commercially insured and Medicare Advantage enrollees of all ages and races throughout the U.S.

Reference:

Huang Y, Schaff HV, Swarna KS, Sangaralingham LR, Nishimura RA, Dearani JA, Crestanello JA, Greason KL. Benefit of Anticoagulation Early After Surgical Aortic Valve Replacement Using Bioprosthetic Valves. Mayo Clin Proc. 2023 Dec;98(12):1797-1808. doi: 10.1016/j.mayocp.2023.08.012. 

The return to sport is one of the main goals following Achilles tendon tear repair. Several psychological factors influence the return to sport after a sports injury. The traditional tools to assess the return to sport do not take into account psychological factors. The ankle ligament reconstruction-return to sport injury (ALR-RSI), validated for ankle instability, is a score to evaluate psychological readiness to return to sport.

E. Shitrit et al conducted a study to validate the ALR-RSI score for the assessment of the readiness to return to sport after Achilles tendon repair. The study been published in “Knee Surgery, Sports Traumatology, Arthroscopy” journal.

The ALR-RSI score, adapted from the anterior cruciate ligament-return to sport injury (ACL-RSI) score used following knee ligament reconstruction, was validated according to the international COSMIN methodology. Patients operated for Achilles tendon repair responded to the questionnaire during the rehabilitation period. The EFAS, FAAM and VISA-A scores were used as reference questionnaires.

Open surgical repair of a recent Achilles tendon tear was performed in all patients of different centres. Patients were immobilised in a boot-with-heel lifts and no weight-bearing for 3 weeks, then, in same position with weight-bearing allowed. Afterwards, they followed an equivalent rehabilitation protocol, including joint range of motion recovery and muscle strengthening.

Key findings of the study were:

• 50 patients were included in the study, 8 women and 42 men.

• The level of sports activity of the patients were:

Five patients (10%) were professional athletes (1 basket, 2 handball, 2 football),

20 patients (40%) practised a sport at the competitive level, and

25 (50%) at the amateur level.

• Eleven of the 50 patients (22%) had returned to sport at 6.8 months of follow-up. Four (36.4%) of these patients returned to sport at the preinjury level of play and 7 patients (63.6%) at a lower level of play.

• No correlation was found between the type, level of sport, and the return to sport.

• The ALR-RSI score was strongly (r>0.5) correlated to the EFAS score: r=0.68 [0.50–0.80] the FAMM sport score: r=0.7 [0.52–0.84] the FAAM AVQ score (r=0.6 [0.35–0.78]), and the VISA A score (r=0.54 [0.26–0.76]).

• The discriminant validity was good with the ALR-RSI, which was significantly lower in the patients that did not return to sport: 60.7 (40–81.4) compared to those that did: 83.2 (64.3–100) p=0.001.

• Reproducibility was excellent with an intra-class correlation coefficient ρ of 0.99 [097–1.00]. The internal consistency was excellent (alpha coefficient=0.95).

The authors concluded – “The results of this series show that the ALR-RSI score is a valuable tool to assess the psychological readiness to return to sport in patients who undergo surgical Achilles tendon suture repair.”

Level of evidence – III.  

VISA-A Victorian institute of sport assessment-Achilles

EFAS European Foot and Ankle Society

FAAM Foot ankle ability measurement

Further reading:

The ALR RSI score can be used to evaluate psychological readiness to return to sport after acute Achilles tendon tear

E. Shitrit, E. Valentin et al

Knee Surgery, Sports Traumatology, Arthroscopy (2023) 31:4961–4968

https://doi.org/10.1007/s00167-023-07548-z

A study at Oregon State University (OSU) has mapped the genome of chia seeds to help future researchers take advantage of the plant’s potential for benefiting human health in various ways.

The study identifies genetic properties in chia seeds that may one day be leveraged in pharmaceuticals for treating high blood pressure and cancer. Other study findings support chia seeds’ antioxidant and anti-inflammatory properties.

The chia plant, Salvia hispanica L., belongs to the family Lamiaceae. It is commonly grown on subsistence farms in marginal agricultural areas.

The chia plant was once considered secondary, along with cassava, yams, millet, small grains, and pulses such as lentils. Being less prioritized, these plants were often considered “orphan” crops.

Historically, more attention has been paid to primary crops, cereal plants like rice, wheat, and maize, and small grains, such as legumes, oilseed, and tubers. These have all been important to the fight against global hunger.

However, orphan foods are growing in popularity for their health benefits. As climate change alters the agricultural landscape, these lesser-grown plants are becoming of interest. The mapping of chia seeds’ genomes is one step in this direction.

The new study presents an entire chia seed reference genome. It is 303.6 MB in size and encodes 48,090 annotated protein-coding genes. It identifies chia genes associated with valuable nutrients.

The study is published in Frontiers in Plant Science.

A closer look at the health benefits of chia seeds

This is the first report of in silico mapping of a plant genome for the purpose of assessing its health benefits.

Dr. Pankaj Jaiswal is a member of OSU’s Department of Botany and Plant Pathology. He was the senior investigator of the new study.

While the study is important for what it reveals about chia seeds, Dr. Jaiswal noted, “It was the first time a plant genome was analyzed for its potential nutritional quality and discovery of biopeptides that may play a role in improving human health conditions.”

Chia seeds are hardly alone in their nutritional qualities that have caught the attention of pharmaceutical researchers.

According to the U.S. Department of Agriculture (USDA), 40% of pharmaceutical drugs currently available in pharmacies in the United States are derived from plants, including the top 20 best-selling medications.

Aspirin, for example, is derived from the bark of a willow tree. Leukemia in children is treated with a medicine based on molecules from the Madagascar periwinkle.

The use of plants for medicinal purposes has a long history, dating back to 3,500 BC and Ancient Egypt. Chinese healers were using plants as drugs by 2,700 BC.

Why are chia seeds so good for you?

For many people in the West, chia seeds are perhaps best-known for the growing “hairs” in chia pets, a favorite childhood and decorative toy.

Nutritionists know, however, they are far more than that.

Michelle Routhenstein, registered dietitian nutritionist and preventive cardiology dietitian at EntirelyNourished.com, not involved in the study, listed some health benefits attributed to chia seeds:

“Chia seeds contain several minerals like calcium and magnesium, which play a role in reducing blood pressure. Additionally, their rich antioxidant and alpha-linolenic acid content, an omega-3 fatty acid derived from plants, may help to alleviate oxidative stress and inflammation, both factors that could contribute to heart disease.”

Dr. Jaiswal likened chia seeds to a “treasure trove” of nutrients.

Describing his chia-seed genetic blueprint as a work in progress, Dr. Jaisway was cautious about ascribing all the reported benefits to the plant.

Still, he said the results of his research thus far have been promising. “It is likely a target for discovering beneficial biomolecules,” Dr. Jaiswal said.

“All of the anti-aging peptides previously reported from chia were found present in the proteins encoded by the genes that were expressed in seeds. In their native form in the seed, they play a role as seed storage protein, but when digested by the digestive juices, the released biopeptides may acquire a different role,” he said.

“Many such health benefit studies were conducted using the whole seeds or the flour. Therefore, we need a lot of support for the research and investigation to connect the molecules we discovered to their health benefits,” Dr. Jaiswal continued.

New research could lead to improved chia seed crops

According to Dr. Jaiswal, one of the study’s benefits is that the chia genome blueprint will “help the plant breeding community in developing genetic resources” to improve crops. Traits of improved chia seed crops might include:

• yield and nutrition quality

• shorter flowering and seed development time

• improved frost and cold tolerance in the northern latitudes

• improved day-neutral or short-day flowering

“We are investigating climate resilience and disease resistance in rice,a global staple food crop, and plan to combine chia and dry beans to discover potential human health benefits by studying molecular interactions,” Dr. Jaiswal said.

Finally, accompanying the research is the development of the Salvia genomics database (SaliviaGDB) to aid future studies and help develop applications for chia seeds.

Reference:

Parul Gupta, Matthew Geniza, Justin Elser, Noor Al-Bader, Rachel Baschieri, Jeremy Levi Phillips, Ebaad Haq, Justin Preece, Sushma Naithani, Pankaj Jaiswal, Reference genome of the nutrition-rich orphan crop chia (Salvia hispanica) and its implications for future breeding,|Frontiers in Plant Science, https://doi.org/10.3389/fpls.2023.1272966