Parental involvement in a child's self-monitoring and treatment, including challenges encountered during treatment, influences the life satisfaction of caregivers of children with type 1 diabetes mellitus (T1DM). This study aimed to assess the level of life satisfaction among parents of children with T1DM and to examine the impact of selected sociodemographic and medical factors on life satisfaction. The study was conducted between September 1st, 2024, and March 1st, 2025, using a questionnaire designed by the author and the standardized Satisfaction with Life Scale (SWLS). Participants were parents of children aged 2 to 18 with a diagnosis of T1DM for more than one year, who were receiving care at four Diabetes Centers in the Mazovian, Pomeranian, and Warmian-Masurian voivodeships in Poland. A total of 327 parents of children with T1DM participated in the study. The mean ages of mothers and fathers were 41.5 ± 6.6 years and 44.1 ± 7.1 years, respectively, and the average age of the children was 11.8 ± 3.9 years. The mean duration of diabetes was 5.47 ± 3.62 years. The median SWLS sten score was 6.0 (4.0÷7.0). Higher life satisfaction was observed among professionally active fathers, parents living in nuclear families, and parents reporting a very good financial situation. Parents of children with T1DM who consulted a psychologist, psychotherapist, or psychiatrist reported lower life satisfaction. The life satisfaction of parents of children with T1DM was average. The parents of children with T1DM who have lower life satisfaction more likely to seek psychological support. The study demonstrated the influence of the roles of family members (mother vs. father), the father's employment status, family structure, and the family's financial status on life satisfaction. Independent sociodemographic factors were parent/caregiver and family financial status. Given the complexity of T1DM management, multidisciplinary support is essential for both children and their families. Efforts should be made to protect the mental health of children with T1DM and their parents. Facilitated access to specialist care should be prioritized. Nurses should develop family-centered care plans and work to reduce factors that negatively affect the life satisfaction of children and their families. The current parental life satisfaction score is important in providing daily care for children with T1DM. If the parental life satisfaction is low, the family should be provided with psychological support. Nurses should actively cooperate with psychologists, psychotherapists, and social workers in caring for children with T1DM, and should also inform caregivers on the current methods of support for families of children with chronic diseases. Up-to-date parental life satisfaction should be assessed during follow-up visits with educational nurses (diabetes educators) at the Diabetes Clinic. The development and implementation of a screening questionnaire would be a valuable component of nursing care planning for children with T1DM and their parents, as it would enable the rapid identification of the needs of both children and their parents (e.g., regarding education, emotional support, and caregiving). This would facilitate comprehensive, family-centered, and personalized care, while helping to prevent caregiver burnout, and improve the quality of family functioning in their home environment. These measures would support the individualization of care plans, enable early crisis intervention, and improve communication between parents and healthcare professionals. Healthcare professionals play a key role in identifying parental difficulties and ensuring specialized care for those most in need. A holistic and systemic approach that addresses both physical and mental health is crucial for improving the outcomes, self-monitoring results, and treatment of T1DM in children and adolescents, as well as for improving the quality of life of children and their parents.
The Finnish Diabetes Risk Score questionnaire is a widely used tool for screening type 2 diabetes mellitus; however, its application in Indigenous populations has been little studied. This study assessed the diagnostic accuracy of this questionnaire for detecting cases consistent with type 2 diabetes mellitus in the Totonac population of the state of Puebla, Mexico, and its performance when stratified by gender. A cross-sectional diagnostic accuracy study with prospective data collection was conducted in 148 adults (≥18 years) without a previous diagnosis of type 2 diabetes mellitus. Participants were residents of communities in the Sierra Nororiental of Puebla and were recruited through convenience sampling with consecutive enrollment during a health fair. The Finnish Diabetes Risk Score questionnaire was used as the index test, evaluated using two cutoff points (≥12 and ≥15); glycated hemoglobin (≥6.5%) was used as the reference standard. Both tests were administered independently and with assessor blinding. Sensitivity, specificity, predictive values, diagnostic accuracy, and the area under the curve were estimated through overall and gender-stratified analyses. At the ≥12 cut-off point, the Finnish Diabetes Risk Score showed an overall sensitivity of 76.4% (95%; CI: 66.6 to 84.0), specificity of 55.9% (95%; CI: 43.3 to 67.9), diagnostic accuracy of 68.2% (95%; CI: 60.4 to 75.2), and an area under the curve of 0.64 (95%; CI: 0.54 to 0.73). In women, sensitivity reached 85.2% (95%; CI: 73.4 to 92.3) and the area under the curve was 0.71 (95%; CI: 0.60 to 0.81), whereas in men the discriminative capacity was limited. The Finnish Diabetes Risk Score questionnaire demonstrated moderate discriminative capacity for detecting cases compatible with type 2 diabetes mellitus in the Totonac Indigenous population, with acceptable performance in women using the cut-off point of ≥12. These findings support its use as an initial screening tool in settings with limited access to confirmatory tests and highlight the need for validation in specific contexts. El cuestionario es una herramienta ampliamente utilizada para el tamizaje de diabetes mellitus tipo 2; sin embargo, su evaluación en poblaciones indígenas es limitada. Este estudio evaluó la exactitud diagnóstica de este instrumento para la detección de casos compatibles con diabetes mellitus tipo 2 en población totonaca del estado de Puebla, México, y su desempeño al estratificar por sexo. Se efectuó un estudio transversal de exactitud diagnóstica con recolección prospectiva, realizado en 148 adultos (de 18 años o más) sin diagnóstico previo de diabetes mellitus tipo 2. Los participantes fueron residentes de comunidades de la Sierra Nororiental de Puebla y reclutados mediante muestreo por conveniencia con inclusión consecutiva durante una feria de salud. El cuestionario se utilizó como prueba índice, evaluado mediante dos puntos de corte (igual o superior a 12 e igual o superior a 15), y la hemoglobina glucosilada (igual o superior a 6,5%) como estándar de referencia. Ambas pruebas fueron aplicadas de forma independiente y con cegamiento entre evaluadores. Se estimaron sensibilidad, especificidad, valores predictivos, exactitud diagnóstica y área bajo la curva, mediante análisis global y estratificado por sexo. Con un valor de corte ≥12, el mostró una sensibilidad general del 76,4% (intervalo de confianza: 95%; 66,6 a 84,0), especificidad de 55,9% (intervalo de confianza: 95%; 43,3 a 67,9), exactitud diagnóstica de 68,2% (intervalo de confianza: 95%; 60,4 a 75,2) y área bajo la curva de 0,64 (intervalo de confianza: 95%; 0,54 a 0,73) al punto de corte igual o superior a 12. En mujeres, la sensibilidad alcanzó 85,2% (intervalo de confianza: 95%; 73,4 a 92,3) con área bajo la curva de 0,71 (intervalo de confianza: 95%; 0,60 a 0,81), mientras que en hombres la capacidad discriminatoria fue limitada. El mostró capacidad discriminatoria moderada para la detección de casos compatibles con diabetes mellitus tipo 2 en población indígena totonaca, con desempeño aceptable en mujeres, utilizando el punto de corte igual o superior a 12. Estos hallazgos respaldan su uso como herramienta inicial de tamizaje en entornos con acceso limitado a pruebas confirmatorias y destacan la necesidad de validación en contextos específicos.
Background and objectives This study validates the discriminative ability of a community-based assessment checklist (CBAC) compared with other point-of-care tools for community screening to identify individuals at high risk of diabetes and hypertension. The data for this study were collected during 2019-20 in selected areas of Mysuru city, Karnataka. Methods CBAC was administered to residents aged 30 yrs and above, without known cases of diabetes mellitus, hypertension, or cancer. Random capillary blood glucose (RCBG) and blood pressure (BP) were measured for comparison with the CBAC score. Screening performance was assessed using receiver operating characteristics (ROC) analysis and the area under the curve (AUC). Results CBAC was administered to 32,686 people, and 31,594 had complete data for CBAC and RBS, and 32,645 had both CBAC scores and BP values. The analysis showed a poor AUC of 0.62 (95% CI: 0.61-0.63) for identifying individuals at risk of diabetes with RCBG value of ≥140 mg/dL and an AUC of 0.61 (95% CI: 0.60-0.61) for individuals at risk of hypertension with BP values of (systolic ≥140 mmHg OR diastolic ≥90 mmHg). Youden's index indicated that the CBAC cut-off of >4, though optimal for both at-risk of diabetes and hypertension, was poor at 0.17 and 0.15, respectively. Interpretation and conclusions The discriminative ability of CBAC was found to be poor compared with other point-of-care tools. We propose that trained frontline health staff administer RCBG and BP tests alongside the CBAC to enable more efficient public health triaging.
Diabetes mellitus (DM) is associated with negative psychological conditions, specifically burnout, in cases where there is less glycemic control and longer illness time. The aim of this study was to adapt and validate the Diabetes Burnout Scale [DBS, Escala do Burnout na Diabetes (EBD)] into European Portuguese, as an evaluation measure tailored to the Portuguese context. The scale was translated, retranslated and adapted. This study resorted to online and in-person collection of a convenience sample of people with DM. Reliability tests and convergent validation tests were performed, using the EQ-5D-5L and Problem Areas in Diabetes Scale 5 (PAID-5) as reference. Factor structure was evaluated using fit and invariance tests. Associations between the total score of the scale and variables like the respondents' most recent glycated hemoglobin (HbA1c) and socioeconomic index were analyzed. A total of 1070 people with DM participated, 50.6% male and 49.3% female, with an average age of 56.0 ± 15.7 years and an average time since diagnosis of 20 ± 12.3 years. A three-factor structure was ascertained with a good fit: exhaustion, detachment and loss of control - invariant by sex and DM type. The internal consistency, as given by Cronbach's Alpha, was 0.885. Spearman's correlation showed the relation between EBD total score and EQ-5D-5L utility index (ρ = -0.382, p < 0.001), PAID-5 total score (ρ = 0.638, p < 0.001), and most recent HbA1c (ρ = 0.295, p < 0.001). The EBD scale was successfully adapted and validated for European Portuguese. Introdução: Em situações de menor controlo glicémico e de doença prolongada, a diabetes mellitus (DM) está associada a condições psicológicas negativas, nomeadamente o burnout. Este trabalho teve como objetivo adaptar culturalmente e validar a Diabetes Burnout Scale [DBS, Escala do Burnout na Diabetes (EBD)] para o português europeu, como medida de avaliação populacional. Métodos: Procedeu-se à tradução, retrotradução e verificação de legibilidade da escala. A validação foi realizada pela recolha online e presencial em amostra de conveniência de pessoas com DM, sendo estudada a precisão e efetuada a validação convergente com as escalas EQ-5D-5L e Problem Areas in Diabetes 5 (PAID-5), já validadas para o português europeu. Realizou-se uma análise fatorial exploratória e confirmatória da EBD e verificou-se a associação entre a pontuação total da escala, o mais recente valor de hemoglobina glicada (HbA1c) e o índice socioeconómico dos inquiridos. Resultados: Participaram 1070 pessoas com DM, 50,6% homens e 49,3% mulheres, com idade média de 56,0 ± 15,7 anos e tempo médio de DM de 20,0 ± 12,3 anos. A EBD foi estruturada com base em três fatores – exaustão, desprendimento e perda de controlo – não diferentes por sexo e por tipo de DM. A consistência interna foi de 0,885 pelo alfa de Cronbach. Determinou-se a correlação de Spearman entre a pontuação total da EBD e o índice de utilidade EQ-5D-5L (ρ = -0,382, p < 0,001), o total PAID-5 (ρ = 0,638, p < 0,001), e a HbA1c mais recente (ρ = 0,295, p < 0,001). Conclusão: Foi possível efetuar a adaptação cultural e validação da escala EBD para o português europeu.
Diabetes-related lower-limb amputation (DLLA) is a severe complication of diabetes associated with considerable disability and mortality. However, the associations of activities of daily living (ADL) and their longitudinal trajectories with DLLA risk remain unclear. Data from the Health and Retirement Study (HRS; n = 3007) and the English Longitudinal Study of Ageing (ELSA; n = 833) were analyzed. ADL trajectories were identified using Group-Based Trajectory Modeling. Associations of ADL levels and trajectories with diabetes-related lower-limb amputation (DLLA) were evaluated using Cox regression models, with competing-risk, nonlinear, subgroup, and mediation analyses performed as sensitivity and exploratory analyses. During a median follow-up of approximately two survey waves (approximately four years), 986 DLLA events occurred in the HRS cohort and 254 events occurred in the ELSA cohort. Multivariable Cox regression analyses demonstrated that ADL scores were significantly associated with DLLA risk after adjustment for potential confounders (HRS: adjusted HR = 1.10, 95% CI: 1.07-1.14; ELSA: adjusted HR = 1.20, 95% CI: 1.12-1.28). Compared with the Stable-low trajectory group, the risks of DLLA were significantly higher in both the Stable-rise and Stable-high groups. The risk increased by approximately 51%-84% in the Stable-rise group and by 36%-1.31-fold in the Stable-high group. Kaplan-Meier survival analysis showed significant differences in DLLA incidence among the ADL trajectory groups (log-rank P < 0.001). The competing risk analyses yielded results consistent with those of the Cox models. RCS analysis indicated a significant nonlinear association between ADL and DLLA risk, with a threshold effect observed around ADL ≈ 2. Furthermore, mediation analysis suggested that depression partially mediated the association between ADL and DLLA risk. ADL levels and their longitudinal trajectories were significantly associated with the risk of DLLA among individuals with diabetes. Individuals with persistently poor functional status or progressively declining function exhibited the highest risk. Dynamic changes in functional status may serve as useful indicators for identifying individuals at elevated risk of DLLA. Routine assessment of ADL may contribute to risk stratification and clinical monitoring in individuals with diabetes.
Type 2 diabetes mellitus (T2DM) requires sustained self-management and lifestyle modification to achieve optimal glycemic control. Hybrid care models that combine digital health technologies with in-person clinical support may enhance patient engagement while improving the accessibility and scalability of diabetes care. However, evidence regarding their effectiveness and feasibility in Southeast Asian populations remains limited. This study aimed to evaluate the preliminary effectiveness and feasibility of a national hybrid digital intervention for individuals with T2DM in Brunei Darussalam. The primary objective was to evaluate the proportion of participants achieving a reduction in glycated hemoglobin (HbA1c) of ≥0.6% after 16 weeks. Secondary objectives included evaluating changes in metabolic parameters, anthropometric outcomes, and health-related quality of life (QoL). This single-arm, nonrandomized pilot trial enrolled adults with T2DM into a 16-week hybrid digital intervention integrating remote health coaching, structured digital education, self-monitoring activities, and asynchronous communication via WhatsApp. Participants attended scheduled video consultations (VCs) and submitted self-monitoring records throughout the intervention period. Clinical outcomes included changes in HbA1c, fasting blood glucose, lipid profile parameters, BMI, waist circumference, and QoL measured using the EQ-5D-5L instrument. Feasibility outcomes included intervention completion, VC attendance, participant engagement, and intervention acceptability. A total of 122 participants were enrolled, and 108 (88.5%) completed the intervention. Among 104 participants with complete HbA1c data, there was a mean reduction of 1.2% (95% CI -1.45 to -0.96; P<.001). Overall, 65.4% (68/104) of participants achieved the predefined HbA1c reduction threshold of ≥0.6%, while 84.6% (88/104) demonstrated an overall reduction in HbA1c. Significant improvements were also observed in fasting blood glucose (-1.7 mmol/L, 95% CI -2.3 to -1.2; P<.001), BMI (-0.4 kg/m², 95% CI -0.6 to -0.2; P<.001), waist circumference (-1.9 cm, 95% CI -2.9 to -0.9; P<.001), total cholesterol (-0.3 mmol/L, 95% CI -0.6 to -0.2; P<.001), triglycerides (-0.5 mmol/L, 95% CI -0.7 to -0.2; P<.001), and EuroQol Visual Analog Scale (EQ-VAS) scores (+6.7 points, 95% CI 3.9 to 9.6; P<.001). The intervention demonstrated favorable feasibility outcomes, including an 88.5% (108/122) completion rate, attendance at ≥5 VCs by 75.9% (82/108) of participants, and high participant satisfaction, with 86.9% (86/99) of respondents reporting satisfaction or extreme satisfaction with the intervention. The pilot trial demonstrated the acceptability, preliminary effectiveness, and feasibility of a national hybrid digital intervention for individuals with T2DM in Brunei Darussalam. High completion rates, sustained participant engagement, and positive participant feedback support the practicality of implementation within a national digital health ecosystem. The intervention was also associated with improvements in glycemic control, metabolic outcomes, anthropometric measures, and health-related QoL. Larger controlled studies are warranted to evaluate long-term effectiveness, scalability, and implementation outcomes.
Posttransplant diabetes mellitus is a chronic metabolic complication that often develops in kidney transplant recipients and is an inflammatory disease that directly affects a patient's immune system. Angiopoietin and angiopoietin -like proteins are intrinsic mediators of immune cells. We assessed the relationship between circulating angiopoietin proteins ANGPT ¹ and ANGPT ²and angiopoietin-like proteins ANGPTL ³, ANGPTL ⁴, ANGPTL ⁶, ANGPTL ⁷, and ANGPTL ⁸ in kidney transplant recipients who develop posttransplant diabetes mellitus (experimental group) versus recipients who do not develop diabetes after transplant (control group). We included 154 age-matched and sex-matched participants (38 with posttransplant diabetes mellitus) and 155 control participants. We collected 3 mL of venous blood from each patient. Plasma levels of angiopoietin proteins ANGPT ¹ and ANGPT ² and angiopoietin-like proteins ANGPTL ³, ANGPTL ⁴, ANGPTL ⁶, ANGPTL ⁷, and ANGPTL ⁸ were determined by enzyme-linked immunosorbent assay. We determined the correlation between plasma levels of ANGPT ¹and ANGPT ² and ANGPTL ³, ANGPTL ⁴, ANGPTL ⁶, ANGPTL ⁷, and ANGPTL ⁸in our posttransplant diabetes mellitus group and the control group. There were highly significant differences between kidney transplant recipients with diabetes versus control participants with regard to plasma levels of ANGPT ¹, ANGPTL ⁶, ANGPTL ⁷, and ANGPTL ⁸ (P < . ⁰⁰¹, P = . ⁰⁰¹, P < . ⁰⁰¹, and P =.⁰⁴, respectively). No significant statistical association was found for ANGPT2, ANGPTL3, and ANGPTL4 in our posttransplant diabetes mellitus cohorts. Plasma levels of ANGPT¹, ANGPTL⁶, ANGPTL⁷, and ANGPTL ⁸ may correlate with disease severity and chronicity in transplant patients who develop posttransplant diabetes mellitus. Thereby these may serve as potential biomarkers of the disease severity with possible early intervention in the management strategy especially with modifiable risk factors such as immunosuppression regimen, antidiabetic medications, and follow-up of the complications of posttransplant diabetes mellitus.
The rising prevalence of early-onset type 2 diabetes (T2DM) has become a major public health concern, with these patients facing a particularly high risk of early diabetic kidney disease (DKD). Although continuous glucose monitoring (CGM)-derived metrics have shown promise in predicting complications in later-onset T2DM, their utility in early-onset T2DM, a more aggressive phenotype characterized by rapid β-cell decline and heightened complication risk, remains unclear. Moreover, the relationship between glycemic variability and renal injury, as well as the mechanisms underlying the associations between CGM metrics and DKD, have not been fully elucidated. This study aimed to evaluate the associations of time in range (TIR), coefficient of variation (CV), and glycemic risk index (GRI) with early DKD in Chinese patients with early-onset T2DM, and to explore the potential mediating role of triglycerides. This cross-sectional study included 810 individuals with early-onset T2DM, defined as diagnosis before age 40. All participants underwent ≥7 days of CGM. Early DKD was defined as a urinary albumin-to-creatinine ratio (UACR) ≥30 mg/g with an estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73m². Multivariable logistic regression, restricted cubic splines, and mediation analysis were used to evaluate independent associations, nonlinear relationships, and the mediating role of triglycerides (TG), respectively. Among the participants, 183 (22.59%) had early DKD. After full adjustment including HbA1c, higher TIR was associated with lower odds of early DKD (per 1% increase: OR 0.99, 95% CI 0.98-0.99, P < 0.001), whereas higher GRI was associated with increased odds (per 1-unit increase: OR 1.01, 95% CI 1.01-1.02, P < 0.001). A U-shaped relationship was observed between CV and early DKD risk, with the nadir observed at approximately 20-30% CV. In mediation analysis, TG statistically accounted for 13.01% of the association between TIR and early DKD, and 11.92% of the association between GRI and early DKD. In Chinese patients with early-onset T2DM, CGM-derived metrics are independently associated with early DKD, with TIR and GRI showing opposite associations and CV exhibiting a U-shaped relationship. The observed association involving triglycerides suggests that lipid metabolism may be a correlate of glycemic control in relation to renal injury. These findings support a multidimensional strategy integrating glucose control, glycemic stability, and lipid management for renal protection in this high-risk population.
To analyze the interplay between family history of type 2 diabetes (T2D) and cardiovascular health (CVH) in relation to T2D onset age and subsequent cardiovascular disease (CVD) risk. A total of 79 831 participants were included to investigate the association between family history and T2D onset age. Then, 7387 diagnosed T2D patients were 1:1 matched with non-T2D individuals to analyze the association of T2D onset age with subsequent CVD risk. The benefit of good CVH was further assessed. Stratified Cox regression and conditional Cox regression were performed to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Family history was associated with younger T2D onset, with an approximately 2.4-year earlier onset of T2D, which further increased the subsequent risk of CVD. Compared with individuals without family history, those with family history had HRs (95% CIs) of 3.911 (3.041, 5.032), 3.785 (3.385, 4.233), 3.627 (3.340, 3.938), 3.465 (3.189, 3.764), and 3.169 (2.787, 3.603) for T2D onset at < 40, 40-50, 50-60, 60-70, and ≥ 70 years old, respectively (Pinteraction = 0.007). Among individuals with family history, HR (95% CI) for incident CVD was 3.598 (1.372, 9.433) for those diagnosed T2D < 50 years compared with those without T2D, while the HR (95% CI) was 2.336 (1.232, 4.428) among those without family history. However, high CVH could mitigate risk of young-onset T2D, and could further decrease CVD risk after their T2D diagnosis. Having family history of T2D increased susceptibility to young-onset T2D and subsequent CVD risks, while ideal CVH could counteract these risks, highlighting the necessity of early screening and intervention.
Fragmentation of health information systems remains a major barrier to effective health system performance across Europe, particularly in decentralized settings. Federated data infrastructures have been proposed as a scalable solution, but evidence on their implementation at population level remains limited. We aimed to describe the implementation of a federated information infrastructure at regional level and assess the completeness and variability of linked data across participating centers, discussing implications of scaling up the approach within the European Health Data Space. We carried out a population-based cohort study linking administrative, clinical, and patient-reported data across three healthcare organizations in Emilia-Romagna, Italy, covering over 2.1 million residents. Data were analyzed using a federated architecture without sharing individual-level information. Baseline characteristics were assessed at 1 January 2019, with longitudinal follow-up over 6 years. We identified 116,552 individuals with diabetes (prevalence 5.6%). Among individuals with available classification, 90.8% had type 2 diabetes. Clinical data were available for 43.5% of patients in charge of diabetes clinics, with substantial heterogeneity across centers (12.8-80.6%). Among those with clinical data, 27.5% had baseline HbA1c levels below 48 mmol/mol, while 69% had elevated systolic pressure (≥130 mmHg) and 56.6% had high diastolic pressure (≥80 mmHg). Sociodemographic variables were largely missing. Patient-reported outcomes were collected in 521 individuals, demonstrating feasibility but limited scalability. Federated linkage of administrative, clinical, and patient-reported data is feasible at regional scale and enables population-level monitoring of diabetes care. However, variability in data completeness was primarily driven by organizational and governance factors rather than technical capacity. These findings provide empirical evidence that strengthening health data systems requires alignment of healthcare organization and service delivery models, beyond technical solutions alone. The REWINDER project built a collaborative information infrastructure using federated linkage of different data sources and person-reported outcomes, independently managed by local healthcare organizations. The project has made available a large database to inform policy and planning of diabetes care across the region. The system may be used as a model that can be conveniently scaled up to other geographical areas and chronic diseases.
To investigate the behavioural and social determinants of type 2 diabetes mellitus (T2DM) self-care adherence in South Ethiopia using the integrated health belief model (HBM) and health-related quality-of-life (HRQoL) frameworks. A cross-sectional study. Three public hospitals in South Ethiopia: Wolaita Sodo University Comprehensive Hospital, Humbo Primary Hospital and Boditi Primary Hospital. 404 systematically sampled adults aged 18-60 years with a confirmed diagnosis of T2DM who had been attending follow-up clinics for at least 12 months. Exclusion criteria included newly diagnosed T2DM, pregnancy, severe comorbidities or critical illness and unwillingness to participate. The primary outcome was adherence to diabetes self-care, assessed using the Summary of Diabetes Self-Care Activities scale across five domains: diet, physical activity, medication intake, blood glucose monitoring and foot care. Good adherence was defined as engagement in recommended behaviours on ≥50% of days per week. Secondary outcomes included socio-demographic factors, clinical variables, HBM constructs (perceived susceptibility, severity, benefits, barriers, cues to action and self-efficacy) and HRQoL domains (physical, psychological, social and environmental). Of 404 participants, 58.4% demonstrated good adherence. In multivariable analysis, insulin-only treatment (AOR=3.0; p<0.001), having comorbidities (AOR=2.02; p=0.007) and poor glycaemic control (AOR=3.6; p=0.003) were positively associated with adherence. Factors associated with poor adherence included low income (AOR=0.18; p=0.002), living alone (AOR=0.19; p=0.012), low self-efficacy (AOR=0.18; p<0.001) and poor psychological health (AOR=0.53; p=0.024). The findings challenge the direct application of standard behavioural models in low-resource settings. Structured factors, such as poverty, can overwhelm psychological mechanisms. Effective interventions must integrate economic support with psychological care to improve self-care adherence.
Chronic kidney disease (CKD) is a growing global health issue that significantly impairs quality of life (QoL), particularly among patients undergoing dialysis. This study examines the relationships between e-health literacy, self-efficacy, and QoL in this vulnerable population. To examine associations among e-health literacy, self-efficacy, and health-related quality of life (HRQoL) among patients receiving hemodialysis in Northern Jordan. A cross-sectional study was conducted among 184 adult HD patients recruited from four hospitals in Northern Jordan. Data were collected using validated Arabic versions of the eHealth Literacy Scale (eHEALS), the Self-Efficacy for Managing Chronic Disease Scale (SEMCD-6), and the Kidney Disease Quality of Life-36 (KDQOL-36). Spearman correlation was used to examine associations between variables. Multiple linear regression was performed to identify independent predictors of KDQOL-36 total scores. Among 184 participants (mean age 49.9 years, 65% male), the mean self-efficacy score was 25.52 (SD = 1.8) and the mean e-health literacy score was 3.62 (SD = 0.58). The mean KDQOL‑36 total score was 105 ± 17, with domain scores of 39 ± 7 for Symptoms/Problems, 25 ± 6 for Effects of Kidney Disease, 11 ± 3 for Burden of Kidney Disease, 29 ± 5 for Social Function, 12 ± 3 for the Physical Component Summary, and 21 ± 4 for the Mental Component Summary. Multivariable regression identified independent predictors of higher quality of life: graduate-level education (B = 8.06, 95% CI: 2.32-13.80, p = 0.006) and employment (B = 7.14, 95% CI: 2.10-12.20, p = 0.006). Diabetes was independently associated with lower quality of life (B = -5.92, 95% CI: -10.90 to -0.95, p = 0.020). Although significant in unadjusted analyses, e-health literacy and self-efficacy were not independent predictors after adjustment for socioeconomic and clinical factors. Health-related quality of life among HD patients appears to be influenced primarily by socioeconomic and clinical factors, particularly educational attainment, employment status, and diabetes mellitus. Although e-health literacy and self-efficacy were associated with HRQoL in unadjusted analyses, these associations were attenuated after adjusting for socioeconomic and clinical characteristics. Interventions that address educational disparities, support patient engagement, and optimize comorbidity management may improve health outcomes among patients receiving hemodialysis.
Type 2 Diabetes Mellitus (T2DM) management requires integrated and continuous care; however, service fragmentation remains prevalent in universal health coverage (UHC) systems. This study examines how governance arrangements influence service integration and patient-reported experiences in T2DM care in Indonesia, to develop strategic recommendations for strengthening integrated governance. A concurrent mixed-methods design, qualitative driven, was employed. Qualitative data were collected through in-depth interviews with policymakers, insurance representatives, hospital managers, clinicians, and primary care providers Quantitative data were collected from 107 adults with T2DM using structured questionnaires assessing knowledge, medication adherence, perceived service quality, and health-related quality of life. Findings were integrated using a joint display guided by Green's PRECEDE framework; strategic positioning was assessed through a SWOT and Internal-External matrix, and a TOWS matrix was developed to formulate recommendations. Qualitative findings identified four governance barriers: fragmented primary-referral care pathways, misaligned financing arrangements, uneven facility and workforce capacity, and weak coordination and monitoring mechanisms. Quantitative findings indicated high patient knowledge (median 86.7%) and medication adherence (76.6% highly adherent), yet generally positive service quality perceptions, though reliability showed the largest gap. Physical quality of life remained suboptimal, particularly in energy and general health. Strategic positioning placed current T2DM governance in the grow-and-build quadrant, indicating capacity for proactive reform. The development of an integrated governance strategy emphasizing structured referral pathways, aligned financing with chronic care needs, institutionalized diabetes educator roles, and accelerated health information system interoperability - offering actionable lessons for universal health coverage systems in low-and middle-income countries. Main findings: Integrated governance of Type 2 Diabetes Mellitus care in Indonesia remains constrained by fragmented referral coordination, limited primary care authority, financing misalignment, and non-interoperable health information systems, despite relatively high patient knowledge, medication adherence, and service quality perceptions.Added knowledge: This study demonstrates how combining patient-reported outcomes, service quality assessment, and multistakeholder governance analysis within a mixed-methods framework can identify system-level priorities and serve as a basis for developing integrated governance strategies for chronic disease care under universal health coverage.Global health impact for policy and action: The findings provide practical lessons for low-and middle income-countries on improving chronic disease outcomes through integrated governance, strategic purchasing, strengthened primary care capacity, multidisciplinary coordination, and interoperable digital health systems.
Early prediction of gestational diabetes mellitus (GDM) enables timely interventions but remains challenging, particularly in women living without obesity who are often overlooked by standard screening methods. This exploratory analysis identifies early pregnancy biomarkers that show associations with GDM up to 8-12 weeks earlier than the established diagnostic timeframe. A retrospective nested case-control study was conducted at Tianjin Central Hospital of Gynecology Obstetrics. After applying the predefined inclusion and exclusion criteria and removing cases with missing blood samples, a total of 136 women were included in the final analysis, comprising 56 women with GDM and 80 non-GDM controls. These data were used to develop multiple machine learning models, including random forest, logistic regression, SVM, XGBoost, and KNN. The performance of these models was assessed by AUC, sensitivity, specificity, positive predictive value, and negative predictive value in an independent validation set. The random forest classifier achieved the best performance with an AUC of 0.992 in the validation set, indicating excellent sensitivity and specificity. The model incorporated six measurable variables: age, BMI, and four cytokines (IL-1β, IL-10, IL-17A, and IL-4) participating in immune regulation in pregnancy. GDM can be predicted with high accuracy early in pregnancy, even among women living without obesity. This study highlights the value of integrating immunological biomarkers with clinical characteristics and machine learning for proactive risk stratification. Although promising, our findings warrant validation in larger, multiethnic cohorts to ensure generalizability.
Diabetes is a major health concern in Malaysia, yet no comprehensive review has assessed the quality of care for these patients. This study aims to systematically review published evidence on type 2 diabetes mellitus (T2DM) management in Malaysian primary health care (PHC), focusing on the achievement of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL-cholesterol (LDL-C) targets (ABC control). A scoping review was conducted, involving a comprehensive search of four databases (PubMed, Embase, Scopus, and MyMedR) and grey literature for publications up to December 2024. Studies were included if they reported on at least one ABC indicator among the general adult T2DM population in Malaysian PHC settings. The scoping review followed the Joanna Briggs Institute (JBI) methodology and PRISMA-ScR guidelines. EndNote was used for deduplication, and Rayyan was utilised for the screening process. Data were extracted and synthesised narratively. A total of 109 publications were included. Publications increased post-2010 but remained geographically concentrated in urban states. Large-scale studies heavily relied on the National Diabetes Registry. HbA1c was the most reported indicator. Findings revealed no evidence of improvement in HbA1c and BP control over two decades; achievement rates were 30-45% for HbA1c (<7.0%) and 20-50% for combined BP target (<130/80 mmHg). Conversely, LDL-C control (≤2.6 mmol/L) showed a modest improvement, with achievement rates rising from approximately 30% to 50% over a decade. Despite a substantial increase in research, the HbA1c and BP control for T2DM in Malaysian PHC has remained static and suboptimal, highlighting a persistent gap between clinical guidelines and real-world outcomes. The modest improvement in LDL-C suggests that progress is achievable. These findings underscore the need for a balanced policy focus on all three ABC indicators, strategies to overcome systemic barriers, and continued investment in the national registry to guide evidence-based improvements in diabetes care.
Excess sugar intake in early life may affect long-term brain health, but evidence for dementia is limited. We used the abrupt end of UK sugar rationing in September 1953 as a natural experiment to test whether exposure to sugar rationing during different windows within the first 1,000 days from conception was associated with adult risk of all-cause dementia, Alzheimer disease (AD), and vascular dementia (VaD). We analyzed UK Biobank participants born around the end of UK sugar rationing. Exposure was classified as rationing in utero only, in utero plus the first year of life, in utero plus 1-2 years of life, or no exposure. Incident dementia was identified from linked ICD-10 records. MRI of the brain and cognitive function were assessed in the imaging subcohort. Adjusted Cox and Gompertz models estimated HRs and 95% CIs, Fine-Gray models accounted for competing risk, and mediation analyses evaluated type 2 diabetes and hypertension. Among 64,737 participants included in the analysis, the mean age at recruitment was 54.6 years, and 56.4% were women; 40,963 were exposed to sugar rationing during fetal and/or early-childhood life, and 23,774 were unexposed. Compared with unexposed individuals, sugar rationing in utero plus the first year of life was associated with lower hazards of all-cause dementia (HR, 0.79; 95% CI 0.66-0.94) and AD (HR, 0.77; 95% CI 0.59-1.00). Similar or slightly stronger associations were observed for exposure in utero plus 1-2 years (all-cause dementia: HR, 0.77; 95% CI 0.63-0.95; AD: HR, 0.72; 95% CI 0.53-0.98). Exposure in utero plus 1-2 years was associated with delayed onset of all-cause dementia by 2.55 years, AD by 2.87 years, and VaD by 2.49 years. Early-life sugar rationing was also associated with higher total gray matter volume (β, 3.27; 95% CI 0.46-6.07), lower white matter hyperintensity volume (β, -0.64; 95% CI -0.97 to -0.31), and better performance in processing speed and reasoning. Incident type 2 diabetes and hypertension jointly mediated 25.5% of the association. Sugar restriction in the first 1,000 days was associated with lower dementia hazards, delayed onset, and more favorable brain-health profiles. These results support early-life sugar reduction as a potential strategy for dementia prevention.
The triglyceride-glucose(TyG) index, a surrogate marker of insulin resistance, has been linked to cardiac dysfunction; however, its underlying associated pathways in patients with type 2 diabetes mellitus(T2DM) remain unclear. This study used cardiac magnetic resonance(CMR) to explore the association of TyG index with subclinical left ventricular(LV) myocardial dysfunction and whether imaging indicators statistically mediate this relationship. In this retrospective cross-sectional study, a total of 235 T2DM patients who underwent CMR examination were included and assigned to three groups based on the tertiles of their TyG indexes as follows: low(< 8.73, n = 78), moderate(8.73-9.36, n = 79), and high TyG index(≥ 9.36, n = 78) groups. LV geometry, function, myocardial energetic efficiency index (MEEi), resting first-pass perfusion, and global peak strain in radial(GRPS), circumferential(GCPS), and longitudinal(GLPS) directions were measured. Univariate and multivariate linear regression models and exploratory mediation analysis were used to analyze the associations of TyG index on LV global strain. Compared with the low and moderate TyG index groups, the high TyG index group had significantly higher LV remodeling index, lower LV global function index, lower MEEi, impaired resting myocardial perfusion, and reduced LV global peak strain (all p ≤ 0.002). Multivariate analysis showed that TyG index remained independently associated with reduced LV strain after adjusting for confounders (GRPS β = -0.261; GCPS β = 0.271; GLPS β = 0.381; all p < 0.001). And MEEi and upslope were also independently associated with reduced LV GRPS and GLPS (all p < 0.05). Further mediation analysis revealed the statistically mediated proportions of the association between the TyG index and LV global strain were 8.2-8.6% for MEEi and 4.3% to 12.5% for upslope. In model comparison analyses, the TyG index demonstrated substantially better model fit than either component alone across all strain directions (all Akaike Information Criterion difference > 150). In patients with T2DM, a higher TyG index is independently associated with decreased LV global strain, and this relationship is statistically mediated by reduced MEEi and impaired resting perfusion upslope. These findings generate hypotheses regarding myocardial energetics and resting perfusion as potential pathways associated with diabetic myocardial dysfunction that warrant prospective investigation.
Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by the destruction of pancreatic β cells, leading to lifelong insulin dependence and an increased risk of severe complications. Three-dimensional stem cells (3D SCs) culture systems have emerged as a superior alternative by more accurately mimicking the in vivo microenvironment and enhancing stemness maintenance, regenerative efficiency, and paracrine secretion. However, studies exploring the application of 3D SCs in T1D remain limited. Here, we developed a novel serum- and cytokine-free orbital-shaking system. It enables efficient and large-scale reprogramming of somatic cells into 3D embryonic-like stem cell spheroids (Sph-Es) characterized by robust pluripotency and improved safety. To enhance therapeutic utility, Sph-Es were irradiated and transduced with INS-expressing adenoviral vectors to generate Sph-R-Ins, allowing transient insulin production without permanent genomic modification. In STZ-induced T1D mice, Sph-R-Ins improved glycemic control and glucose tolerance and increased mouse insulin and C-peptide responses, indicating improved endogenous islet function. Donor-cell tracking analyses showed no pancreatic engraftment, supporting an indirect mode of action. Additional transcriptomic, immunological, and ex vivo studies indicated that the therapeutic benefit was accompanied by ECM-related signaling changes, reduced inflammatory infiltration, enhanced M2 macrophage polarization and Treg-associated immune regulation, improved metabolic signaling, and spheroid-derived paracrine support of islet function. Together, these findings establish a mechanically guided 3D stem cell-gene therapy platform with both endocrine and immunometabolic benefits in T1D.
Gestational diabetes mellitus (GDM) is a common pregnancy complication with profound short- and long-term consequences for both mother and offspring. Beyond transient hyperglycemia, GDM represents a multifactorial metabolic condition shaped by the interplay of genetic predisposition, epigenetic regulation, and alterations in the maternal microbiome. Dysbiosis of the gut and reproductive tract microbiota contributes to inflammation, insulin resistance, and dyslipidemia during pregnancy, while microbial metabolites influence placental physiology and epigenetic remodeling of key metabolic and imprinted genes. These modifications, including changes in DNA methylation and non-coding RNA expression, link maternal hyperglycemia and microbial shifts to persistent alterations in gene expression that affect trophoblast activity, fetal growth trajectories, and long-term metabolic risk in offspring. Vertical transmission of maternal microbiota further imprints the neonatal microbiome, establishing an early-life foundation for reproductive and metabolic health. Although current diagnostic criteria and biomarkers remain inconsistent across populations, recent advances highlight the microbiome-epigenome axis as a promising source of predictive markers and therapeutic targets. Interventions such as probiotics, prebiotics, synbiotics, and dietary modulation show potential for improving maternal glycemic control, shaping placental function, and modulating fetal programming, although evidence for long-term efficacy is still emerging. Viewing GDM as both a metabolic stress test and a window of reproductive opportunity underscores the importance of early diagnosis and precision strategies. Integrating microbiome research and epigenetic insights into clinical practice offers new avenues to improve maternal outcomes, optimize fetal development, and reduce the intergenerational transmission of reproductive and metabolic disease risk.
Maternal diabetes during pregnancy increases the risk of metabolic and cardiac disorders in offspring. Nevertheless, the mechanism by which intrauterine hyperglycemia affects neonatal cardiac remodeling remains uncertain. This study aims to characterize the prenatal environment in the context of gestational diabetes mellitus and to identify the corresponding fetal changes. Using an intrauterine hyperglycemia rodent model, we observe cardiac remodeling and inflammatory responses in offspring hearts. Moreover, the O-GlcNAcylation levels are increased in neonatal hearts exposed to gestational diabetes. Further mechanistic investigations, supported by RNA sequencing and mitochondrial functional analyses, reveal that gestational diabetes triggers O-GlcNAcylation-dependent activation of CaMKIIδ during the embryonic stage. This activation leads to the release of mitochondrial DNA (mtDNA) from the mitochondrial matrix into the cytosol, which subsequently activates STING signaling and triggers an inflammatory response in neonatal cardiomyocytes. Pharmacological or genetic inhibition of O-GlcNAcylation attenuates mtDNA-induced myocardial inflammation and improves cardiac function in neonatal offspring subjected to intrauterine hyperglycemia. Together, these findings identify a previously unrecognized CaMKIIδ/mtDNA/STING axis in which CaMKIIδ O-GlcNAcylation leads to mtDNA-dependent activation of cardiac remodeling, suggesting that plasma mtDNA levels could serve as a predictive biomarker in neonatal cardiac inflammatory injury.