ObjectiveNutrition therapy is an integral part of self-management education in patients with type 2 diabetes. Carbohydrates with a low glycemic index are recommended, but the ideal amount of carbohydrate in the diet is unclear. We performed a meta-analysis comparing diets containing low to moderate amounts of carbohydrate (LCD) (energy percentage below 45%) to diets containing high amounts of carbohydrate (HCD) in subjects with type 2 diabetes.Research design and methodsWe systematically reviewed Cochrane library databases, EMBASE, and MEDLINE in the period 2004–2014 for guidelines, meta-analyses, and randomized trials assessing the outcomes HbA1c, BMI, weight, LDL cholesterol, quality of life (QoL), and attrition.ResultsWe identified 10 randomized trials comprising 1376 participants in total. In the first year of intervention, LCD was followed by a 0.34% lower HbA1c (3.7 mmol/mol) compared with HCD (95% CI 0.06 (0.7 mmol/mol), 0.63 (6.9 mmol/mol)). The greater the carbohydrate restriction, the greater the glucose-lowering effect (R=−0.85, p<0.01). At 1 year or later, however, HbA1c was similar in the 2 diet groups. The effect of the 2 types of diet on BMI/body weight, LDL cholesterol, QoL, and attrition rate was similar throughout interventions.LimitationsGlucose-lowering medication, the nutrition therapy, the amount of carbohydrate in the diet, glycemic index, fat and protein intake, baseline HbA1c, and adherence to the prescribed diets could all have affected the outcomes.ConclusionsLow to moderate carbohydrate diets have greater effect on glycemic control in type 2 diabetes compared with high-carbohydrate diets in the first year of intervention. The greater the carbohydrate restriction, the greater glucose lowering, a relationship that has not been demonstrated earlier. Apart from this lowering of HbA1c over the short term, there is no superiority of low-carbohydrate diets in terms of glycemic control, weight, or LDL cholesterol.

Increased serum levels of AGEs, unlike serum levels of CML, are associated with heart stiffness in patients with type 1 diabetes, possibly mediated by the cross-linking properties of AGEs.

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The St Vincent Declaration, a joint initiative on diabetes care and research of the World Health Organization (Europe) and the International Diabetes Federation (Europe), includes 5-year targets for improvement in diabetes outcomes as a central tenet. Accordingly, the establishment of state of the art monitoring and control systems is urged as a basis for the implementation of quality management. As a prerequisite for both targets, a diabetes dataset (fields and definitions) has been agreed to allow common monitoring of diabetes throughout Europe. This dataset has been further developed as the foundation stone of DiabCare, an initiative for continuous quality development in diabetes care. In a formal consensus process using the Delphi method, over 130 European diabetologists from 21 countries contributed to the development of this dataset, which includes fields covering true patient outcomes, intermediate metabolic outcomes, markers of diabetes tissue damage, risk factors, pregnancy, and life-style. The tools for documentation of the quality of health status have been developed in three formats for use in different health care settings. These tools, the DiabCare Diabetes Dataset, the DiabCare Basic Information Sheet, and the DiabCare Computer Program, are designed to allow local feedback-driven improvement in the quality of care, but are also the subject of communication protocols to compare performance between centres, regions, and countries. Whether implemented with or without the benefits of modern information technology, these initiatives can be the basis for both monitoring the targets of the St Vincent Declaration and for implementation of continuing quality development in diabetes care.

38Diabetic patients have an increased risk of foot ulcers, and glycation of collagen may increase tissue 39 stiffness. We hypothesized that the level of glycemic control (glycation) may affect Achilles tendon 40 stiffness, which can influence gait pattern. We therefore investigated the relationship between 41 collagen glycation, Achilles tendon stiffness parameters and plantar pressure in poorly (n = 22) and 42 well (n = 22) controlled diabetic patients, including healthy age matched (45-70 yrs) controls (n = 43 11). There were no differences in any of outcome parameters (collagen cross-linking or tendon 44 stiffness) between patients with well-controlled and poorly controlled diabetes. The overall effect of 45 diabetes was explored by collapsing the diabetes groups (DB) compared to the controls. Skin 46 collagen cross-linking lysylpyridinoline (LP), hydroxylysylpyridinoline (HP), (136%, 80%, P < 47 0.01) and pentosidine concentrations (55%, P < 0.05) were markedly greater in DB. Furthermore, 48

ObjectiveTo assess the effect of metformin versus placebo both in combination with insulin analogue treatment on changes in carotid intima-media thickness (IMT) in patients with type 2 diabetes.Design and settingInvestigator-initiated, randomised, placebo-controlled trial with a 2×3 factorial design conducted at eight hospitals in Denmark.Participants and interventions412 participants with type 2 diabetes (glycated haemoglobin (HbA1c) ≥7.5% (≥58 mmol/mol); body mass index >25 kg/m2) were in addition to open-labelled insulin treatment randomly assigned 1:1 to 18 months blinded metformin (1 g twice daily) versus placebo, aiming at an HbA1c ≤7.0% (≤53 mmol/mol).OutcomesThe primary outcome was change in the mean carotid IMT (a marker of subclinical cardiovascular disease). HbA1c, insulin dose, weight and hypoglycaemic and serious adverse events were other prespecified outcomes.ResultsChange in the mean carotid IMT did not differ significantly between the groups (between-group difference 0.012 mm (95% CI −0.003 to 0.026), p=0.11). HbA1c was more reduced in the metformin group (between-group difference −0.42% (95% CI −0.62% to −0.23%), p<0.001)), despite the significantly lower insulin dose at end of trial in the metformin group (1.04 IU/kg (95% CI 0.94 to 1.15)) compared with placebo (1.36 IU/kg (95% CI 1.23 to 1.51), p<0.001). The metformin group gained less weight (between-group difference −2.6 kg (95% CI −3.3 to −1.8), p<0.001). The groups did not differ with regard to number of patients with severe or non-severe hypoglycaemic or other serious adverse events, but the metformin group had more non-severe hypoglycaemic episodes (4347 vs 3161, p<0.001).ConclusionsMetformin in combination with insulin did not reduce carotid IMT despite larger reduction in HbA1c, less weight gain, and smaller insulin dose compared with placebo plus insulin. However, the trial only reached 46% of the planned sample size and lack of power may therefore have affected our results.Trial registration numberNCT00657943; Results.

Background: Despite recommendations, many patients with type 2 diabetes receive dietary advice from nurses or doctors instead of individualized nutrition therapy (INT) that is provided by a dietitian. Objective: We performed a meta-analysis to compare the effect of INT that is provided by a registered dietitian with the effect of dietary advice that is provided by other healthcare professionals. Design: A systematic review was conducted of Cochrane library databases, EMBASE, CINAHL, and MEDLINE in the period 2004-2017 for guidelines, reviews, and randomized controlled trials (RCTs) that assessed the outcomes glycated hemoglobin (HbA1c), weight, body mass index (BMI; in kg/m 2 ), and LDL cholesterol. Risk of bias and the quality of evidence were assessed according to the Grading of Recommendations Assessment, Development and Evaluation guidelines. Results: We identified 5 RCTs comprising 912 participants in total.In the first year of intervention (at 6 or 12 mo), nutrition therapy compared with dietary advice was followed by a 0.45% (95% CI: 0.36%, 0.53%) lower mean difference in HbA1c, a 0.55 (95% CI: 0.02, 1.1) lower BMI, a 2.1-kg (95% CI: 1.2-, 2.9-kg) lower weight, and a 0.17-mmol/L (95% CI: 0.11-, 0.23-mmol/L) lower LDL cholesterol. No longer-term data were available. Some of the included studies had a potential bias, and therefore, the quality of the evidence was low or moderate. In addition, it was necessary to pool primary and secondary outcomes. Conclusions: INT that is provided by a dietitian compared with dietary advice that is provided by other health professionals leads to a greater effect on HbA1c, weight, and LDL cholesterol. Because of the potential bias, we recommend considering nutrition therapy that is provided by a dietitian as part of lifestyle intervention in type 2 diabetes, but further randomized studies are warranted.Am J Clin Nutr 2017;106:1394-400.

CIMT is designed to provide evidence as to whether metformin is advantageous even during insulin treatment and to provide evidence regarding which insulin analogue regimen is most advantageous with regard to cardiovascular disease.