XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

1. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification and diagnosis of diabetes

Statistical Methods for Health Care Research

Objective: Our objective was to update the guidelines for the evaluation and treatment of androgen deficiency syndromes in adult men published previously in 2006. Participants: The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee of The Endocrine Society, five additional experts, a methodologist, and a medical writer. The Task Force received no corporate funding or remuneration. Conclusions: We recommend making a diagnosis of androgen deficiency only in men with consistent symptoms and signs and unequivocally low serum testosterone levels. We suggest the measurement of morning total testosterone level by a reliable assay as the initial diagnostic test. We recommend confirmation of the diagnosis by repeating the measurement of morning total testosterone and, in some men in whom total testosterone is near the lower limit of normal or in whom SHBG abnormality is suspected by measurement of free or bioavailable testosterone level, using validated assays. We recommend testos...

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Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline.

Determination of vitamin D status in different age-groups in a community and in different climates of a country is necessary and has important implications for general health. The study was conducted to determine the prevalence of vitamin D deficiency among the adult population of Isfahan, a centrallylocated city in Iran. In this cross-sectional study, 1,111 healthy people-243 men and 868 women-aged 41.4 (mean 14 and range 20-80) years, who attended a single-consultation outpatient clinic, were selected. Serum 25-hydroxy vitamin D (25-OHD), parathyroid hormone (PTH), calcium and phosphorus concentrations were measured. Mild, moderate and severe vitamin D deficiencies were defined as 25-OHD values of 20-30 ng/mL, 10-20 ng/mL, and <10 ng/mL respectively. The median (range) concentrations of 25-OHD were 21 (4.0-105.0) ng/mL in males and 18 (1.5-117) ng/mL in females (p=0.05). The prevalence of mild, moderate and severe vitamin D deficiencies among the adult population was 19.6%, 23.9%, and 26.9% respectively. Vitamin D deficiency was more prevalent among women (p=0.001) and younger age-group (p=0.001). Medians of 25-OHD in spring-summer and autumn-winter were 21 ng/mL and 18 ng/mL respectively (p=0.005). The prevalence of severe vitamin D deficiency was higher in autumn-winter than in spring-summer (odds ratio=1.6, 95% confidence interval 1.2-2.2, p=0.001). The prevalence of vitamin D deficiency was high in a sunny city-Isfahan- especially among women and younger population. The high prevalence of vitamin D deficiency in this city emphasizes the necessity of vitamin D supplementation as more exposure to sun is limited due to the type of clothing required by current law. Key words: Adult; Cross-sectional studies; Parathyroid hormone; Seasonal variation; Vitamin D deficiency; Iran DOI: http://dx.doi.org/10.3329/jhpn.v29i2.7857 J HEALTH POPUL NUTR 2011 Apr;29(2):149-155

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Prevalence of Vitamin D Deficiency among Adult Population of Isfahan City, Iran

Depression is a common co-morbidity in patients with type 2 diabetes mellitus (T2DM). Untreated depression in these patients adversely affects self-care activities and other diabetes complications. The aim of this study is to estimate the prevalence of depression among patients with T2DM by conducting a meta-analysis of observational studies. MEDLINE, Web of Science, Science Direct, and Google Scholar databases were searched for all observational studies that assessed depression in T2DM. Relevant articles were searched using the combination of Medical Subject Heading (MeSH) terms of “depression”, “depressive disorder”, and “diabetes mellitus” published between January 2007 and July 2018. Random effects model was used to estimate the weighted prevalence rates and 95% CI using “metaprop program in STATA 11”. In total, the 248 included studies (with 273 reported prevalence) identified 83,020,812 participants; of them, 23,245,827 (28%; 95% CI 27, 29) suffered from different severity levels of depressive disorders. The prevalence of depression was separately reported in 137,372 males and 134,332 females. Of them, 31,396 males (23%, 95% CI: 20, 26) and 45,673 females (34%, 95% CI: 31, 38) were depressed. Compared with global estimate, depression prevalence was lower in Europe (24%) and Africa (27%), but higher in Australia (29%) and Asia (32%). The prevalence in America was equal to the estimated prevalence in the world (28%). Depression was more common in subjects younger than 65 compared with elderlies (31% vs. 21%). Our findings demonstrated that almost one in four adults with T2DM experienced depression. Given the high prevalence of depressive disorders in diabetic patients, screening these patients for co-morbid depression and its relevant risk factors is highly recommended.

The prevalence of comorbid depression in patients with type 2 diabetes: an updated systematic review and meta-analysis on huge number of observational studies.

Background and Aims: Vitamin D is important for calcium absorption and bone growth. Hypovitaminosis and vitamin D deficiency have been observed in developed and developing countries

Prevalence of vitamin D deficiency in Isfahani high school students in 2004.

OBJECTIVES: Oxidative stress can contribute to microvascular complications in diabetes. A decisive event associated with this condition may be the decrease in the synthesis of zinc-containing antioxidant enzymes such as superoxide dismutase and glutathione peroxidase. This consideration led us to investigate the effect of zinc supplementation versus placebo on microalbuminuria in diabetic patients in a randomized double blind clinical trial. METHODS: Fifty diabetic patients with microalbuminuria were enrolled. Fasting plasma glucose, HbA1c, lipid profiles, plasma zinc levels and random urine for albumin and creatinine were measured. Patients randomly received 30 mg elemental zinc (group 1) or placebo (group 2) for 3 months. After a 4 week wash-out period, the groups were crossed over (i.e. the zinc group were given placebo, and the placebo group were given zinc) and the protocol was repeated. RESULTS: From an initial number of 50 selected patients (25 in each of two groups), 39 patients (21 in group 1 and 18 in group 2) completed the study. In group 1, after zinc supplementation, urinary albumin excretion decreased significantly from 86.5 ± 57 to 75 ± 71 mg/g (p = 0.01). After placebo, patients in group 1 showed no significant reduction in microalbuminuria (85 ± 72 mg/g to 83 ± 63 mg/g creatinine). In group 2, no change in albumin excretion was observed after placebo treatment (90.5 ± 63 mg/g to 90 ± 60 mg/g creatinine). After zinc supplementation, a significant reduction was observed in albumin excretion, from 90 ± 60 mg/g to 85 ± 57 mg/g creatinine (p = 0.003). CONCLUSIONS: Zinc supplementation reduced albumin excretion in microalbuminuric type 2 diabetic patients. This outcome may be due to the antioxidant effect of zinc.

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Effect of Zinc Supplementation on Microalbuminuria in Patients With Type 2 Diabetes: A Double Blind, Randomized, Placebo-Controlled, Cross-Over Trial

BACKGROUND AND AIMS Vitamin D deficiency is one of the major health problems and unexpectedly has a high prevalence in sunny countries (e.g. Middle East). In this study we determined the prevalence of vitamin D deficiency in pregnant women and their newborns in Isfahan, a sunny city in Iran. METHODS In a cross-sectional study, 88 newborns born in Beheshty hospital, affiliated to Isfahan University of Medical Sciences (August-September, 2005) and their mothers were studied. Their data were collected by questionnaires and blood sampling was done to measure serum alkaline phosphatase (ALP), calcium, phosphorus, 25 (OH) vitamin D and parathormone (PTH). Vitamin D deficiency defined as levels of 25 (OH) D < 20 and < 12.5 ng/ml for mothers and newborns, respectively and local cut-offs defined as levels in which mean serum PTH started to increase. RESULTS The prevalence of vitamin D deficiency according to 25 (OH) D < 20 ng/ml in mothers and < 12.5 ng/ml in newborns was 5.7% and 4.5%, respectively. According to local cut-offs (35 ng/ml for mothers and 26 ng/ml for newborns) 26.1% of mothers and 53.4% of newborns were vitamin D deficient. CONCLUSION According to local definition, vitamin D deficiency is a health problem in pregnant women and their newborns in this sunny city.

Ashraf Aminorroaya

Papers

Prevalence of Vitamin D Deficiency among Adult Population of Isfahan City, Iran

The prevalence of comorbid depression in patients with type 2 diabetes: an updated systematic review and meta-analysis on huge number of observational studies.

Prevalence of vitamin D deficiency in Isfahani high school students in 2004.

Effect of Zinc Supplementation on Microalbuminuria in Patients With Type 2 Diabetes: A Double Blind, Randomized, Placebo-Controlled, Cross-Over Trial

Vitamin D deficiency among pregnant women and their newborns in Isfahan, Iran.