There is, I think, something ethereal about i —the square root of minus one. I remember first hearing about it at school. It seemed an odd beast at that time—an intruder hovering on the edge of reality.

Usually familiarity dulls this sense of the bizarre, but in the case of i it was the reverse: over the years the sense of its surreal nature intensified. It seemed that it was impossible to write mathematics that described the real world in …

I and i

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 purpose of this Position Stand is to provide guidance to professionals who counsel and prescribe individualized exercise to apparently healthy adults of all ages. These recommendations also may apply to adults with certain chronic diseases or disabilities, when appropriately evaluated and advised by a health professional. This document supersedes the 1998 American College of Sports Medicine (ACSM) Position Stand, "The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Healthy Adults." The scientific evidence demonstrating the beneficial effects of exercise is indisputable, and the benefits of exercise far outweigh the risks in most adults. A program of regular exercise that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health is essential for most adults. The ACSM recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for ≥30 min·d on ≥5 d·wk for a total of ≥150 min·wk, vigorous-intensity cardiorespiratory exercise training for ≥20 min·d on ≥3 d·wk (≥75 min·wk), or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500-1000 MET·min·wk. On 2-3 d·wk, adults should also perform resistance exercises for each of the major muscle groups, and neuromotor exercise involving balance, agility, and coordination. Crucial to maintaining joint range of movement, completing a series of flexibility exercises for each the major muscle-tendon groups (a total of 60 s per exercise) on ≥2 d·wk is recommended. The exercise program should be modified according to an individual's habitual physical activity, physical function, health status, exercise responses, and stated goals. Adults who are unable or unwilling to meet the exercise targets outlined here still can benefit from engaging in amounts of exercise less than recommended. In addition to exercising regularly, there are health benefits in concurrently reducing total time engaged in sedentary pursuits and also by interspersing frequent, short bouts of standing and physical activity between periods of sedentary activity, even in physically active adults. Behaviorally based exercise interventions, the use of behavior change strategies, supervision by an experienced fitness instructor, and exercise that is pleasant and enjoyable can improve adoption and adherence to prescribed exercise programs. Educating adults about and screening for signs and symptoms of CHD and gradual progression of exercise intensity and volume may reduce the risks of exercise. Consultations with a medical professional and diagnostic exercise testing for CHD are useful when clinically indicated but are not recommended for universal screening to enhance the safety of exercise.

/pdf/quantity-and-quality-of-exercise-for-developing-and-1fohxlhqop.pdf

Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults: Guidance for Prescribing Exercise

The metabolic syndrome

admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

Renal sinus fat (RSF) is an ectopic fat depot shown to be associated with visceral adiposity and hypertension in predominantly white populations. The purpose of this analysis is to investigate RSF and associations between RSF and blood pressure in a cohort of African American (AA) and European American (EA) adults. A secondary purpose was to explore risk factors associated with RSF. Participants were 116 A A and EA adult men and women. Ectopic fat depots were assessed with MRI: RSF, intraabdominal adipose tissue (IAAT), intermuscular adipose tissue (IMAT), perimuscular adipose tissue (PMAT), and liver fat. Cardiovascular measures included diastolic blood pressure (DBP), systolic blood pressure (SBP), pulse pressure, mean arterial pressure, and flow mediated dilation. Matsuda index was calculated for insulin sensitivity. Pearson correlations were used to investigate associations of RSF with cardiovascular measures. Multiple linear regression was used to evaluate contributions of RSF on SBP and DBP and to explore factors associated with RSF. No difference was observed in RSF between AA and EA participants. RSF was positively associated with DBP in AA participants, but this was not independent of age and sex. Age, male sex, and total body fat were positively associated with RSF in AA participants. Insulin sensitivity was inversely and IAAT and PMAT were positively associated with RSF in EA participants. Differential associations of RSF with age, insulin sensitivity, and adipose depots among AA and EA adults suggest unique pathophysiological mechanisms influence RSF deposition, which may contribute to chronic disease etiology and progression. 

Associations of renal sinus fat with blood pressure and ectopic fat in a diverse cohort of adults

for 1 yr following weight loss in overweight women Aerobic exercise training conserves insulin sensitivity

Low circulating concentrations of the natriuretic peptides (NPs) have been associated with greater risk for Type 2 diabetes (T2D). As a group, African Americans (AA) have lower NP levels and are disproportionately burdened by T2D. Insulin, which is higher in AA, has been shown to regulate NP concentration by increasing the NP clearance receptor. This secondary analysis tests the hypothesis that higher insulin in AA will be associated with lower levels of plasma N-terminal pro-atrial natriuretic peptide (NT-proANP).
 
 Participants were 120 AA and European American (EA) men and women ages 19-45 years. Measures of insulin, including fasting insulin and insulin total and incremental area under the curve (AUC and iAUC, respectively, at 30 and 120 m), were derived from an oral glucose tolerance test (OGTT). Insulin sensitivity (SI
 Clamp
 ) was assessed using the euglycemic glucose clamp. NT-proANP was measured from fasting samples obtained during the OGTT. Differences in NT-proANP by race was evaluated with analysis of covariance while adjusting for age, sex, and BMI. Linear regression models were used to examine associations between NT-proANP and insulin measures while adjusting for age, sex, race, and BMI.
 
 Relative to EA, AA had higher insulin concentrations, lower insulin sensitivity, and lower NT-proANP levels (p<0.05). Fasting insulin and 30 m insulin AUC were inversely associated with NT-proANP (p=0.02, p=0.02, and p=0.04, respectively).
 These results suggest that the lower NT-proANP observed in AA is related to higher insulin. Future research is needed to investigate the relationship between insulin, ANP, and the NP clearance receptor, particularly in populations at risk for chronic disease.

Abstract P157: Racial Differences In Atrial Natriuretic Peptide And Insulin

Reply to G Muscogiuri et al

Background Aerobic exercise training has well established effects on increasing insulin sensitivity. However, the extent to which exercise in the absence of weight loss and/or negative energy balance results in sustained elevation in insulin sensitivity is unclear. Objective This study aimed to assess the effects of long-term aerobic exercise training on insulin sensitivity in healthy premenopausal women while controlling for energy balance. Design Female participants ages 20–40 (Mean BMI=27.0) trained three times per week throughout the study on a cycle ergometer under supervision of an exercise physiologist. Participants completed a pre-training evaluation and three post-training evaluations at times ranging from 8 to 20 weeks post-baseline, including insulin sensitivity and peak VO2 testing. Before each evaluation, participants stayed overnight in a room calorimeter for 23 h and food intake was adjusted to maintain energy balance. A cycle ergometer graded exercise test was completed after warm-up to determine peak oxygen uptake (VO2peak). Hyperinsulinemic-euglycemic clamp measures were conducted to determine insulin sensitivity. Adjusted and unadjusted models were performed for log insulin sensitivity and peak VO2 using linear model for repeated measures. Results Data from 31 participants with complete data were analyzed. The models determined that mean VO2peak (F = 5.56 (3,89) p = 0.0015) and mean insulin sensitivity (F = 3.92 (3,65) p = 0.0123) differed among timepoints. Exercise training elicited an increase in VO2peak from pre-training (25.5 ± 1.15) to all three post-training evaluations (26.7 ± 1.15 vs. 27.4 ± 1.07 vs. 27.2 ± 1.17, respectively). In contrast, insulin sensitivity increased from pre-training to first post-training evaluation, but then returned to levels not different from baseline at the subsequent two evaluations. Conclusions Improvement in insulin sensitivity resulting from exercise training appears to be transient and returns to baseline with continued training.

Barbara A. Gower

Papers

Associations of renal sinus fat with blood pressure and ectopic fat in a diverse cohort of adults

for 1 yr following weight loss in overweight women Aerobic exercise training conserves insulin sensitivity

Abstract P157: Racial Differences In Atrial Natriuretic Peptide And Insulin

Reply to G Muscogiuri et al

Transient effect of aerobic exercise training on insulin sensitivity