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

We review the literature on the familial resemblance of body mass index (BMI) and other adiposity measures and find strikingly convergent results for a variety of relationships. Results from twin studies suggest that genetic factors explain 50 to 90% of the variance in BMI. Family studies generally report estimates of parent–offspring and sibling correlations in agreement with heritabilities of 20 to 80%. Data from adoption studies are consistent with genetic factors accounting for 20 to 60% of the variation in BMI. Based on data from more than 25,000 twin pairs and 50,000 biological and adoptive family members, the weighted mean correlations are .74 for MZ twins, .32 for DZ twins, .25 for siblings, .19 for parent–offspring pairs, .06 for adoptive relatives, and .12 for spouses. Advantages and disadvantages of twin, family, and adoption studies are reviewed. Data from the Virginia 30,000, including twins and their parents, siblings, spouses, and children, were analyzed using a structural equation model (Stealth) which estimates additive and dominance genetic variance, cultural transmission, assortative mating, nonparental shared environment, and special twin and MZ twin environmental variance. Genetic factors explained 67% of the variance in males and females, of which half is due to dominance. A small proportion of the genetic variance was attributed to the consequences of assortative mating. The remainder of the variance is accounted for by unique environmental factors, of which 7% is correlated across twins. No evidence was found for a special MZ twin environment, thereby supporting the equal environment assumption. These results are consistent with other studies in suggesting that genetic factors play a significant role in the causes of individual differences in relative body weight and human adiposity.

Genetic and environmental factors in relative body weight and human adiposity.

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure

textBackground: A region-specific (urban and rural parts of north, east, west, and south India) systematic review and meta-analysis of the prevalence, awareness, and control of hypertension among Indian patients have not been done before. Methods: Medline, Web of Science, and Scopus databases from 1950 to 30 April 2013 were searched for 'prevalence, burden, awareness, and control of blood pressure (BP) or hypertension (140 SBP and or 90 DBP) among Indian adults' (18 years). Of the total 3047 articles, 142 were included. Results: Overall prevalence for hypertension in India was 29.8% (95% confidence interval: 26.7-33.0). Significant differences in hypertension prevalence were noted between rural and urban parts [27.6% (23.2-32.0) and 33.8% (29.7-37.8); P=0.05]. Regional estimates for the prevalence of hypertension were as follows: 14.5% (13.3-15.7), 31.7% (30.2-33.3), 18.1% (16.9-19.2), and 21.1% (20.1-22.0) for rural north, east, west, and south India; and 28.8% (26.9-30.8), 34.5% (32.6-36.5), 35.8% (35.2-36.5), and 31.8% (30.4-33.1) for urban north, east, west, and south India, respectively. Overall estimates for the prevalence of awareness, treatment, and control of BP were 25.3% (21.4-29.3), 25.1% (17.0-33.1), and 10.7% (6.5-15.0) for rural Indians; and 42.0% (35.2-48.9), 37.6% (24.0-51.2), and 20.2% (11.6-28.7) for urban Indians. Conclusion: About 33% urban and 25% rural Indians are hypertensive. Of these, 25% rural and 42% urban Indians are aware of their hypertensive status. Only 25% rural and 38% of urban Indians are being treated for hypertension. One-tenth of rural and one-fifth of urban Indian hypertensive population have their BP under control.

Hypertension in India: A systematic review and meta-analysis of prevalence, awareness, and control of hypertension

Background—Preeclampsia is a pregnancy-specific disorder resulting in hypertension and multiorgan dysfunction. There is growing evidence that these effects persist after pregnancy. We aimed to syst...

Preeclampsia and Future Cardiovascular Health: A Systematic Review and Meta-Analysis.

Background: The blood pressure and anthropometric measurements are important for evaluating the health of children, adolescents as well as adults. Aim: The aim is to study the blood pressure and body dimensions and to find out the prevalence of overweight/obesity and hypertension among adults. Materials and Methods: A cross-sectional study was conducted of all the people belonging to the Punjabi community, residing in Roshanara area and Jaina building in Delhi, for the past 20 years and aged 18-50 years. The men were engaged in transport business and women were mainly housewives. Results: Mean values of all the measurements, that is, height, weight, upper arm circumference, pulse rate, systolic blood pressure (SBP), and diastolic blood pressure (DBP) were higher among males as compared with females, except skinfold thicknesses. Body mass index (BMI) and fat percentage was found to be higher among females as compared with males. There was a significant positive correlation between BMI, fat percentage, and blood pressure both SBP as well as DBP. Odds ratio showed that overweight/obese subjects were more likely to have hypertension than those with normal BMI. Conclusion: Prevalence of prehypertension among overweight/obese suggested an early clinical detection of prehypertension and intervention including life style modification, particularly weight management.

Body Mass Index Relates to Blood Pressure Among Adults

Purpose. To find the prevalence of overweight/obesity and hypertension, and to study the association between BMI, blood pressure, and age. Methods. Cross-sectional study was carried out among 257 Tangkhul Naga males of Northeast India, age ranging from 20–70 years. The subjects were divided into five different age groups to study age trend. Results. Mean systolic, and diastolic BP was higher among subjects with elevated BMI and among older subjects. Minimum BP was found among underweight and maximum among obese. BP was found lowest among the youngest age group and higher among the elderly subjects. BMI was also found to be associated with age independently. Although the magnitude of correlation differed, there was significant positive correlation among BMI, age, systolic and diastolic BP. Odd ratios showed overweight/obese subjects to be more likely to have hypertension than those with normal BMI. Changing socioeconomic environment intensifies the prevalence of overweight/obesity and hypertension among the Tangkhul Nagas.

/pdf/association-between-bmi-blood-pressure-and-age-study-among-2x1k4dpzx2.pdf

Association between BMI, Blood Pressure, and Age: Study among Tangkhul Naga Tribal Males of Northeast India

Objective: To study the relationship of ethnicity with overweight/obesity, variation in adiposity levels, regional distribution of fat and its impact on cardio-respiratory health among selected ethnic groups. Materials and methods : A cross-sectional study was carried out among 300 young adults of three ethnic groups from different geographical regions of India ranging in age from 20 to 30 years. Stature, weight, circumferences, body fat percentage, and skinfold thicknesses were measured. Obesity indices like body mass index (BMI), grand mean thickness (GMT), waist hip ratio (WHR), waist height ratio (WHtR), and conicity index (CI) were computed. Cardio-respiratory health indicators such as lung functions including forced expiratory volume in 1 s (FEV 1.0 ), forced vital capacity (FVC), forced expiratory ratio (FER), peak expiratory flow rate (PEFR), breath holding time (BHT), and systolic and diastolic BP (blood pressure) were taken and associated with obesity indices. Results: General body fat deposition, assessed by BMI, GMT, and fat percentage, was found to be the highest among Delhi females and males. However, central adiposity as assessed from WHR, WHtR, and CI was found to be significantly higher among the Manipur subjects signifying a relatively more androidal pattern of fat deposition. Most of the inter-group differences for adiposity indices were significant; however, it was not so in the case of blood pressure among different ethnic groups. On the other hand, the respiratory efficiency varied significantly between different ethnic groups. Ethnicity, adiposity, and cardio-respiratory health were found to be interrelated. Conclusions: Subjects belonging to three ethnic groups showed marked differences in different body dimension, adiposity indices, and cardio-respiratory health. Central obesity has been found to be a better pointer for cardiovascular health risk. There were ethnic and gender differences with respect to adiposity measures and cardio-respiratory health indicators

Ethnicity, obesity and health pattern among Indian population

Objective: The aim of our study was to investigate blood pressure (BP) levels and their association with different indices of body fat in adult Baniyas. Design and setting: A cross-sectional survey was carried out on an endogamous group of 577 adults (307 females and 270 males) aged 25–60 years in Delhi, India. Methods: Data were collected for weight, height, waist circumference and blood pressure using standardized procedure. Body mass index (BMI), waist to hip ratio (WHR), waist to height ratio (WHtR) and grand mean thickness (GMT) were calculated to assess obesity. Also, the sex-specific prevalence estimates for various BP categories was calculated. Correlation was calculated between systolic and diastolic BP and various indices of obesity. Odds ratios for association of hypertension with obesity indices were obtained using multiple logistic regression. Results: Prevalence of prehypertension and hypertension was higher among males and prevalence of obesity was higher in females. Correlations of BP with all indices of obesity were significant. Odds ratio of hypertension was higher in males than in females for all the indices of obesity at 95% CI. Conclusion: Although obesity was found to be higher among females, males were found to be at higher risk of hypertension. High odds ratios of obesity indicate that the optimum cut-off should be calculated for screening those who are at-risk of becoming hypertensive and thus are at the greater risk of developing cardiovascular diseases. (Ethn Dis. 2010;20:370–375)

Sex differences in blood pressure levels and its association with obesity indices: who is at greater risk.

The aim of the study was to determine the cut-offs of anthropometric markers for detecting hypertension in an endogamous North Indian population. A cross-sectional study was carried out to collect data from 578 adult Aggarwal Baniya subjects (271 men and 307 women, mean age: 43.4 ± 5.3 and 38.7 ± 4.9 respectively) using multistage, stratified sampling method. Individual body weight, height, waist circumference (WC), hip circumference, blood pressure were assessed. Receiver operating characteristic (ROC) analysis was used to find out the optimal cut-off values of various anthropometric markers to predict hypertension. The likelihood ratios for having hypertension in subjects with various cut-off values were calculated. Logistic regression analysis was used to examine the independent relationship between the anthropometric markers and odds of having hypertension. The BMI cut-off to predict hypertension was 22.8 kg/m2 in men and 28.8 kg/m2 in women. The optimal WC cut-offs varied from 91–92 cm in both men and women. The WHR cut-off was about 0.90 in men and 0.78 in women respectively, and the optimal WHtR cut-off was 0.56 in men and 0.43 in women. The cut-off levels for BMI, WC and WHtR corresponded to the inflexion points in the likelihood ratio graphs. The area under curve (AUC) and odds ratios showed that the risk of having hypertension was highest with respect to increased BMI and that BMI is the best predictor of having hypertension. The cut-off points for detecting cardiovascular risk factors among our population are lower than the criteria by the World Health Organization. Although these results may not be readily applied to the rest of the Indian populations due to the multiethnic composition, they point to the necessity of similar studies with large randomized samples to find the cut-off levels for chronic conditions in different populations.

Satwanti Kapoor

Papers

Body Mass Index Relates to Blood Pressure Among Adults

Association between BMI, Blood Pressure, and Age: Study among Tangkhul Naga Tribal Males of Northeast India

Ethnicity, obesity and health pattern among Indian population

Sex differences in blood pressure levels and its association with obesity indices: who is at greater risk.

Optimal cut-off values of anthropometric markers to predict hypertension in North Indian population.