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

Gene families are growing rapidly, but standard methods for inferring phylogenies do not scale to alignments with over 10,000 sequences. We present FastTree, a method for constructing large phylogenies and for estimating their reliability. Instead of storing a distance matrix, FastTree stores sequence profiles of internal nodes in the tree. FastTree uses these profiles to implement neighbor-joining and uses heuristics to quickly identify candidate joins. FastTree then uses nearest-neighbor interchanges to reduce the length of the tree. For an alignment with N sequences, L sites, and a different characters, a distance matrix requires O(N^2) space and O(N^2 L) time, but FastTree requires just O( NLa + N sqrt(N) ) memory and O( N sqrt(N) log(N) L a ) time. To estimate the tree's reliability, FastTree uses local bootstrapping, which gives another 100-fold speedup over a distance matrix. For example, FastTree computed a tree and support values for 158,022 distinct 16S ribosomal RNAs in 17 hours and 2.4 gigabytes of memory. Just computing pairwise Jukes-Cantor distances and storing them, without inferring a tree or bootstrapping, would require 17 hours and 50 gigabytes of memory. In simulations, FastTree was slightly more accurate than neighbor joining, BIONJ, or FastME; on genuine alignments, FastTree's topologies had higher likelihoods. FastTree is available at http://microbesonline.org/fasttree.

/pdf/fast-tree-computing-large-minimum-evolution-trees-with-4grq0gwfpy.pdf

Fast Tree: Computing Large Minimum-Evolution Trees with Profiles instead of a Distance Matrix

The authors have taken the liberty of presenting this manuscript in two parts. The first is a brief primer on microbial ecology, because, although the importance of microbial ecology in periodontal diseases is widely recognized, most of us do not know precisely what is meant by the term. The second section is a rather extensive overview of current studies of oral microbial ecology based almost entirely on recent in vivo studies.

https://laurieximenez.files.wordpress.com/2011/02/ref-2_socransky-2005_p2000.pdf

Periodontal microbial ecology.

Humans are virtually identical in their genetic makeup, yet the small differences in our DNA give rise to tremendous phenotypic diversity across the human population. By contrast, the metagenome of the human microbiome—the total DNA content of microbes inhabiting our bodies—is quite a bit more variable, with only a third of its constituent genes found in a majority of healthy individuals. Understanding this variability in the “healthy microbiome” has thus been a major challenge in microbiome research, dating back at least to the 1960s, continuing through the Human Microbiome Project and beyond. Cataloguing the necessary and sufficient sets of microbiome features that support health, and the normal ranges of these features in healthy populations, is an essential first step to identifying and correcting microbial configurations that are implicated in disease. Toward this goal, several population-scale studies have documented the ranges and diversity of both taxonomic compositions and functional potentials normally observed in the microbiomes of healthy populations, along with possible driving factors such as geography, diet, and lifestyle. Here, we review several definitions of a ‘healthy microbiome’ that have emerged, the current understanding of the ranges of healthy microbial diversity, and gaps such as the characterization of molecular function and the development of ecological therapies to be addressed in the future.

/pdf/the-healthy-human-microbiome-1rjspdir39.pdf

The healthy human microbiome

The proportion of older people continues to grow worldwide, especially in developing countries. Non-communicable diseases are fast becoming the leading causes of disability and mortality, and in coming decades health and social policy-makers will face tremendous challenges posed by the rapidly changing burden of chronic diseases in old age. Chronic disease and most oral diseases share common risk factors. Globally, poor oral health amongst older people has been particularly evident in high levels of tooth loss, dental caries experience, and the prevalence rates of periodontal disease, xerostomia and oral precancer/cancer. The negative impact of poor oral conditions on the quality of life of older adults is an important public health issue, which must be addressed by policy-makers. The means for strengthening oral health programme implementation are available; the major challenge is therefore to translate knowledge into action programmes for the oral health of older people. The World Health Organization recommends that countries adopt certain strategies for improving the oral health of the elderly. National health authorities should develop policies and measurable goals and targets for oral health. National public health programmes should incorporate oral health promotion and disease prevention based on the common risk factors approach. Control of oral disease and illness in older adults should be strengthened through organization of affordable oral health services, which meet their needs. The needs for care are highest among disadvantaged, vulnerable groups in both developed and developing countries. In developing countries the challenges to provision of primary oral health care are particularly high because of a shortage of dental manpower. In developed countries reorientation of oral health services towards prevention should consider oral care needs of older people. Education and continuous training must ensure that oral health care providers have skills in and a profound understanding of the biomedical and psychosocial aspects of care for older people. Research for better oral health should not just focus on the biomedical and clinical aspects of oral health care; public health research needs to be strengthened particularly in developing countries. Operational research and efforts to translate science into practice are to be encouraged. WHO supports national capacity building in the oral health of older people through intercountry and interregional exchange of experiences.

https://who.int/oral_health/publications/en/orh_cdoe05_vol33.pdf

Improving the oral health of older people: the approach of the WHO Global Oral Health Programme

The loss of teeth is known to influence the mastication of foods and nutritional status. Therefore, we hypothesize that poor dentition status can impair the systemic health of the aged. To clarify the influence of dentition status on deterioration in physical ability, mental impairment, and mortality, we conducted a six-year prospective cohort study of the institutionalized elderly living in 29 of the 30 institutions for the elderly in Kitakyushu, Japan. Bivariate analysis revealed that worse dentition status at baseline led to significantly worse physical and mental impairment, and higher mortality. In a multiple logistic regression analysis, the physical ability of edentulous subjects without dentures significantly deteriorated compared with that of dentate subjects with 20 or more teeth. The six-year mortality rate of the edentulous subjects without dentures was significantly higher than that of the subjects with 20 or more teeth. Poorer dentition status, especially edentulousness without dentures, may therefore be related to deterioration in the systemic health of the aged.

Influence of Dentition Status on Physical Disability, Mental Impairment, and Mortality in Institutionalized Elderly People:

Upper body obesity, related to visceral fat accumulation, is known to increase the risk of various adult diseases, especially type 2 diabetes and cardiovascular disease. This study was conducted to clarify the relationship between upper body obesity and periodontitis. We studied 643 apparently healthy, dentulous Japanese adults who attended programs at Fukuoka Health Promotion Center. Waist-hip ratio, body-mass index (BMI), and body fat were significant risk indicators for periodontitis after adjustment for known risk factors (p < 0.002). Subjects were divided into four BMI (or body fat) categories. In only the subjects with high waist-hip ratio, higher categories of BMI (or body fat) significantly increased the adjusted risk of periodontitis, compared with subjects with low waist-hip ratios and the lowest category of BMI (or body fat). The reported relationship between cardiovascular disease and periodontitis should be reconsidered, since abdominal adiposity or visceral fat can be related to both diseases.

Relationship between Upper Body Obesity and Periodontitis

To the Editor: We recently noted a relation between obesity, which is a risk factor for various diseases, and periodontitis, which is a major cause of tooth loss in adults. We studied 241 apparentl...

Obesity and Periodontitis

Background: Recent studies have reported a relationship between obesity and periodontal disease. Obesity is the strongest risk factor for type 2 diabetes, which is, in turn, a risk factor for periodontal disease. An oral glucose tolerance test is necessary to diagnose diabetes; however, no study has examined the relationship between obesity and periodontal disease by taking oral glucose tolerance test results into consideration.



Methods:  In all, 584 Japanese women aged between 40 and 79 years old, with at least 10 teeth, underwent health examinations. Body mass index, waist–hip ratio, body fat, and oral glucose tolerance test results were used as independent variables with known risk factors for periodontal disease. Mean probing pocket depth and mean attachment loss were used as the dependent variables.



Results:  In all of the analyses, body mass index, body fat, and waist–hip ratio were significantly associated with the highest quintile of mean probing pocket depth, even when adjusted for oral glucose tolerance test results. In the multivariate analysis, the subjects with the highest quartile of body mass index had a significantly higher odds ratio (OR) for the highest quintile of mean probing pocket depth [OR, 4.3; 95% confidence interval (CI), 2.1–8.9; p < 0.001], whereas neither impaired glucose tolerance nor diabetes were significantly associated with deep pockets. The relationships between the obesity indexes and mean attachment loss did not reach statistical significance.



Conclusion:  Obesity was associated with deep pockets in Japanese women, even after adjusting for oral glucose tolerance test.

Relationship between obesity, glucose tolerance, and periodontal disease in Japanese women : the Hisayama study

Being overweight and obese are important riskfactors for various adult diseases, including type 2diabetes, hyperlipemia, hypertension, cholelithiasis,arteriosclerosis, and cardiovascular and cerebro-vascular disease (31). Type 2 diabetes is rapidlybecoming prevalent in Japan and the U.S.A. and ismuch more common in the obese. Cardiovasculardisease is the most common cause of death and ac-counts for more than 17 million deaths annually. TheWorld Health Organization (WHO) estimated that 1billion people were overweight [body mass index(BMI) > 25] or obese (BMI > 30) in 2005 and thenumber will increase to 1.5 billion by 2015 if currenttrends continue (85). Although obesity was onceconsidered a health problem only in wealthy coun-tries, the WHO now states that obesity is rising dra-matically in poor and intermediate countries. This isthe result of a number of lifestyle-related factors,including a global shift in diet towards increasedenergy, fat, and sugar intake, and a trend towardsdecreased physical activity because of the sedentarynature of modern work and transportation.Recently, obesity has emerged as one of the riskindicators of periodontal disease (Fig. 1A) and con-versely, the remote effects of periodontal disease onvarious systemic diseases have been proposed(Fig. 2). Among the systemic health disorders shownin Fig. 2, type 2 diabetes and cardiovascular diseaseare established obesity-related diseases (25, 31, 45,67). If obesity is a true risk factor for periodontaldisease, the association among periodontal disease,obesity, and type 2 diabetes or cardiovascular diseasemust be very complex because each is a confoundingfactor for the other. In addition, several studies havesuggested that periodontal disease affects both glu-cose and lipid metabolisms, which are themselvesvery important factors in the development of bothtype 2 diabetes and cardiovascular disease. Consid-ering these issues, the knowledge from various recentreports must be consolidated. The ﬁrst part of thisdocument reviews the relationship between obesityand periodontal disease. Then, it reviews and dis-cusses reports on the inﬂuence of periodontal diseaseon obesity-related metabolic disorders, such as glu-cose and lipid metabolism, which cause glucoseintolerance and dyslipidemia.

Yoshihiro Shimazaki

Papers

Influence of Dentition Status on Physical Disability, Mental Impairment, and Mortality in Institutionalized Elderly People:

Relationship between Upper Body Obesity and Periodontitis

Obesity and Periodontitis

Relationship between obesity, glucose tolerance, and periodontal disease in Japanese women : the Hisayama study

Metabolic disorders related to obesity and periodontal disease.