Showing papers in "Diabetes Care in 2002"
TL;DR: Differences in rates of progression between ethnic groups was reduced by adjustment for various lengths of follow-up and testing rates, so that women appeared to progress to type 2 diabetes at similar rates after a diagnosis of GDM.
Abstract: OBJECTIVE —To examine factors associated with variation in the risk for type 2 diabetes in women with prior gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS —We conducted a systematic literature review of articles published between January 1965 and August 2001, in which subjects underwent testing for GDM and then testing for type 2 diabetes after delivery. We abstracted diagnostic criteria for GDM and type 2 diabetes, cumulative incidence of type 2 diabetes, and factors that predicted incidence of type 2 diabetes. RESULTS —A total of 28 studies were examined. After the index pregnancy, the cumulative incidence of diabetes ranged from 2.6% to over 70% in studies that examined women 6 weeks postpartum to 28 years postpartum. Differences in rates of progression between ethnic groups was reduced by adjustment for various lengths of follow-up and testing rates, so that women appeared to progress to type 2 diabetes at similar rates after a diagnosis of GDM. Cumulative incidence of type 2 diabetes increased markedly in the first 5 years after delivery and appeared to plateau after 10 years. An elevated fasting glucose level during pregnancy was the risk factor most commonly associated with future risk of type 2 diabetes. CONCLUSIONS —Conversion of GDM to type 2 diabetes varies with the length of follow-up and cohort retention. Adjustment for these differences reveals rapid increases in the cumulative incidence occurring in the first 5 years after delivery for different racial groups. Targeting women with elevated fasting glucose levels during pregnancy may prove to have the greatest effect for the effort required.
2,063 citations
TL;DR: Self-management education improves GHb levels at immediate follow-up, and increased contact time increases the effect, suggesting that learned behaviors change over time.
Abstract: Objective To evaluate the efficacy of self-management education on GHb in adults with type 2 diabetes. Research design and methods We searched for English language trials in Medline (1980-1999), Cinahl (1982-1999), and the Educational Resources Information Center database (ERIC) (1980-1999), and we manually searched review articles, journals with highest topic relevance, and reference lists of included articles. Studies were included if they were randomized controlled trials that were published in the English language, tested the effect of self-management education on adults with type 2 diabetes, and reported extractable data on the effect of treatment on GHb. A total of 31 studies of 463 initially identified articles met selection criteria. We computed net change in GHb, stratified by follow-up interval, tested for trial heterogeneity, and calculated pooled effects sizes using random effects models. We examined the effect of baseline GHb, follow-up interval, and intervention characteristics on GHb. Results On average, the intervention decreased GHb by 0.76% (95% CI 0.34-1.18) more than the control group at immediate follow-up; by 0.26% (0.21% increase - 0.73% decrease) at 1-3 months of follow-up; and by 0.26% (0.05-0.48) at > or = 4 months of follow-up. GHb decreased more with additional contact time between participant and educator; a decrease of 1% was noted for every additional 23.6 h (13.3-105.4) of contact. Conclusions Self-management education improves GHb levels at immediate follow-up, and increased contact time increases the effect. The benefit declines 1-3 months after the intervention ceases, however, suggesting that learned behaviors change over time. Further research is needed to develop interventions effective in maintaining long-term glycemic control.
1,757 citations
TL;DR: Administrative data can be used to establish population-based incidence and prevalence of diabetes, which is increasing in Ontario and is considerably higher than self-reported rates.
Abstract: OBJECTIVE —Accurate information about the magnitude and distribution of diabetes can inform policy and support health care evaluation. We linked physician service claims (PSCs) and hospital discharge abstracts (HDAs) to determine diabetes prevalence and incidence. RESEARCH DESIGN AND METHODS —A retrospective cohort was constructed using administrative data from the national HDA database, PSCs for Ontario (population 11 million), and registries carrying demographics and vital statistics. All HDAs and PSCs bearing a diagnosis of diabetes (ICD9-CM 250) were selected for 1991–1999. Two previously reported algorithms for identification of diabetes were applied as follows: “1-claim” (any HDA or PSC showing diabetes) and “2-claim” (one HDA or two PSCs within 2 years showing diabetes). Incident cases were defined as individuals who met the criteria for diabetes for the first time after at least 2 years of observation. For validation, diagnostic data abstracted from primary care charts ( n =3,317) of 57 randomly selected physicians were linked to the administrative data cohort, and sensitivity and specificity were calculated. RESULTS —In 1998, 696,938 individuals met the 1-claim criteria and 528,280 met the 2-claim criteria. Sensitivity for diabetes was 90 and 86%; for the 1- and 2-claim algorithms, specificity was 92 and 97%, respectively, and positive predictive values were 61 and 80%, respectively. Using the 2-claim algorithm, the all-age prevalence increased from 3.2% in 1993 to 4.5% in 1998 (6.1% in adults). Incidence remained stable. CONCLUSIONS —Administrative data can be used to establish population-based incidence and prevalence of diabetes. Diabetes prevalence is increasing in Ontario and is considerably higher than self-reported rates.
1,218 citations
TL;DR: This 2002 technical review provides principles and recommendations classified according to the level of evidence available, and grades nutrition principles into four categories based on the available evidence: those with strong supporting evidence, those with some supporting evidence), those with limited supporting evidence and those based on expert consensus.
Abstract: Historically, nutrition principles and recommendations for diabetes and related complications have been based on scientific evidence and diabetes knowledge when available and, when evidence was not available, on clinical experience and expert consensus. Often it has been difficult to discern the level of evidence used to construct the nutrition principles and recommendations. Furthermore, in clinical practice, many nutrition recommendations that have no scientific supporting evidence have been and are still being given to individuals with diabetes. To address these problems and to incorporate the research done in the past 8 years, this 2002 technical review provides principles and recommendations classified according to the level of evidence available. It reviews the evidence from randomized, controlled trials; cohort and case-controlled studies; and observational studies, which can also provide valuable evidence (1,2), and takes into account the number of studies that have provided consistent outcomes of support. In this review, nutrition principles are graded into four categories based on the available evidence: those with strong supporting evidence, those with some supporting evidence, those with limited supporting evidence and those based on expert consensus.
Evidence-based nutrition recommendations attempt to translate research data and clinically applicable evidence into nutrition care. However, the best available evidence must still be moderated by individual circumstances and preferences. The goal of evidence-based recommendations is to improve the quality of clinical judgments and facilitate cost-effective care by increasing the awareness of clinicians and patients with diabetes of the evidence supporting nutrition services and the strength of that evidence, both in quality and quantity.
Before 1994, the American Diabetes Association’s (ADA’s) nutrition principles and recommendations attempted to define an “ideal” nutrition prescription that would apply to everyone with diabetes (3,4,5). Although individualization was a major principle of all recommendations, it was usually done within defined …
1,149 citations
TL;DR: Knowing the relationship between HbA(1c) and plasma glucose (PG) levels in patients with type 1 diabetes can help patients with diabetes and their healthcare providers set day-to-day targets for PG to achieve specific HBA( 1c) goals.
Abstract: OBJECTIVE — To define the relationship between HbA1c and plasma glucose (PG) levels in patients with type 1 diabetes using data from the Diabetes Control and Complications Trial (DCCT). RESEARCH DESIGN AND METHODS — The DCCT was a multicenter, randomized clinical trial designed to compare intensive and conventional therapies and their relative effects on the development and progression of diabetic complications in patients with type 1 diabetes. Quarterly HbA 1c and corresponding seven-point capillary blood glucose profiles (premeal, postmeal, and bedtime) obtained in the DCCT were analyzed to define the relationship between HbA 1c and PG. Only data from complete profiles with corresponding HbA1c were used (n 26,056). Of the 1,441 subjects who participated in the study, 2 were excluded due to missing data. Mean plasma glucose (MPG) was estimated by multiplying capillary blood glucose by 1.11. Linear regression analysis weighted by the number of observations per subject was used to correlate MPG and HbA 1c.
1,000 citations
TL;DR: Australia has a rapidly rising prevalence of diabetes and other categories of abnormal glucose tolerance, one of the highest yet reported from a developed nation with a predominantly Europid background.
Abstract: OBJECTIVE —To determine the population-based prevalence of diabetes and other categories of glucose intolerance (impaired glucose tolerance [IGT] and impaired fasting glucose [IFG]) in Australia and to compare the prevalence with previous Australian data.
RESEARCH DESIGN AND METHODS —A national sample involving 11,247 participants aged ≥25 years living in 42 randomly selected areas from the six states and the Northern Territory were examined in a cross-sectional survey using the 75-g oral glucose tolerance test to assess fasting and 2-h plasma glucose concentrations. The World Health Organization diagnostic criteria were used to determine the prevalence of abnormal glucose tolerance.
RESULTS —The prevalence of diabetes in Australia was 8.0% in men and 6.8% in women, and an additional 17.4% of men and 15.4% of women had IGT or IFG. Even in the youngest age group (25–34 years), 5.7% of subjects had abnormal glucose tolerance. The overall diabetes prevalence in Australia was 7.4%, and an additional 16.4% had IGT or IFG. Diabetes prevalence has more than doubled since 1981, and this is only partially explained by changes in age profile and obesity.
CONCLUSIONS —Australia has a rapidly rising prevalence of diabetes and other categories of abnormal glucose tolerance. The prevalence of abnormal glucose tolerance in Australia is one of the highest yet reported from a developed nation with a predominantly Europid background.
977 citations
TL;DR: The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of autoantibodies, urine albumin, insulin, proinsulin, C-peptide, and other analytes are addressed.
Abstract: BACKGROUND Multiple laboratory tests are used to diagnose and manage patients with diabetes mellitus. The quality of the scientific evidence supporting the use of these tests varies substantially. APPROACH An expert committee compiled evidence-based recommendations for the use of laboratory testing for patients with diabetes. A new system was developed to grade the overall quality of the evidence and the strength of the recommendations. Draft guidelines were posted on the Internet and presented at the 2007 Arnold O. Beckman Conference. The document was modified in response to oral and written comments, and a revised draft was posted in 2010 and again modified in response to written comments. The National Academy of Clinical Biochemistry and the Evidence-Based Laboratory Medicine Committee of the American Association for Clinical Chemistry jointly reviewed the guidelines, which were accepted after revisions by the Professional Practice Committee and subsequently approved by the Executive Committee of the American Diabetes Association. CONTENT In addition to long-standing criteria based on measurement of plasma glucose, diabetes can be diagnosed by demonstrating increased blood hemoglobin A 1c (HbA 1c ) concentrations. Monitoring of glycemic control is performed by self-monitoring of plasma or blood glucose with meters and by laboratory analysis of HbA 1c . The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of autoantibodies, urine albumin, insulin, proinsulin, C-peptide, and other analytes are addressed. SUMMARY The guidelines provide specific recommendations that are based on published data or derived from expert consensus. Several analytes have minimal clinical value at present, and their measurement is not recommended.
834 citations
TL;DR: PRT as an adjunct to standard of care is feasible and effective in improving glycemic control and some of the abnormalities associated with the metabolic syndrome among high-risk older adults with type 2 diabetes.
Abstract: OBJECTIVE—To determine the efficacy of high-intensity progressive resistance training (PRT) on glycemic control in older adults with type 2 diabetes. RESEARCH DESIGN AND METHODS—We performed a 16-week randomized controlled trial in 62 Latino older adults (40 women and 22 men; mean ± SE age 66 ± 8 years) with type 2 diabetes randomly assigned to supervised PRT or a control group. Glycemic control, metabolic syndrome abnormalities, body composition, and muscle glycogen stores were determined before and after the intervention. RESULTS—Sixteen weeks of PRT (three times per week) resulted in reduced plasma glycosylated hemoglobin levels (from 8.7 ± 0.3 to 7.6 ± 0.2%), increased muscle glycogen stores (from 60.3 ± 3.9 to 79.1 ± 5.0 mmol glucose/kg muscle), and reduced the dose of prescribed diabetes medication in 72% of exercisers compared with the control group, P = 0.004–0.05. Control subjects showed no change in glycosylated hemoglobin, a reduction in muscle glycogen (from 61.4 ± 7.7 to 47.2 ± 6.7 mmol glucose/kg muscle), and a 42% increase in diabetes medications. PRT subjects versus control subjects also increased lean mass (+1.2 ± 0.2 vs. −0.1 ± 0.1 kg), reduced systolic blood pressure (–9.7 ± 1.6 vs. +7.7 ± 1.9 mmHg), and decreased trunk fat mass (−0.7 ± 0.1 vs. +0.8 ± 0.1 kg; P = 0.01–0.05). CONCLUSIONS—PRT as an adjunct to standard of care is feasible and effective in improving glycemic control and some of the abnormalities associated with the metabolic syndrome among high-risk older adults with type 2 diabetes.
785 citations
TL;DR: Depression in individuals with diabetes is associated with increased health care use and expenditures, even after adjusting for differences in age, sex, race/ethnicity, health insurance, and comorbidity.
Abstract: OBJECTIVE —This study ascertained the odds of diagnosed depression in individuals with diabetes and the relation between depression and health care use and expenditures. RESEARCH DESIGN AND METHODS —First, we compared data from 825 adults with diabetes with that from 20,688 adults without diabetes using the 1996 Medical Expenditure Panel Survey (MEPS). Second, in patients with diabetes, we compared depressed and nondepressed individuals to identify differences in health care use and expenditures. Third, we adjusted use and expenditure estimates for differences in age, sex, race/ethnicity, health insurance, and comorbidity with analysis of covariance. Finally, we used the Consumer Price Index to adjust expenditures for inflation and used SAS and SUDAAN software for statistical analyses. RESULTS —Individuals with diabetes were twice as likely as a comparable sample from the general U.S. population to have diagnosed depression (odds ratio 1.9, 95% CI 1.5–2.5). Younger adults ( P P P CONCLUSIONS —The odds of depression are higher in individuals with diabetes than in those without diabetes. Depression in individuals with diabetes is associated with increased health care use and expenditures, even after adjusting for differences in age, sex, race/ethnicity, health insurance, and comorbidity.
783 citations
TL;DR: High-intensity progressive resistance training, in combination with moderate weight loss, was effective in improving glycemic control in older patients with type 2 diabetes.
Abstract: OBJECTIVE —To examine the effect of high-intensity progressive resistance training combined with moderate weight loss on glycemic control and body composition in older patients with type 2 diabetes.
RESEARCH DESIGN AND METHODS —Sedentary, overweight men and women with type 2 diabetes, aged 60–80 years ( n = 36), were randomized to high-intensity progressive resistance training plus moderate weight loss (RT & WL group) or moderate weight loss plus a control program (WL group). Clinical and laboratory measurements were assessed at 0, 3, and 6 months.
RESULTS —HbA1c fell significantly more in RT & WL than WL at 3 months (0.6 ± 0.7 vs. 0.07 ± 0.8%, P < 0.05) and 6 months (1.2 ± 1.0 vs. 0.4 ± 0.8%, P < 0.05). Similar reductions in body weight (RT & WL 2.5 ± 2.9 vs. WL 3.1 ± 2.1 kg) and fat mass (RT & WL 2.4 ± 2.7 vs. WL 2.7 ± 2.5 kg) were observed after 6 months. In contrast, lean body mass (LBM) increased in the RT & WL group (0.5 ± 1.1 kg) and decreased in the WL group (0.4 ± 1.0) after 6 months ( P < 0.05). There were no between-group differences for fasting glucose, insulin, serum lipids and lipoproteins, or resting blood pressure.
CONCLUSIONS —High-intensity progressive resistance training, in combination with moderate weight loss, was effective in improving glycemic control in older patients with type 2 diabetes. Additional benefits of improved muscular strength and LBM identify high-intensity resistance training as a feasible and effective component in the management program for older patients with type 2 diabetes.
734 citations
TL;DR: High-risk men engaging in currently recommended levels of physical activity were less likely to develop the metabolic syndrome than sedentary men and cardiorespiratory fitness was also strongly protective, although possibly not independent of mediating factors.
Abstract: OBJECTIVE —Little is known about the association of leisure-time physical activity (LTPA) and cardiorespiratory fitness with development of the metabolic syndrome, which predisposes diseases such as diabetes and atherosclerosis. We studied the associations of LTPA and cardiorespiratory fitness with development of the metabolic syndrome (World Health Organization [WHO] and the National Cholesterol Education Program [NCEP] definitions). RESEARCH DESIGN AND METHODS —LTPA over the previous 12 months, V o 2max (ml · kg −1 · min −1 ), and cardiovascular and metabolic risk factors were assessed in a population-based cohort of 612 middle-aged men without the metabolic syndrome. RESULTS —At the 4-year follow-up, 107 men had metabolic syndrome (WHO definition). Men engaging in >3 h/week of moderate or vigorous LTPA were half as likely as sedentary men to have the metabolic syndrome after adjustment for major confounders (age, BMI, smoking, alcohol, and socioeconomic status) or potentially mediating factors (insulin, glucose, lipids, and blood pressure), especially in high-risk men. Vigorous LTPA had an even stronger inverse association, particularly in unfit men. Men in the upper third of V o 2max were 75% less likely than unfit men to develop the metabolic syndrome, even after adjustment for major confounders. Adjustment for possible mediating factors attenuated the association. Associations of LTPA and V o 2max with development of the metabolic syndrome, as defined by the NCEP, were qualitatively similar. CONCLUSIONS —In particular, high-risk men engaging in currently recommended levels of physical activity were less likely to develop the metabolic syndrome than sedentary men. Cardiorespiratory fitness was also strongly protective, although possibly not independent of mediating factors.
TL;DR: A significant association between HOMA-IR and risk of CVD after adjustment for multiple covariates is found, however, additional studies are required, particularly among women and minority populations.
Abstract: OBJECTIVE —The prospective association between insulin levels and risk of cardiovascular disease (CVD) is controversial. The objective of the present study was to investigate the relationship of the homeostasis model assessment of insulin resistance (HOMA-IR), as well as insulin levels, with risk of nonfatal and fatal CVD over the 8-year follow-up of the San Antonio Heart Study. RESEARCH DESIGN AND METHODS —Between 1984 and 1988, randomly selected Mexican-American and non-Hispanic white residents of San Antonio participated in baseline examinations that included fasting blood samples for glucose, insulin, and lipids, a glucose tolerance test, anthropometric measurements, and a lifestyle questionnaire. Between 1991 and 1996, 2,569 subjects who were free of diabetes at baseline were reexamined using the same protocol. RESULTS —Over the follow-up period, 187 subjects experienced an incident cardiovascular event (heart attack, stroke, heart surgery, angina, or CVD death). Logistic regression analysis indicated that risk of a CVD event increased across quintiles of HOMA-IR after adjustment for age, sex, and ethnicity ( P for trend P for trend 0.02; quintile 5 vs. quintile 1, OR 1.94, 95% CI 1.05–3.59). Furthermore, there were no significant interactions between HOMA-IR and ethnicity, sex, hypertension, dyslipidemia, glucose tolerance (impaired glucose tolerance versus normal glucose tolerance), or obesity. The magnitude and direction of the relationship between insulin concentration and incident CVD were similar. CONCLUSIONS —We found a significant association between HOMA-IR and risk of CVD after adjustment for multiple covariates. The topic remains controversial, however, and additional studies are required, particularly among women and minority populations.
TL;DR: Low testosterone levels in men and highosterone levels in women predict insulin resistance and incident type 2 diabetes in older adults.
Abstract: OBJECTIVE —To determine the prospective association between endogenous sex hormones and the development of type 2 diabetes in older men and women.
RESEARCH DESIGN AND METHODS —A standardized medical history was obtained, an oral glucose tolerance test was performed, and plasma samples for sex hormones and covariates were collected from ambulatory, community-dwelling men and women at baseline from 1984 to 1987. Approximately 8 years later (1992–1996), another medical history was obtained, an oral glucose tolerance test was performed, fasting and 2-h insulin levels were measured, and the homeostasis model assessment for insulin resistance (HOMA-IR) was evaluated. This report is based on the 294 men and 233 women, aged 55–89 years, who completed both visits and who did not have diabetes as determined by history or glucose tolerance test at baseline, as well as women who were postmenopausal and not taking replacement estrogen.
RESULTS —In age-adjusted correlation analyses, total testosterone was inversely and significantly related to subsequent levels of fasting and postchallenge glucose and insulin in men, whereas bioavailable testosterone and bioavailable estradiol were positively and significantly related to fasting and postchallenge glucose and insulin in women (all P <0.05). There was similar significant association with insulin resistance (HOMA-IR) in unadjusted and multiply adjusted analyses ( P <0.05). There were 26 men and 17 women with new (incident) diabetes. The odds for new diabetes were 2.7 (95% CI 1.1–6.6) for men in the lowest quartile of total testosterone and 2.9 (1.1–8.4) for women in the highest quartile of bioavailable testosterone.
CONCLUSIONS —Low testosterone levels in men and high testosterone levels in women predict insulin resistance and incident type 2 diabetes in older adults.
TL;DR: Total and saturated fat intake and processed meat intake were associated with a higher risk of type 2 diabetes, but these associations were not independent of BMI.
Abstract: OBJECTIVE —To examine dietary fat and meat intake in relation to risk of type 2 diabetes. RESEARCH DESIGN AND METHODS —We prospectively followed 42,504 male participants of the Health Professionals Follow-Up Study who were aged 40–75 years and free of diagnosed diabetes, cardiovascular disease, and cancer in 1986. Diet was assessed by a validated food frequency questionnaire and updated in 1990 and 1994. During 12 years of follow-up, we ascertained 1,321 incident cases of type 2 diabetes. RESULTS —Intakes of total fat (multivariate RR for extreme quintiles 1.27, CI 1.04–1.55, P for trend=0.02) and saturated fat (1.34, 1.09–1.66, P for trend=0.01) were associated with a higher risk of type 2 diabetes. However, these associations disappeared after additional adjustment for BMI (total fat RR 0.97, CI 0.79–1.18; saturated fat 0.97, 0.79–1.20). Intakes of oleic acid, trans -fat, long-chain n-3 fat, and α-linolenic acid were not associated with diabetes risk after multivariate adjustment. Linoleic acid was associated with a lower risk of type 2 diabetes in men P for trend=0.01) and in men with a BMI 2 (0.53, 0.33–0.85, P for trend=0.006) but not in older and obese men. Frequent consumption of processed meat was associated with a higher risk for type 2 diabetes (RR 1.46, CI 1.14–1.86 for ≥5/week vs. P for trend CONCLUSIONS —Total and saturated fat intake were associated with a higher risk of type 2 diabetes, but these associations were not independent of BMI. Frequent consumption of processed meats may increase risk of type 2 diabetes.
TL;DR: The data indicate a substantially elevated risk of CVD before clinical diagnosis of type 2 diabetes in women and suggest that aggressive management of cardiovascular risk factors is warranted in individuals at increased risk for diabetes.
Abstract: OBJECTIVE —To examine whether the risk of cardiovascular disease (CVD) is elevated before clinical diagnosis of type 2 diabetes in women. RESEARCH DESIGN AND METHODS —A total of 117,629 female nurses aged 30–55 years who were free of diagnosed CVD at baseline were recruited in 1976 and followed for 20 years. RESULTS —A total of 1,508 women had diagnosed type 2 diabetes at baseline in 1976. During 20 years of follow-up, 110,227 women remained free of diabetes diagnosis and 5,894 women developed type 2 diabetes. During 2.2 million person-years of follow-up, we documented 1,556 new cases of myocardial infarction (MI), 1,405 strokes, 815 fatal coronary heart disease (CHD), and 300 fatal strokes. Among women who developed type 2 diabetes during follow-up, the age-adjusted RRs of MI were 3.75 (95% CI 3.10–4.53) for the period before the diagnosis and 4.57 (3.87–5.39) for the period after the diagnosis, compared with women who remained free of diabetes diagnosis. The multivariate RRs further adjusting for BMI, smoking, and other cardiovascular risk factors were 3.17 (2.61–3.85) and 3.97 (3.35–4.71). The risk of stroke was also significantly elevated before diagnosis of diabetes (multivariate RR = 2.30 [1.76–2.99]). Further adjustment for history of hypertension or hypercholesterolemia did not appreciably alter the results. CONCLUSIONS —Our data indicate a substantially elevated risk of CVD before clinical diagnosis of type 2 diabetes in women. These findings suggest that aggressive management of cardiovascular risk factors is warranted in individuals at increased risk for diabetes.
TL;DR: HOMA-IR was an independent predictor of both prevalent and incident CVD and the improvement of insulin resistance might have beneficial effects not only on glucose control but also on CVD in patients with type 2 diabetes.
Abstract: OBJECTIVE—To evaluate whether homeostasis model assessment-estimated insulin resistance (HOMA-IR) is an independent predictor of cardiovascular disease (CVD) in type 2 diabetes. RESEARCH DESIGN AND METHODS—Conventional CVD risk factors (sex, age, smoking, plasma lipids, blood pressure, and metabolic control) and insulin resistance (estimated by HOMA) were evaluated at baseline in 1,326 patients with type 2 diabetes examined within the Verona Diabetes Complications Study. At baseline and after a mean follow-up of 4.5 years, CVD was assessed by medical history, physical examination, electrocardiography, and echo-Doppler of carotid and lower limb arteries. Death certificates and medical records of subjects who died during the follow-up were carefully scrutinized to identify cardiovascular deaths. In statistical analyses, CVD was an aggregate end point including both fatal and nonfatal coronary, cerebrovascular, and peripheral vascular disease as well as ischemic electrocardiographic abnormalities and vascular lesions identified by echo-Doppler. RESULTS—At baseline, 441 subjects were coded positive for CVD (prevalent cases). Incident cases numbered 126. Multiple logistic regression analyses showed that, along with sex, age, smoking, HDL/total cholesterol ratio, and hypertension, HOMA-IR was an independent predictor of both prevalent and incident CVD. A 1-unit increase in (log)HOMA-IR value was associated with an odds ratio for prevalent CVD at baseline of 1.31 (95% CI 1.10–1.56, P = 0.002) and for incident CVD during follow-up of 1.56 (95% CI 1.14–2.12, P CONCLUSIONS—HOMA-IR is an independent predictor of CVD in type 2 diabetes. The improvement of insulin resistance might have beneficial effects not only on glucose control but also on CVD in patients with type 2 diabetes.
TL;DR: Older women with diabetes have an increased risk of falling, partly because of the increased rates of known fall risk factors, and may benefit from interventions to prevent falls.
Abstract: OBJECTIVE —To determine whether older women with diabetes have an increased risk of falls and whether known risk factors for falls account for any increased risk. RESEARCH DESIGN AND METHODS —This prospective cohort study included 9,249 women ≥67 years of age enrolled in the Study of Osteoporotic Fractures. Diabetes was determined by questionnaire at baseline. Physical performance was measured at the second examination. Subsequently, falls were ascertained every 4 months by postcard. RESULTS —A total of 629 (6.8%) women had diabetes, including 99 who used insulin. During an average of 7.2 years, 1,640 women (18%) fell more than once a year. Diabetes, stratified by insulin use, was associated with an increased risk of falling more than once a year (age-adjusted odds ratio [OR] 1.68 [95% CI 1.37–2.07] for non–insulin-treated diabetes; age-adjusted OR 2.78 [1.82–4.24] for insulin-treated diabetes). In the first 2 years of follow-up, women with diabetes were not more likely to fall than women without diabetes (44 vs. 42%; P = 0.26), but they had more falls (3.1 vs. 2.4; P CONCLUSIONS —Older women with diabetes have an increased risk of falling, partly because of the increased rates of known fall risk factors, and may benefit from interventions to prevent falls. Further research is needed to determine whether diabetes treatment reduces fall risk.
TL;DR: Investigating for the first time the prevalence of diabetes and impaired glucose tolerance nationwide in Turkey and the relationships between glucose intolerance and lifestyle and physical risk factors found associations with obesity and hypertension have been confirmed.
Abstract: OBJECTIVES —To investigate for the first time the prevalence of diabetes and impaired glucose tolerance (IGT) nationwide in Turkey; to assess regional variations and relationships between glucose intolerance and lifestyle and physical risk factors. RESEARCH DESIGN AND METHODS —The Turkish Diabetes Epidemiology Study (TURDEP) is a cross-sectional, population-based survey that included 24,788 subjects (age ≥20 years, women 55%, response 85%). Glucose tolerance was classified according to World Health Organization recommendations on the basis of 2-h blood glucose values. RESULTS —Crude prevalence of diabetes was 7.2% (previously undiagnosed, 2.3%) and of IGT, 6.7% (age-standardized to world and European populations, 7.9 and 7.0%). Both were more frequent in women than men ( P P P P CONCLUSIONS —Diabetes and IGT are moderately common in Turkey by international standards. Associations with obesity and hypertension have been confirmed. Other lifestyle factors had a variable relationship with glucose tolerance.
TL;DR: In this paper, the authors evaluated the efficacy of the addition of insulin when maximal sulfonylurea therapy is inadequate in individuals with type 2 diabetes and found that the early addition of a small amount of insulin can significantly improve glycemic control without promoting increased hypoglycemia or weight gain.
Abstract: OBJECTIVE—To evaluate the efficacy of the addition of insulin when maximal sulfonylurea therapy is inadequate in individuals with type 2 diabetes. RESEARCH DESIGN AND METHODS—Glycemic control, hypoglycemia, and body weight were monitored over 6 years in 826 patients with newly diagnosed type 2 diabetes in 8 of 23 U.K. Prospective Diabetes Study (UKPDS) centers that used a modified protocol. Patients were randomly allocated to a conventional glucose control policy, primarily with diet (n = 242) or an intensive policy with insulin alone (n = 245), as in the main study. However, for patients randomized to an intensive policy with sulfonylurea (n = 339), insulin was added automatically if the fasting plasma glucose remained >108 mg/dl (6.0 mmol/l) despite maximal sulfonylurea doses. RESULTS—Over 6 years, ∼53% of patients allocated to treatment with sulfonylurea required additional insulin therapy. Median HbA1c in the sulfonylurea ± insulin group was significantly lower (6.6%, interquartile range [IQR] 6.0–7.6) than in the group taking insulin alone (7.1%, IQR 6.2–8.0; P = 0.0066), and significantly more patients in the sulfonylurea ± insulin group had an HbA1c CONCLUSIONS—Early addition of insulin when maximal sulfonylurea therapy is inadequate can significantly improve glycemic control without promoting increased hypoglycemia or weight gain.
TL;DR: Postchallenge hyperglycemia is an independent risk factor for CVD, but the marginal predictive value of 2hPG beyond knowledge of standard CVD risk factors is small.
Abstract: OBJECTIVE —To test the hypothesis that fasting hyperglycemia (FHG) and 2-h postchallenge glycemia (2hPG) independently increase the risk for cardiovascular disease (CVD). RESEARCH DESIGN AND METHODS —During 1991–1995, we examined 3,370 subjects from the Framingham Offspring Study who were free from clinical CVD (coronary heart disease, stroke, or intermittent claudication) or medication-treated diabetes, and we followed them for 4 years for incident CVD events. We used proportional-hazards regression to assess the risk associated with FHG (fasting plasma glucose ≥7.0 mmol/l) and 2hPG, independent of the risk predicted by standard CVD risk factors. RESULTS —Mean subject age was 54 years, 54% were women, and previously undiagnosed diabetes was present in 3.2% by FHG and 4.9% (164) by FHG or a 2hPG ≥11.1 mmol/l. Of these 164 subjects, 55 (33.5%) had 2hPG ≥11.1 without FHG, but these 55 subjects represented only 1.7% of the 3,261 subjects without FHG. During 12,242 person-years of follow-up, there were 118 CVD events. In separate sex- and CVD risk-adjusted models, relative risk (RR) for CVD with fasting plasma glucose ≥7.0 mmol/l was 2.8 (95% CI 1.6–5.0); RR for CVD per 2.1 mmol/l increase in 2hPG was 1.2 (1.1–1.3). When modeled together, the RR for FHG decreased to 1.5 (0.7–3.6), whereas the RR for 2hPG remained significant (1.1, 1.02–1.3). The c -statistic for a model including CVD risk factors alone was 0.744; with addition of FHG, it was 0.746, and with FHG and 2hPG, it was 0.752. CONCLUSIONS —Postchallenge hyperglycemia is an independent risk factor for CVD, but the marginal predictive value of 2hPG beyond knowledge of standard CVD risk factors is small.
TL;DR: Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients, paying particular attention to interactions with immunOSuppressive drugs.
Abstract: OBJECTIVES— To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS— We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS— Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower ( CONCLUSIONS— Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs.
TL;DR: The data strongly support the notion that inflammation is important in the pathogenesis of diabetes and metabolic disorders in women, and CRP was not a significant predictor of the development of the metabolic syndrome in men.
Abstract: OBJECTIVE —Recent evidence suggests that C-reactive protein (CRP) may predict development of diabetes in Caucasian populations. We evaluated CRP as a possible risk factor of the development of diabetes and metabolic syndrome in a 6-year study of 515 men and 729 women from the Mexico City Diabetes Study. RESEARCH DESIGN AND METHODS —Baseline CRP, indexes of adiposity, and insulin resistance (homeostasis model assessment [HOMA-IR]) were used to predict development of the metabolic syndrome, defined as including two or more of the following: 1 ) dyslipidemia (triglyceride ≥2.26 mmol/l or HDL cholesterol ≤0.91 mmol/l in men and ≤1.17 mmol/l in women; 2 ) hypertension (blood pressure >140/90 mmHg or on hypertensive medication); or 3 ) diabetes (1999 World Health Organization criteria). RESULTS —At baseline, CRP correlated significantly ( P CONCLUSIONS —CRP was not a significant predictor of the development of the metabolic syndrome in men. Our data strongly support the notion that inflammation is important in the pathogenesis of diabetes and metabolic disorders in women.
TL;DR: Obesity and the presence of complications are important determinants of HRQOL in patients with type 2 diabetes in the Netherlands and which patient characteristics are associated with quality of life and treatment satisfaction are examined.
Abstract: OBJECTIVE — To estimate the health-related quality of life (HRQOL) and treatment satisfaction for patients with type 2 diabetes in the Netherlands and to examine which patient characteristics are associated with quality of life and treatment satisfaction. RESEARCH DESIGN AND METHODS —For a sample of 1,348 type 2 diabetes patients, recruited by 29 general practitioners, we collected data regarding HRQOL. This study was performed as part of a larger European study (Cost of Diabetes in Europe - Type 2 [CODE-2]). We used a generic instrument (Euroqol 5D) to measure HRQOL. Treatment satisfaction was assessed using the Diabetes Treatment Satisfaction Questionnaire. RESULTS —Patients without complications had an HRQOL (0.74) only slightly lower than similarly aged persons in the general population. Insulin therapy, obesity, and complications were associated with a lower HRQOL, independent of age and sex. Although higher fasting blood glucose and HbA 1c levels were negatively associated with HRQOL, these factors were not significant after adjustment for other factors using multivariate analysis. Overall treatment satisfaction was very high. Younger patients, patients using insulin, and patients with higher HbA 1c levels were less satisfied with the treatment than other patients. CONCLUSIONS —Obesity and the presence of complications are important determinants of HRQOL in patients with type 2 diabetes.
TL;DR: This study confirms the effectiveness of culturally competent diabetes self-management education on improving health outcomes of Mexican Americans, particularly for those individuals with HbA(1c) levels >10%.
Abstract: OBJECTIVE —To determine the effects of a culturally competent diabetes self-management intervention in Mexican Americans with type 2 diabetes. RESEARCH DESIGN AND METHODS —A prospective, randomized, repeated measures study was conducted on the Texas-Mexico border in Starr County. A total of 256 randomly selected individuals with type 2 diabetes between 35 and 70 years of age, diagnosed with type 2 diabetes after 35 years of age, and accompanied by a family member or friend were included. The intervention consisted of 52 contact hours over 12 months and was provided by bilingual Mexican American nurses, dietitians, and community workers. The intervention involved 3 months of weekly instructional sessions on nutrition, self-monitoring of blood glucose, exercise, and other self-care topics and 6 months of biweekly support group sessions to promote behavior changes. The approach was culturally competent in terms of language, diet, social emphasis, family participation, and incorporation of cultural health beliefs. Outcomes included indicators of metabolic control (HbA 1c and fasting blood glucose), diabetes knowledge, and diabetes-related health beliefs. RESULTS —Experimental groups showed significantly lower levels of HbA 1c and fasting blood glucose at 6 and 12 months and higher diabetes knowledge scores. At 6 months, the mean HbA 1c of the experimental subjects was 1.4% below the mean of the control group; however, the mean level of the experimental subjects was still high (>10%). CONCLUSIONS —This study confirms the effectiveness of culturally competent diabetes self-management education on improving health outcomes of Mexican Americans, particularly for those individuals with HbA 1c levels >10%.
TL;DR: Components of the metabolic syndrome are common and are associated with incident cardiovascular disease and diabetes after 5 years, and interventions to alter BMI, lipid levels, and blood pressure may decrease incident diabetes and cardiovascular disease.
Abstract: OBJECTIVE —To determine whether components of the metabolic syndrome precede the 5-year incidence of cardiovascular disease and diabetes.
RESEARCH DESIGN AND METHODS —A population of individuals aged 43–84 years was evaluated from 1988 to 1990 and again 5 years later. Medical history, blood pressure, and laboratory measures were obtained at both examinations following the same protocols. Subjects without diabetes were classified according to level of glycemia, high blood pressure, high-risk lipid levels, high uric acid levels, and proteinuria at baseline. History of incident myocardial infarction, angina, stroke, and diabetes was obtained at follow-up.
RESULTS —Of the 4,423 subjects without diabetes, 6.9% had elevated levels of glycemia, 18.4% had high blood pressure, 82.7% had high-risk lipid levels (either high serum total cholesterol or low HDL cholesterol or high ratio of these two levels), 27% had elevated uric acid levels, 33.2% had high BMI, and 3.3% had proteinuria (≥30 mg/dl). The risk of incident cardiovascular disease 5 years later increased with the number of the components present; 2.5% of those with one component developed cardiovascular disease, whereas 14.9% of those with four or more components developed cardiovascular disease. Of those with one component, diabetes developed in 1.1% 5 years later, whereas diabetes developed in 17.9% of those with four or more components.
CONCLUSIONS —Components of the metabolic syndrome are common and are associated with incident cardiovascular disease and diabetes after 5 years. Interventions to alter BMI, lipid levels, and blood pressure may decrease incident diabetes and cardiovascular disease.
TL;DR: The majority of individuals with type 2 diabetes were overweight, did not engage in recommended levels of physical activity, and did not follow dietary guidelines for fat and fruit and vegetable consumption.
Abstract: OBJECTIVE —To describe diet and exercise practices from a nationally representative sample of U.S. adults with type 2 diabetes. METHODS —We analyzed data from 1,480 adults older than 17 years with a self-reported diagnosis of type 2 diabetes in the Third National Health and Nutrition Examination Survey (NHANES III). Fruit and vegetable consumption was obtained from a food frequency questionnaire; the percentages of total calories from fat and saturated fat were obtained from a 24-h food recall. Physical activity was based on self report during the month before the survey. RESULTS —Of individuals with type 2 diabetes, 31% reported no regular physical activity and another 38% reported less than recommended levels of physical activity. Sixty-two percent of respondents ate fewer than five servings of fruits and vegetables per day. Almost two thirds of the respondents consumed >30% of their daily calories from fat and >10% of total calories from saturated fat. Mexican Americans and individuals over the age of 65 years ate a higher number of fruits and vegetables and a lower percentage of total calories from fat. Lower income and increasing age were associated with physical inactivity. Thirty-six percent of the sample were overweight and another 46% were obese. CONCLUSIONS —The majority of individuals with type 2 diabetes were overweight, did not engage in recommended levels of physical activity, and did not follow dietary guidelines for fat and fruit and vegetable consumption. Additional measures are needed to encourage regular physical activity and improve dietary habits in this population.
TL;DR: These results reveal important isomer-specific metabolic actions of CLA in abdominally obese humans and provide physiological insights into the role of specific dietary fatty acids as modulators of insulin resistance in humans.
Abstract: OBJECTIVE —Conjugated linoleic acid (CLA) is a group of dietary fatty acids with antiobesity and antidiabetic effects in some animals. The trans 10 cis 12 ( t 10 c 12) CLA isomer seems to cause these effects, including improved insulin sensitivity. Whether such isomer-specific effects occur in humans is unknown. The aim of this study was to investigate whether t 10 c 12 CLA or a commercial CLA mixture could improve insulin sensitivity, lipid metabolism, or body composition in obese men with signs of the metabolic syndrome.
RESEARCH DESIGN AND METHODS —In a randomized, double-blind controlled trial, abdominally obese men ( n = 60) were treated with 3.4 g/day CLA (isomer mixture), purified t 10 c 12 CLA, or placebo. Euglycemic-hyperinsulinemic clamp, serum hormones, lipids, and anthropometry were assessed before and after 12 weeks of treatment.
RESULTS —Baseline metabolic status was similar between groups. Unexpectedly, t 10 c 12 CLA increased insulin resistance (19%; P < 0.01) and glycemia (4%; P < 0.001) and reduced HDL cholesterol (−4%; P < 0.01) compared with placebo, whereas body fat, sagittal abdominal diameter, and weight decreased versus baseline, but the difference was not significantly different from placebo. The CLA mixture did not change glucose metabolism, body composition, or weight compared with placebo but lowered HDL cholesterol (−2%; P < 0.05).
CONCLUSIONS —These results reveal important isomer-specific metabolic actions of CLA in abdominally obese humans. A CLA-induced insulin resistance has previously been described only in lipodystrophic mice. Considering the use of CLA-supplements among obese individuals, it is important to clarify the clinical consequences of these results, but they also provide physiological insights into the role of specific dietary fatty acids as modulators of insulin resistance in humans.
TL;DR: In inhibition of DPP IV is a feasible approach to the treatment of type 2 diabetes in the early stage of the disease, as concluded in a placebo-controlled double-blind multicenter study.
Abstract: OBJECTIVE —Glucagon-like peptide-1 (GLP-1) has been proposed as a new treatment modality for type 2 diabetes. To circumvent the drawback of the short half-life of GLP-1, inhibitors of the GLP-1–degrading enzyme dipeptidyl peptidase IV (DPP IV) have been examined. Such inhibitors improve glucose tolerance in insulin-resistant rats and mice. In this study, we examined the 4-week effect of 1-[[[2-[(5-cyanopyridin-2-yl)amino]ethyl]amino]acetyl]-2-cyano-(S)-pyrrolidine (NVP DPP728), a selective, orally active inhibitor of DPP IV, in subjects with diet-controlled type 2 diabetes in a placebo-controlled double-blind multicenter study. RESEARCH DESIGN AND METHODS —A total of 93 patients (61 men and 32 women), aged 64 ± 9 years (means ± SD) and with BMI 27.3 ± 2.7 kg/m 2 , entered the study. Fasting blood glucose was 8.5 ± 1.5 mmol/l, and HbA 1c was 7.4 ± 0.7%. Before and after treatment with NVP DPP728 at 100 mg × 3 ( n = 31) or 150 mg × 5 ( n = 32) or placebo ( n = 30), subjects underwent a 24-h study with standardized meals (total 2,000 kcal). RESULTS —Compared with placebo, NVP DPP728 at 100 mg t.i.d. reduced fasting glucose by 1.0 mmol/l (mean), prandial glucose excursions by 1.2 mmol/l, and mean 24-h glucose levels by 1.0 mmol/l (all P P = 0.017 and P = 0.023). Although not an efficacy parameter foreseen in the study protocol, HbA 1c was reduced to 6.9 ± 0.7% in the combined active treatment groups ( P CONCLUSIONS —We conclude that inhibition of DPP IV is a feasible approach to the treatment of type 2 diabetes in the early stage of the disease.
TL;DR: Although the treatment of diabetes has become increasingly sophisticated, with over a dozen pharmacological agents available to lower blood glucose, a multitude of ancillary supplies and equipment available, and a clear recognition by health care professionals and patients that diabetes is a serious disease, the normalization of blood glucose for any appreciable time is seldom achieved.
TL;DR: Rosiglitazone increases plasma adiponectin levels in type 2 diabetic subjects, which may contribute to the antihyperglycemic and putative antiatherogenic benefits of PPAR-gamma agonists in type 1 diabetic patients warrants further investigation.
Abstract: OBJECTIVE —Adiponectin, a plasma protein exclusively synthesized and secreted by adipose tissue, has recently been shown to have anti-inflammatory, antiatherogenic properties in vitro and beneficial metabolic effects in animals. Lower plasma levels of adiponectin have been documented in human subjects with metabolic syndrome and coronary artery disease. We investigated whether the level of this putative protective adipocytokine could be increased by treatment with a peroxisome proliferator-activated receptor-γ (PPAR-γ) agonist in diabetic patients. RESEARCH DESIGN AND METHODS —Type 2 diabetic patients (30 in the treatment group and 34 in the placebo group) were recruited for a randomized double-blind placebo-controlled trial for 6 months with the PPAR-γ agonist rosiglitazone. Blood samples were collected and metabolic variables and adiponectin levels were determined in all patients before initiation of the study. RESULTS —In the rosiglitazone group, mean plasma adiponectin level was increased by more than twofold ( P r 2 = 0.24) after adjusting for age, sex, and changes in fasting plasma glucose, HbA 1c , insulin resistance index, and BMI. CONCLUSIONS —Rosiglitazone increases plasma adiponectin levels in type 2 diabetic subjects. Whether this may contribute to the antihyperglycemic and putative antiatherogenic benefits of PPAR-γ agonists in type 2 diabetic patients warrants further investigation.