Showing papers in "Diabetes Care in 2008"
TL;DR: This position statement provides evidence-based recommendations and interventions for diabetes MNT and focuses on key references published since the year 2000, and uses grading according to the level of evidence available.
Abstract: Medical nutrition therapy (MNT) is important in preventing diabetes, managing existing diabetes, and preventing, or at least slowing, the rate of development of diabetes complications. It is, therefore, important at all levels of diabetes prevention. MNT is also an integral component of diabetes self-management education (or training). This position statement provides evidence-based recommendations and interventions for diabetes MNT. The previous position statement with accompanying technical review was published in 2002 and modified slightly in 2004. This statement updates previous position statements, focuses on key references published since the year 2000, and uses grading according to the level of evidence available...
1,786 citations
TL;DR: A1C levels can be expressed as eAG for most patients with type 1 and type 2 diabetes, and linear regression analysis between the A1C and AG values provided the tightest correlations.
Abstract: OBJECTIVE — The A1C assay, expressed as the percent of hemoglobin that is glycated, measures chronic glycemia and is widely used to judge the adequacy of diabetes treatment and adjust therapy. Day-to-day management is guided by self-monitoring of capillary glucose concentrations (milligrams per deciliter or millimoles per liter). We sought to define the mathematical relationship between A1C and average glucose (AG) levels and determine whether A1C could be expressed and reported as AG in the same units as used in self-monitoring. RESEARCH DESIGN AND METHODS — A total of 507 subjects, including 268 patients with type 1 diabetes, 159 with type 2 diabetes, and 80 nondiabetic subjects from 10 international centers, was included in the analyses. A1C levels obtained at the end of 3 months and measured in a central laboratory were compared with the AG levels during the previous 3 months. AG was calculated by combining weighted results from at least 2 days of continuous glucose monitoring performed four times, with seven-point daily self-monitoring of capillary (fingerstick) glucose performed at least 3 days per week. RESULTS — Approximately 2,700 glucose values were obtained by each subject during 3 months. Linear regression analysis between the A1C and AG values provided the tightest correlations (AGmg/dl 28.7 A1C 46.7, R 2 0.84, P 0.0001), allowing calculation of an estimated average glucose (eAG) for A1C values. The linear regression equations did not differ significantly across subgroups based on age, sex, diabetes type, race/ethnicity, or smoking status. CONCLUSIONS — A1C levels can be expressed as eAG for most patients with type 1 and type 2 diabetes. Diabetes Care 31:1473–1478, 2008
1,471 citations
TL;DR: Evidence is provided of the importance of avoiding prolonged uninterrupted periods of sedentary (primarily sitting) time and new public health recommendations regarding breaking up sedentary time that are complementary to those for physical activity are suggested.
Abstract: OBJECTIVE —Total sedentary (absence of whole-body movement) time is associated with obesity, abnormal glucose metabolism, and the metabolic syndrome. In addition to the effects of total sedentary time, the manner in which it is accumulated may also be important. We examined the association of breaks in objectively measured sedentary time with biological markers of metabolic risk.
RESEARCH DESIGN AND METHODS —Participants ( n = 168, mean age 53.4 years) for this cross-sectional study were recruited from the 2004–2005 Australian Diabetes, Obesity and Lifestyle study. Sedentary time was measured by an accelerometer (counts/minute−1 < 100) worn during waking hours for seven consecutive days. Each interruption in sedentary time (counts/min ≥100) was considered a break. Fasting plasma glucose, 2-h plasma glucose, serum triglycerides, HDL cholesterol, weight, height, waist circumference, and resting blood pressure were measured. MatLab was used to derive the breaks variable; SPSS was used for the statistical analysis.
RESULTS —Independent of total sedentary time and moderate-to-vigorous intensity activity time, increased breaks in sedentary time were beneficially associated with waist circumference (standardized β = −0.16, 95% CI −0.31 to −0.02, P = 0.026), BMI (β = −0.19, −0.35 to −0.02, P = 0.026), triglycerides (β = −0.18, −0.34 to −0.02, P = 0.029), and 2-h plasma glucose (β = −0.18, −0.34 to −0.02, P = 0.025).
CONCLUSIONS —This study provides evidence of the importance of avoiding prolonged uninterrupted periods of sedentary (primarily sitting) time. These findings suggest new public health recommendations regarding breaking up sedentary time that are complementary to those for physical activity.
1,399 citations
TL;DR: In this article, the authors systematically tabulate published and unpublished sources of reliable glycemic index (GI) values to improve the quality and quantity of GI data available for research and clinical practice.
Abstract: OBJECTIVE —To systematically tabulate published and unpublished sources of reliable glycemic index (GI) values. RESEARCH DESIGN AND METHODS —A literature search identified 205 articles published between 1981 and 2007. Unpublished data were also included where the data quality could be verified. The data were separated into two lists: the first representing more precise data derived from testing healthy subjects and the second primarily from individuals with impaired glucose metabolism. RESULTS —The tables, which are available in the online-only appendix, list the GI of over 2,480 individual food items. Dairy products, legumes, and fruits were found to have a low GI. Breads, breakfast cereals, and rice, including whole grain, were available in both high and low GI versions. The correlation coefficient for 20 staple foods tested in both healthy and diabetic subjects was r = 0.94 ( P CONCLUSIONS —These tables improve the quality and quantity of GI data available for research and clinical practice.
1,392 citations
TL;DR: Depression is associated with a 60% increased risk of type 2 diabetes, and Type 2 diabetes isassociated with only modest increasedrisk of depression.
Abstract: OBJECTIVE —It has been argued that the relationship between depression and diabetes is bi-directional, but this hypothesis has not been explicitly tested. This systematic review examines the bi-directional prospective relationships between depression and type 2 diabetes. RESEARCH DESIGN AND METHODS —A search was conducted using Medline for publications from 1950 through 2007. Reviewers assessed the eligibility of each report by exposure/outcome measurement and study design. Only comparative prospective studies of depression and type 2 diabetes that excluded prevalent cases of depression (for diabetes predicting depression) or diabetes (for depression predicting diabetes) were included. Two sets of pooled risk estimates were calculated using random effects: depression predicting type 2 diabetes and type 2 diabetes predicting depression. RESULTS —Of 42 full-text publications reviewed, 13 met eligibility for depression predicting onset of diabetes, representing 6,916 incident cases. Seven met criteria for diabetes predicting onset of depression, representing 6,414 incident cases. The pooled relative risk (RR) for incident depression associated with baseline diabetes was 1.15 (95% CI 1.02–1.30). The RR for incident diabetes associated with baseline depression was 1.60 (1.37–1.88). CONCLUSIONS —Depression is associated with a 60% increased risk of type 2 diabetes. Type 2 diabetes is associated with only modest increased risk of depression. Future research should focus on identifying mechanisms linking these conditions.
1,271 citations
TL;DR: It is stated that aspirin therapy should be used as a primary prevention strategy in diabetic patients at increased cardiovascular risk, including those who are >40 years old or have additional risk factors.
Abstract: The American Diabetes Association (ADA) has released a Standards of Medical Care in Diabetes Position Statement for 2008 (1). In this document, it is stated that aspirin therapy should be used as a primary prevention strategy in diabetic patients at increased cardiovascular (CV) risk, including those who are >40 years old or have additional risk factors. The recommendation is based on evidence graded “A,” which is defined by the ADA as “evidence from well-conducted, randomized controlled trials that are adequately powered or compelling nonexperimental evidence.” As this indication seemed very …
1,260 citations
TL;DR: In this article, the authors examined the associations of objectively measured sedentary time and physical activity with continuous indexes of metabolic risk in Australian adults without known diabetes, and highlighted the importance of decreasing the amount of time spent in physical activity for metabolic health.
Abstract: OBJECTIVE —We examined the associations of objectively measured sedentary time and physical activity with continuous indexes of metabolic risk in Australian adults without known diabetes. RESEARCH DESIGN AND METHODS —An accelerometer was used to derive the percentage of monitoring time spent sedentary and in light-intensity and moderate-to-vigorous–intensity activity, as well as mean activity intensity, in 169 Australian Diabetes, Obesity and Lifestyle Study (AusDiab) participants (mean age 53.4 years). Associations with waist circumference, triglycerides, HDL cholesterol, resting blood pressure, fasting plasma glucose, and a clustered metabolic risk score were examined. RESULTS —Independent of time spent in moderate-to-vigorous–intensity activity, there were significant associations of sedentary time, light-intensity time, and mean activity intensity with waist circumference and clustered metabolic risk. Independent of waist circumference, moderate-to-vigorous–intensity activity time was significantly beneficially associated with triglycerides. CONCLUSIONS —These findings highlight the importance of decreasing sedentary time, as well as increasing time spent in physical activity, for metabolic health.
969 citations
TL;DR: Depression is common in patients with diabetes and is associated with worse treatment outcomes, but its relationship to treatment adherence has not been systematically reviewed, and treatment nonadherence may represent an important pathway between depression and worse diabetes clinical outcomes.
Abstract: OBJECTIVE —Depression is common in patients with diabetes and is associated with worse treatment outcomes. Its relationship to treatment adherence, however, has not been systematically reviewed. We used meta-analysis to examine the relationship between depression and treatment nonadherence in patients with type 1 and type 2 diabetes.
RESEARCH DESIGN AND METHODS —We searched MEDLINE and PsycINFO databases for all studies published by June 2007 and reviewed references of published articles. Meta-analytic procedures were used to estimate the effect size r in a random effects model. Significance values, weighted effect sizes, 95% CIs, and tests of homogeneity of variance were calculated.
RESULTS —Results from 47 independent samples showed that depression was significantly associated with nonadherence to the diabetes treatment regimen ( z = 9.97, P < 0.0001). The weighted effect size was near the medium range ( r = 0.21, 95% CI 0.17–0.25). Moderator analyses showed that the effect was significantly larger in studies that measured self-care as a continuous versus categorical variable ( P = 0.001). Effect sizes were largest for missed medical appointments and composite measures of self-care ( r values = 0.31, 0.29). Moderation analyses suggest that effects for most other types of self-care are also near the medium range, especially in studies with stronger methodologies.
CONCLUSIONS —These findings demonstrate a significant association between depression and treatment nonadherence in patients with diabetes. Studies that used stronger methodologies had larger effects. Treatment nonadherence may represent an important pathway between depression and worse diabetes clinical outcomes.
854 citations
TL;DR: It is unclear whether lipoprotein parameters other than LDL or non-HDL cholesterol provide clinically significant additional prognostic information regarding CVD risk, yield more information about the effectiveness of therapy, or indicate more appropriate treatment targets.
Abstract: Risk factors for type 2 diabetes and cardiovascular disease (CVD) often cluster, including obesity (particularly central), insulin resistance, hyperglycemia, dyslipoproteinemia, and hypertension. These conditions can also occur in isolation, and they are exaggerated by physical inactivity and smoking. Since each of these factors increases risk of CVD, the concept of global cardiometabolic risk (CMR) (Fig. 1) is of value (1). Lipoprotein abnormalities, including elevated triglycerides, low HDL cholesterol, and increased numbers of small dense LDL particles, are common findings in patients with CMR. Clinical entities with increased CMR include type 2 diabetes, familial combined hyperlipidemia, familial hypoalphalipoproteinemia, and polycystic ovary syndrome (2). These disorders often share the CMR characteristics of central obesity, insulin resistance, dyslipoproteinemia, and hypertension.
There are stringent lipid treatment goals for patients with type 2 diabetes or CVD; however, guidelines for treatment of dyslipoproteinemia in high-risk subjects without diabetes or CVD are less intense and are based primarily on LDL cholesterol concentrations, with non-HDL concentrations a secondary consideration in some subjects. Numerous trials have demonstrated that therapies (primarily statins) directed at LDL cholesterol lowering clearly reduce risk of CVD events in patients with diabetes and in those without diabetes but with other CVD risk factors; yet, a number of questions remain. Even with adequate LDL cholesterol lowering, many patients on statin therapy have significant residual CVD risk. It is unclear whether lipoprotein parameters other than LDL or non-HDL cholesterol provide clinically significant additional prognostic information regarding CVD risk, yield more information about the effectiveness of therapy, or indicate more appropriate treatment targets. Many patients with CMR or diabetes have relatively normal levels of LDL cholesterol but increased numbers of small dense LDL particles and other atherogenic lipoproteins. Some have advocated that assessment of other lipoprotein parameters might be more helpful than assessment limited to LDL or non-HDL …
792 citations
University of Miami1, Rosalind Franklin University of Medicine and Science2, Veterans Health Administration3, United States Department of Veterans Affairs4, American Association of Clinical Endocrinologists5, University of Missouri–Kansas City6, American Diabetes Association7, Texas A&M University8, University of Missouri9, University of Arizona10, Washington University in St. Louis11, Icahn School of Medicine at Mount Sinai12, University of Pittsburgh13
TL;DR: A task force was assembled by the ADA to address and concisely summarize recent literature in this area and then recommend what should be included in the comprehensive foot exam for adult patients with diabetes.
Abstract: It is now 10 years since the last technical review on preventative foot care was published (1), which was followed by an American Diabetes Association (ADA) position statement on preventive foot care in diabetes (2). Many studies have been published proposing a range of tests that might usefully identify patients at risk of foot ulceration, creating confusion among practitioners as to which screening tests should be adopted in clinical practice. A task force was therefore assembled by the ADA to address and concisely summarize recent literature in this area and then recommend what should be included in the comprehensive foot exam for adult patients with diabetes. The committee was cochaired by the immediate past and current chairs of the ADA Foot Care Interest Group (A.J.M.B. and D.G.A.), with other panel members representing primary care, orthopedic and vascular surgery, physical therapy, podiatric medicine and surgery, and the American Association of Clinical Endocrinologists.
The lifetime risk of a person with diabetes developing a foot ulcer may be as high as 25%, whereas the annual incidence of foot ulcers is ∼2% (3–7). Up to 50% of older patients with type 2 diabetes have one or more risk factors for foot ulceration (3,6). A number of component causes, most importantly peripheral neuropathy, interact to complete the causal pathway to foot ulceration (1,3–5). A list of the principal contributory factors that might result in foot ulcer development is provided in Table 1.
View this table:
Table 1—
Risk factors for foot ulcers
The most common triad of causes that interact and ultimately result in ulceration has been identified as neuropathy, deformity, and trauma (5). As identification of those patients at risk of foot problems is the first step in preventing such complications, this report will focus on key components of the …
737 citations
TL;DR: Current developments in the field of reactive oxygen species and cardiovascular disease are highlighted, focusing specifically on the recently identified novel Nox family of NAD(P)H oxidases in hypertension, and the potential role of targeting ROS as a therapeutic possibility in the management of hypertension and cardiovascular Disease is discussed.
Abstract: Reactive oxygen species (ROS) influence many physiological processes including host defense, hormone biosynthesis, fertilization, and cellular signaling. Increased ROS production (termed "oxidative stress") has been implicated in various pathologies, including hypertension, atherosclerosis, diabetes, and chronic kidney disease. A major source for vascular and renal ROS is a family of nonphagocytic NAD(P)H oxidases, including the prototypic Nox2 homolog-based NAD(P)H oxidase, as well as other NAD(P)H oxidases, such as Nox1 and Nox4. Other possible sources include mitochondrial electron transport enzymes, xanthine oxidase, cyclooxygenase, lipoxygenase, and uncoupled nitric oxide synthase. NAD(P)H oxidase-derived ROS plays a physiological role in the regulation of endothelial function and vascular tone and a pathophysiological role in endothelial dysfunction, inflammation, hypertrophy, apoptosis, migration, fibrosis, angiogenesis, and rarefaction, important processes underlying cardiovascular and renal remodeling in hypertension and diabetes. These findings have evoked considerable interest because of the possibilities that therapies against nonphagocytic NAD(P)H oxidase to decrease ROS generation and/or strategies to increase nitric oxide (NO) availability and antioxidants may be useful in minimizing vascular injury and renal dysfunction and thereby prevent or regress target organ damage associated with hypertension and diabetes. Here we highlight current developments in the field of reactive oxygen species and cardiovascular disease, focusing specifically on the recently identified novel Nox family of NAD(P)H oxidases in hypertension. We also discuss the potential role of targeting ROS as a therapeutic possibility in the management of hypertension and cardiovascular disease.
TL;DR: Hyperinsulinemia is often both a result and a driver of insulin resistance, and situations where insulin itself appears to be a proximate and important quantitative contributor to insulin resistance are examined.
Abstract: Insulin resistance, recently recognized as a strong predictor of disease in adults, has become the leading element of the metabolic syndrome and renewed as a focus of research. The condition exists when insulin levels are higher than expected relative to the level of glucose. Thus, insulin resistance is by definition tethered to hyperinsulinemia. The rising prevalence of medical conditions where insulin resistance is common has energized research into the causes. Many causes and consequences have been identified, but the direct contributions of insulin itself in causing or sustaining insulin resistance have received little sustained attention. We examine situations where insulin itself appears to be a proximate and important quantitative contributor to insulin resistance. 1) Mice transfected with extra copies of the insulin gene produce basal and stimulated insulin levels that are two to four times elevated. The mice are of normal weight but show insulin resistance, hyperglycemia, and hypertriglyceridemia. 2) Somogyi described patients with unusually high doses of insulin and hyperglycemia. Episodes of hypoglycemia with release of glucose-raising hormones, postulated as the culprits in early studies, have largely been excluded by studies including continuous glucose monitoring. 3) Rats and humans treated with escalating doses of insulin show both hyperinsulinemia and insulin resistance. 4) The pulsatile administration of insulin (rather than continuous) results in reduced requirements for insulin. 5) Many patients with insulinoma who have elevated basal levels of insulin have reduced (but not absent) responsiveness to administered insulin. In summary, hyperinsulinemia is often both a result and a driver of insulin resistance.
TL;DR: A hyperglycemic intrauterine environment appears to be involved in the pathogenesis of type 2 diabetes/pre-diabetes in adult offspring of primarily Caucasian women with either diet-treated GDM or type 1 diabetes during pregnancy.
Abstract: Objective: The role of intrauterine hyperglycemia and future risk of type 2 diabetes in human offspring is debated. We studied glucose tolerance in adult offspring of women with either gestational diabetes (GDM) or type 1 diabetes, taking the impact of both intrauterine hyperglycemia and genetic predisposition to type 2 diabetes into account.
Research Design and Methods: The glucose tolerance status following a 2-hour 75-g oral glucose tolerance test (OGTT) was evaluated in 597 primarily Caucasians aged 18-27 years. They were subdivided into four groups according to maternal glucose metabolism during pregnancy and genetic predisposition to type 2 diabetes: 1) offspring of women with diet-treated GDM (O-GDM), 2) offspring of genetically predisposed women with a normal OGTT (O-NoGDM), 3) offspring of women with type 1 diabetes (O-Type1) and 4) offspring of women from the background population (O-BP).
Results: The prevalence of type 2 diabetes and pre-diabetes (impaired glucose tolerance or impaired fasting glucose) in the four groups was 21%, 12%, 11% and 4% respectively. In multiple logistic regression analysis, the adjusted odds ratios (OR) for type 2 diabetes/pre-diabetes were 7.76 (95% CI 2.58-23.39) in O-GDM and 4.02 (1.31-12.33) in O-Type1 compared to O-BP. In O-Type1 the risk of type 2 diabetes/pre-diabetes was significantly associated with elevated maternal blood glucose in late pregnancy: OR 1.41 (1.04-1.91) per mmol/l.
Conclusions: A hyperglycemic intrauterine environment appears to be involved in the pathogenesis of type 2 diabetes/pre-diabetes in adult offspring of primarily Caucasian women with either diet-treated GDM or type 1 diabetes during pregnancy.
TL;DR: In this article, a retrospective study of 175,249 women ages 13-58 years with 209,287 singleton deliveries of ≥ 20 weeks gestation from 1999 through 2005 in all Kaiser Permanente hospitals in southern California, information from clinical databases and birth certificates were used to estimate the prevalence of pre-existing diabetes and gestational diabetes mellitus.
Abstract: Objective: To assess changes in prevalence of pre-existing diabetes (diabetes antedating pregnancy) and gestational diabetes mellitus (GDM) from 1999 through 2005. Research Design and Methods: In this retrospective study of 175,249 women ages 13-58 years with 209,287 singleton deliveries of ≥ 20 weeks gestation from 1999 through 2005 in all Kaiser Permanente hospitals in southern California, information from clinical databases and birth certificates were used to estimate the prevalence of pre-existing diabetes and GDM. Results: Pre-existing diabetes mellitus was identified in 2,784 (1.3%) of all pregnancies, rising from an age and race/ethnicity adjusted prevalence of 0.81/100 in 1999 to 1.82/100 in 2005 (p for trend Conclusions: The stable prevalence of GDM and increase in the prevalence of pre-existing diabetes were independent of changes in the age and race/ethnicity of the population. The increase in pre-existing diabetes, particularly among younger women early in their reproductive years, is of concern.
TL;DR: Closed-loop glucose control using an external sensor and insulin pump provides a means to achieve near-normal glucose concentrations in youth with type 1 diabetes during the overnight period and the addition of small manual priming bolus doses of insulin improves postprandial glycemic excursions.
Abstract: OBJECTIVE —The most promising β-cell replacement therapy for children with type 1 diabetes is a closed-loop artificial pancreas incorporating continuous glucose sensors and insulin pumps. The Medtronic MiniMed external physiological insulin delivery (ePID) system combines an external pump and sensor with a variable insulin infusion rate algorithm designed to emulate the physiological characteristics of the β-cell. However, delays in insulin absorption associated with the subcutaneous route of delivery inevitably lead to large postprandial glucose excursions.
RESEARCH DESIGN AND METHODS —We studied the feasibility of the Medtronic ePID system in youth with type 1 diabetes and hypothesized that small manual premeal “priming” boluses would reduce postprandial excursions during closed-loop control. Seventeen adolescents (aged 15.9 ± 1.6 years; A1C 7.1 ± 0.8%) underwent 34 h of closed-loop control; 8 with full closed-loop (FCL) control and 9 with hybrid closed-loop (HCL) control (premeal priming bolus).
RESULTS —Mean glucose levels were 135 ± 45 mg/dl in the HCL group versus 141 ± 55 mg/dl in the FCL group ( P = 0.09); daytime glucose levels averaged 149 ± 47 mg/dl in the HCL group versus 159 ± 59 mg/dl in the FCL group ( P = 0.03). Peak postprandial glucose levels averaged 194 ± 47 mg/dl in the HCL group versus 226 ± 51 mg/dl in the FCL group ( P = 0.04). Nighttime control was similar in both groups (111 ± 27 vs. 112 ± 28 mg/dl).
CONCLUSIONS —Closed-loop glucose control using an external sensor and insulin pump provides a means to achieve near-normal glucose concentrations in youth with type 1 diabetes during the overnight period. The addition of small manual priming bolus doses of insulin, given 15 min before meals, improves postprandial glycemic excursions.
TL;DR: The increase in fractures with rosiglitazone occurred in pre- and postmenopausal women, and fractures were seen predominantly in the lower and upper limbs.
Abstract: Objective: To examine possible factors associated with the increased risk of fractures observed with rosiglitazone in ADOPT (A Diabetes Outcome Progression Trial). Research Design and Methods: Data from the 1840 women and 2511 men randomized in ADOPT to rosiglitazone, metformin or glyburide for a median of 4.0 years were examined with respect to time to first fracture, rates of occurrence and sites of fractures. Results: In men, fracture rates did not differ between treatment groups. In women, at least one fracture was reported with rosiglitazone in 60 patients (9.3% of patients, 2.74/100 patient years [PY]), metformin in 30 (5.1%, 1.54/100 PY) and glyburide in 21 (3.5%, 1.29/100 PY). The cumulative incidence (95% CI) of fractures in women at five years was 15.1% (11.2, 19.1) with rosiglitazone, 7.3% (4.4, 10.1) with metformin and 7.7% (3.7, 11.7) with glyburide, representing hazard ratios of 1.81 (1.17, 2.80) and 2.13 (1.30, 3.51) for rosiglitazone compared to metformin and glyburide, respectively. The increase in fractures with rosiglitazone occurred in pre- and postmenopausal women, and was predominantly in the lower and upper limb. No particular risk factor underlying the increased fractures in female patients who received rosiglitazone therapy was identified. Conclusions: Further investigation into the risk factors and underlying pathophysiology for the increased fracture rate in women taking rosiglitazone is required to relate them to preclinical data and better understand the clinical implications of and possible interventions for these findings.
TL;DR: The metabolic syndrome, however defined, has a stronger association with incident diabetes than that previously demonstrated for coronary heart disease and its clinical value for diabetes prediction remains uncertain.
Abstract: OBJECTIVE —Our objective was to perform a quantitative review of prospective studies examining the association between the metabolic syndrome and incident diabetes.
RESEARCH DESIGN AND METHODS —Using the title terms “diabetes” and “metabolic syndrome” in PubMed, we searched for articles published since 1998.
RESULTS —Based on the results from 16 cohorts, we performed a meta-analysis of estimates of relative risk (RR) and incident diabetes. The random-effects summary RRs were 5.17 (95% CI 3.99–6.69) for the 1999 World Health Organization definition (ten cohorts); 4.45 (2.41–8.22) for the 1999 European Group for the Study of Insulin Resistance definition (four cohorts); 3.53 (2.84–4.39) for the 2001 National Cholesterol Education Program definition (thirteen cohorts); 5.12 (3.26–8.05) for the 2005 American Heart Association/National Heart, Lung, and Blood Institute definition (five cohorts); and 4.42 (3.30–5.92) for the 2005 International Diabetes Federation definition (nine cohorts). The fixed-effects summary RR for the 2004 National Heart, Lung, and Blood Institute/American Heart Association definition was 5.16 (4.43–6.00) (six cohorts). Higher number of abnormal components was strongly related to incident diabetes. Compared with participants without an abnormality, estimates of RR for those with four or more abnormal components ranged from 10.88 to 24.4. Limited evidence suggests fasting glucose alone may be as good as metabolic syndrome for diabetes prediction.
CONCLUSIONS —The metabolic syndrome, however defined, has a stronger association with incident diabetes than that previously demonstrated for coronary heart disease. Its clinical value for diabetes prediction remains uncertain.
TL;DR: NPWT appears to be as safe as and more efficacious than AMWT for the treatment of diabetic foot ulcers and patients experienced significantly (P = 0.035) fewer secondary amputations.
Abstract: Objective The purpose of this study was to evaluate safety and clinical efficacy of negative pressure wound therapy (NPWT) compared with advanced moist wound therapy (AMWT) to treat foot ulcers in diabetic patients. Research design and methods This multicenter randomized controlled trial enrolled 342 patients with a mean age of 58 years; 79% were male. Complete ulcer closure was defined as skin closure (100% reepithelization) without drainage or dressing requirements. Patients were randomly assigned to either NPWT (vacuum-assisted closure) or AMWT (predominately hydrogels and alginates) and received standard off-loading therapy as needed. The trial evaluated treatment until day 112 or ulcer closure by any means. Patients whose wounds achieved ulcer closure were followed at 3 and 9 months. Each study visit included closure assessment by wound examination and tracings. Results A greater proportion of foot ulcers achieved complete ulcer closure with NPWT (73 of 169, 43.2%) than with AMWT (48 of 166, 28.9%) within the 112-day active treatment phase (P = 0.007). The Kaplan-Meier median estimate for 100% ulcer closure was 96 days (95% CI 75.0-114.0) for NPWT and not determinable for AMWT (P = 0.001). NPWT patients experienced significantly (P = 0.035) fewer secondary amputations. The proportion of home care therapy days to total therapy days for NPWT was 9,471 of 10,579 (89.5%) and 12,210 of 12,810 (95.3%) for AMWT. In assessing safety, no significant difference between the groups was observed in treatment-related complications such as infection, cellulitis, and osteomyelitis at 6 months. Conclusions NPWT appears to be as safe as and more efficacious than AMWT for the treatment of diabetic foot ulcers.
TL;DR: A retrospective analysis on the database of the Laboratory Information System of the Clinical Chemistry Laboratory at the Verona University Hospital to retrieve results on the association between uric acid and glucose homeostasis found that the age- and sex-adjusted hazard ratios for diabetes were low.
Abstract: We read with interest the recent article by Dehghan et al. (1), who suggest that serum uric acid might be a strong and independent risk factor for diabetes. In particular, it was reported that the age- and sex-adjusted hazard ratios for diabetes were 1.30 for the 2nd quartile, 1.63 for the 3rd quartile, and 2.83 for the 4th quartile of serum uric acid, in comparison with the 1st quartile. To further investigate the association between uric acid and glucose homeostasis, we performed a retrospective analysis on the database of the Laboratory Information System of the Clinical Chemistry Laboratory at the Verona University Hospital to retrieve results …
TL;DR: Fear of hypoglycemia is the strongest barrier to regular physical activity in adults with type 1 diabetes, who should therefore be informed and supported in hyp glucosecemia management.
Abstract: OBJECTIVE—To determine, in an adult population with type 1 diabetes, barriers to regular physical activity using a diabetes-specific barriers measure (the Barriers to Physical Activity in Diabetes [type 1] [BAPAD1] scale) and factors associated with these barriers.
RESEARCH DESIGN AND METHODS—One hundred adults with type 1 diabetes answered a questionnaire assessing perceived barriers to physical activity and related factors. A1C was obtained from the medical chart of each individual.
RESULTS—Fear of hypoglycemia was identified as being the strongest barrier to physical activity. Greater knowledge about insulin pharmacokinetics and using appropriate approaches to minimize exercise-induced hypoglycemia were factors associated with fewer perceived barriers. Greater barriers were positively correlated with A1C levels (r = 0.203; P = 0.042) and negatively with well-being (r = −0.45; P < 0.001).
CONCLUSIONS—Fear of hypoglycemia is the strongest barrier to regular physical activity in adults with type 1 diabetes, who should therefore be informed and supported in hypoglycemia management.
TL;DR: In this article, the association between serum uric acid level and risk of type 2 diabetes was investigated, and the results of this population-based study suggest that serum urological acid is a strong and independent risk factor for diabetes.
Abstract: OBJECTIVE —To investigate the association between serum uric acid level and risk of type 2 diabetes. RESEARCH DESIGN AND METHODS —The population for analysis consisted of 4,536 subjects free from diabetes at baseline. During a mean of 10.1 years of follow-up, 462 subjects developed diabetes. RESULTS —The age- and sex-adjusted hazard ratios (HRs) (95% CIs) for diabetes were 1.30 (0.96–1.76) for the second, 1.63 (1.21–2.19) for the third, and 2.83 (2.13–3.76) for the fourth quartile of serum uric acid, in comparison with the first quartile. After adjustment for BMI, waist circumference, systolic and diastolic blood pressure, and HDL cholesterol, the HRs decreased to 1.08 (0.78–1.49), 1.12 (0.81–1.53), and 1.68 (1.22–2.30), respectively. CONCLUSIONS —The results of this population-based study suggest that serum uric acid is a strong and independent risk factor for diabetes.
TL;DR: In this article, the authors examined trends in A1C levels for adults with diagnosed diabetes using three consecutive waves of the National Health and Nutrition Examination Survey (NHANES): 1999-2000, 2001-2002, and 2003-2004.
Abstract: OBJECTIVE —The purpose of this study was to examine whether glycemic control has improved in recent years among individuals with diagnosed diabetes. RESEARCH DESIGN AND METHODS —We examined trends in A1C levels for adults with diagnosed diabetes using three consecutive waves of the National Health and Nutrition Examination Survey (NHANES): 1999–2000, 2001–2002, and 2003–2004. We estimated mean A1C levels and the proportion with A1C RESULTS —Mean A1C levels among individuals with diagnosed diabetes declined from 7.82% in 1999–2000 to 7.47 and 7.18% in 2001–2002 and 2003–2004, respectively. After controlling for demographics and diabetes duration, A1C levels were 0.308 ( P = 0.20) and 0.511 ( P = 0.03) percentage points lower in 2001–2002 and 2003–2004, respectively, than in 1999–2000. The logistic results indicated corresponding improvements over time: the predictive margin for having A1C CONCLUSIONS —Glycemic control improved between 1999 and 2004. This trend may represent an important improvement in diabetes care and is encouraging for future reduction of diabetes-related complications.
TL;DR: Young women with GDM had a substantially increased risk for CVD compared with women without GDM, and much of this increased risk was attributable to subsequent development of type 2 diabetes.
Abstract: OBJECTIVE—To determine whether women with gestational diabetes mellitus (GDM) have an increased risk of cardiovascular disease (CVD) following pregnancy.
RESEARCH DESIGN AND METHODS—All women aged 20–49 years with live births between April 1994 and March 1997 in Ontario, Canada, were identified. Women with GDM were matched with 10 women without GDM and were followed for CVD.
RESULTS—The matched cohorts included 8,191 women with GDM and 81,262 women without GDM. Mean age at entry was 31 years, and median follow-up was 11.5 years. The hazard ratio for CVD events was 1.71 (95% CI 1.08–2.69). After adjustment for subsequent type 2 diabetes, the hazard ratio was attenuated (1.13 [95% CI 0.67–1.89]).
CONCLUSIONS—Young women with GDM had a substantially increased risk for CVD compared with women without GDM. Much of this increased risk was attributable to subsequent development of type 2 diabetes.
TL;DR: Stavudine and zidovudine are significantly associated with diabetes after adjustment for risk factors for diabetes and lipids, suggesting that the two thymidine analogs probably directly contribute to insulin resistance, potentially through mitochondrial toxicity.
Abstract: OBJECTIVE—The aims of this study were to determine the incidence of diabetes among HIV-infected patients in the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) cohort, to identify demographic, HIV-related, and combination antiretroviral therapy (cART)-related factors associated with the onset of diabetes, and to identify possible mechanisms for any relationships found. RESEARCH DESIGN AND METHODS—D:A:D is a prospective observational study of 33,389 HIV-infected patients; diabetes is a study end point. Poisson regression models were used to assess the relation between diabetes and exposure to cART after adjusting for known risk factors for diabetes, CD4 count, lipids, and lipodystrophy. RESULTS—Over 130,151 person-years of follow-up (PYFU), diabetes was diagnosed in 744 patients (incidence rate of 5.72 per 1,000 PYFU [95% CI 5.31–6.13]). The incidence of diabetes increased with cumulative exposure to cART, an association that remained significant after adjustment for potential risk factors for diabetes. The strongest relationship with diabetes was exposure to stavudine; exposures to zidovudine and didanosine were also associated with an increased risk of diabetes. Time-updated measurements of total cholesterol, HDL cholesterol, and triglycerides were all associated with diabetes. Adjusting for each of these variables separately reduced the relationship between cART and diabetes slightly. Although lipodystrophy was significantly associated with diabetes, adjustment for this did not modify the relationship between cART and diabetes. CONCLUSION—Stavudine and zidovudine are significantly associated with diabetes after adjustment for risk factors for diabetes and lipids. Adjustment for lipodystrophy did not modify the relationship, suggesting that the two thymidine analogs probably directly contribute to insulin resistance, potentially through mitochondrial toxicity.
TL;DR: Consumption of green leafy vegetables and fruit was associated with a lower hazard of diabetes, whereas consumption of fruit juices may be associated with an increased hazard among women.
Abstract: OBJECTIVE—The purpose of this study was to examine the association between fruit, vegetable, and fruit juice intake and development of type 2 diabetes.
RESEARCH DESIGN AND METHODS—A total of 71,346 female nurses aged 38–63 years who were free of cardiovascular disease, cancer, and diabetes in 1984 were followed for 18 years, and dietary information was collected using a semiquantitative food frequency questionnaire every 4 years. Diagnosis of diabetes was self-reported.
RESULTS—During follow-up, 4,529 cases of diabetes were documented, and the cumulative incidence of diabetes was 7.4%. An increase of three servings/day in total fruit and vegetable consumption was not associated with development of diabetes (multivariate-adjusted hazard ratio 0.99 [95% CI 0.94–1.05]), whereas the same increase in whole fruit consumption was associated with a lower hazard of diabetes (0.82 [0.72–0.94]). An increase of 1 serving/day in green leafy vegetable consumption was associated with a modestly lower hazard of diabetes (0.91 [0.84–0.98]), whereas the same change in fruit juice intake was associated with an increased hazard of diabetes (1.18 [1.10–1.26]).
CONCLUSIONS—Consumption of green leafy vegetables and fruit was associated with a lower hazard of diabetes, whereas consumption of fruit juices may be associated with an increased hazard among women.
TL;DR: The high prevalence of diabetes in working-age adults in Iran is an ominous sign for this developing nation, as the relatively young Iranian population ages in the future and urbanization continues or accelerates, the prevalence of Diabetes will likely escalate.
Abstract: OBJECTIVE —Despite concerns regarding a diabetes epidemic in the Middle East, internationally published data on national estimates of prevalent type 2 diabetes in Iran do not exist. With this article, we document a dramatically high prevalence of diabetes in Iran.
RESEARCH DESIGN AND METHODS —Our data are based on the results of the first Survey of Risk Factors of Non-Communicable Diseases of Iran, 2005. In this national cross-sectional survey, 70,981 Iranian citizens aged 25–64 years were recruited.
RESULTS —We found that 7.7% of adults aged 25–64 years, or 2 million adults, have diabetes, among whom one-half are undiagnosed. An additional 16.8%, or 4.4 million, of Iranian adults have impaired fasting glucose.
CONCLUSIONS —The high prevalence of diabetes in working-age adults is an ominous sign for this developing nation. As the relatively young Iranian population ages in the future and urbanization continues or accelerates, the prevalence of diabetes will likely escalate.
TL;DR: Lactic acidosis during current use of oral antidiabetes drugs was very rare and was associated with concurrent comorbidity.
Abstract: OBJECTIVE — Lactic acidosis has been associated with use of metformin. Hypoglycemia is a major concern using sulfonylureas. The aim of this study was to compare the risk of lactic acidosis and hypoglycemia among patients with type 2 diabetes using oral antidiabetes drugs. RESEARCH DESIGN AND METHODS — This study is a nested case-control analysis using the U.K.-based General Practice Research Database to identify patients with type 2 diabetes who used oral antidiabetes drugs. Within the study population, all incident cases of lactic acidosis and hypoglycemia were identified, and hypoglycemia case subjects were matched to up to four control patients based on age, sex, practice, and calendar time. RESULTS — Among the study population of 50,048 type 2 diabetic subjects, six cases of lactic acidosis during current use of oral antidiabetes drugs were identified, yielding a crude incidence rate of 3.3 cases per 100,000 person-years among metformin users and 4.8 cases per 100,000 person-years among users of sulfonylureas. Relevant comorbidities known as risk factors for lactic acidosis could be identified in all case subjects. A total of 2,025 case subjects with hypoglycemia and 7,278 matched control subjects were identified. Use of sulfonylureas was associated with a materially elevated risk of hypoglycemia. The adjusted odds ratio for current use of sulfonylureas was 2.79 (95% CI 2.23–3.50) compared with current metformin use. CONCLUSIONS — Lactic acidosis during current use of oral antidiabetes drugs was very rare and was associated with concurrent comorbidity. Hypoglycemic episodes were substantially more common among sulfonylurea users than among users of metformin.
Santa Clara Valley Medical Center1, Stanford University2, Harvard University3, MetroHealth4, University of Texas at San Antonio5, Kaiser Permanente6, University of Michigan7, University of California, San Francisco8, University of California, Los Angeles9, University of Washington10, University of Southern California11, Northwestern University12, Mount Sinai St. Luke's and Mount Sinai Roosevelt13, St. Joseph's Hospital and Medical Center14, American Diabetes Association15
TL;DR: This document presents consensus panel recommendations for the medical care of pregnant women with preexisting diabetes, including type 1 and type 2 diabetes, to help clinicians deal with the broad spectrum of problems that arise in management of diabetes before and during pregnancy, and to prepare diabetic women for treatment that may reduce complications in the years after pregnancy.
Abstract: This document presents consensus panel recommendations for the medical care of pregnant women with preexisting diabetes, including type 1 and type 2 diabetes. The intent is to help clinicians deal with the broad spectrum of problems that arise in management of diabetes before and during pregnancy, and to prepare diabetic women for treatment that may reduce complications in the years after pregnancy. A thorough discussion of the evidence supporting the recommendations is presented in the book, Management of Preexisting Diabetes and Pregnancy , authored by the consensus panel and published by the American Diabetes Association (ADA) in 2008 (1). A consensus statement on obstetrical and postpartum management will appear separately.
The recommendations are diagnostic and therapeutic actions that are known or believed to favorably affect maternal and perinatal outcomes in pregnancies complicated by diabetes. The grading system adapted by the ADA was used to clarify and codify the evidence that forms the basis for the recommendations (2). Unfortunately there is a paucity of randomized controlled trials (RCTs) of the different aspects of management of diabetes and pregnancy. Therefore our recommendations are often based on trials conducted in nonpregnant diabetic women or nondiabetic pregnant women, as well as on peer-reviewed experience before and during pregnancy in women with preexisting diabetes (3–4). We also reviewed and adapted existing diabetes and pregnancy guidelines (5–10) and guidelines on diabetes complications and comorbidities (2,3,11–14).
### A. Organization of preconception and pregnancy care
#### Recommendations
TL;DR: In older diabetic adults, reducing diabetes-related complications may prevent falls, and achieving lower A1C levels with oral hypoglycemic medications was not associated with more frequent falls, but, among those using insulin, A 1C ≤6% increased fall risk.
Abstract: Background: Older adults with type 2 diabetes are more likely to fall but little is known about risk factors for falls in this population. We determined if diabetes-related complications or treatments are associated with fall risk in older diabetic adults. Methods: In the Health, Aging, and Body Composition cohort of well-functioning older adults, participants reported falls in the previous year at annual visits. Odds ratios for more frequent falls among 446 diabetic participants whose mean age was 73.6 years, with an average follow-up of 4.9 years, were estimated with continuation ratio models. Results: In the first year, 24% reported falling; 22%, 26%, 31%, and 30% fell in subsequent years. In adjusted models, reduced peroneal nerve response amplitude (OR=1.50; 95% CI 1.07, 2.12, worst quartile vs others), higher cystatin-C, a marker of reduced renal function, (OR=1.38; 95% CI 1.11, 1.71, for 1SD increase), poorer contrast sensitivity (OR=1.41; 95% CI 0.97, 2.04, worst quartile vs others), and low A1C in insulin users (OR = 4.36; 95% CI 1.32, 14.46, A1C≤6% vs >8%) were associated with fall risk. In those using oral hypoglycemic medications but not insulin, low A1C was not associated with fall risk (OR = 1.29; 95% CI 0.65, 2.54, A1C≤6% vs >8%). Adjustment for physical performance explained some, but not all, of these associations. Conclusions: In older diabetic adults, reducing diabetes-related complications may prevent falls. Achieving lower A1C levels with oral hypoglycemic medications was not associated with more frequent falls, but, among those using insulin, A1C ≤6% increased fall risk.
TL;DR: In well-controlled GDM pregnancies, maternal lipids are strong predictors for fetal lipids and fetal growth, while insulin-to-glucose ratio and FFAs were the highest in LGA newborns.
Abstract: RESEARCH DESIGN AND METHODS — In 150 pregnancies, serum triglycerides (TGs), cholesterol, free fatty acids (FFAs), glycerol, insulin, and glucose were determined in maternal serum and cord blood during the 3rd trimester. Maternal glucose values came from oral glucose tolerance testing and glucose profiles. Measurements of fetal abdominal circumference (AC) were performed simultaneously with maternal blood sampling and birth weight, and BMI and neonatal fat mass were obtained following delivery. RESULTS — Maternal TGs and FFAs correlated with fetal AC size (at 28 weeks: triglycerides, P 0.001; FFAs, P 0.02), and at delivery they correlated with all neonatal anthropometric measures (FFA: birth weight, P 0.002; BMI, P 0.001; fat mass, P 0.01). After adjustment for confounding variables, maternal FFAs and TGs at delivery remained the only parameters independently related to newborns large for gestational age (LGA) (P 0.008 and P 0.04, respectively). Maternal FFA levels were higher in mothers with LGA newborns than in those with appropriate for gestational age (AGA) newborns (362.8 101.7 vs. 252.4 10.1, P 0.002). Maternal levels of TGs, FFAs, and glycerol at delivery correlated with those in cord blood (P 0.003, P 0.004, and P 0.005, respectively). Fetal triglyceride and cholesterol levels were negatively correlated with newborn birth weight (P 0.001), BMI (P 0.004), and fat mass (P 0.001). TGs were significantly higher in small for gestational age (SGA) newborns compared with AGA or LGA newborns, while insulin-to-glucose ratio and FFAs were the highest in LGA newborns. CONCLUSIONS — In well-controlled GDM pregnancies, maternal lipids are strong predictors for fetal lipids and fetal growth. Infants with abnormal growth seem to be exposed to a distinct intrauterine environment compared with those with appropriate growth. Diabetes Care 31:1858–1863, 2008