United Kingdom prospective diabetes study (UKPDS): what now or so what?

Key Nutrients for Optimal Blood Glucose Control and Mental Health in Individuals with Diabetes: A Review of the Evidence

Diabetes is associated with an increased risk of mental disorders, including depression, anxiety, and cognitive decline. Mental disorders can also contribute to the development of diabetes through various mechanisms including increased stress, poor self-care behaviors, and adverse effects on glucose metabolism. Consequently, individuals suffering from either of these conditions frequently experience comorbidity with the other. Nutrition plays an important role in both diabetes and mental health disorders including depression and anxiety. Deficiencies in specific nutrients such as omega-3 fatty acids, vitamin D, B vitamins, zinc, chromium, magnesium, and selenium have been implicated in the pathogenesis of both diabetes and mental disorders. While the impact of nutrition on the progression and control of diabetes and mental disorders is broadly acknowledged, there is a notable knowledge gap concerning the implications of distinct nutrients in preventing and mitigating symptoms of both conditions when they coexist. The aim of this study was to examine the role of nutrition in improving glucose homeostasis and promoting mental well-being among individuals with diabetes. Further, we evaluated the preventive or delaying effects of key nutrients on the simultaneous manifestation of these conditions when one of them is present. Our findings indicated that the use of personalized dietary interventions and targeted nutrient supplementation can improve metabolic and mental health outcomes in patients with type 2 diabetes.

Global comparison of the effect of non-pharmacological interventions on glycemic control in patients with type 2 diabetes: A network meta-analysis from 107 randomized controlled trials

OBJECTIVE

To investigate the effectiveness of non-pharmacological interventions (NPIs) on glycemic control in patients with type 2 diabetes (T2D) and to provide guidance for clinical healthcare-giver.

DESIGN

Network meta-analysis (NMA).

SETTING AND PARTICIPANTS

Randomized controlled trials comparing the effect of NPIs with usual care, waitlist, or other NPIs on glycemic control in patients with T2D.

METHODS

This NMA was guided by frequentist framework. PubMed, Embase, the Cochrane Library Central Register of Controlled Trials, Cumulated Index to Nursing and Allied Health Literature, and Web of Science were searched from their inception until January 2023. The primary outcome was HbA1c and secondary outcomes were cardiovascular risk scores and related psychosocial scores. Mean differences and standardized mean differences were pooled using NMA. Study quality was assessed with the Confidence in Network Meta-analysis.

RESULTS

A total of 107 studies (10,496 participants) were included. The median sample size of the included studies was 64 (range, 10-563) and the median duration was 3 months (range, 1-24). Compared to usual care, all NPIs except acupuncture (MD: -0.28; 95 % CI: -1.02, 0.26) and psychological therapy (MD: -0.29; 95 % CI: -0.66, 0.08) showed significantly differences in improving glycemic control in patients with T2D. And according to the results of surface under the cumulative ranking analysis and Cluster ranking, meditation therapy was considered to the best choice when balancing the efficacy of glycemic control with self-efficacy and diabetes related problems, while nutrition therapy was considered to the best choice when balancing quality of life with risk of cardiovascular complications.

CONCLUSIONS

These findings validate the efficacy of NPIs for glycemic control in patients with T2D and suggest that healthcare-giver should consider both the efficacy of interventions and the psychosocial needs of patients when developing NPIs programs.

Preoperative HbA1c and Blood Glucose Measurements in Diabetes Mellitus before Oral Surgery and Implantology Treatments

Diabetes mellitus has become a worldwide epidemic and is frequently accompanied by a number of complications proportional to the duration of hyperglycemia. The aim of this narrative review is to assess the most up-to-date guidelines on DM provided by both diabetes and dental associations. Furthermore, to gather evidence on the uni/bidirectional relationships of elevated HbA1c levels on dental surgery, implantology, bone augmentation, and periodontology and to demonstrate the importance of measuring HbA1c levels before invasive dental treatments. HbA1c and blood glucose measurements are a minimally invasive method for preventing complications in diabetes mellitus. The authors conducted a literature review to determine which oral conditions are affected by diabetes mellitus. MEDLINE served as a source with the use of a specific search key. Regarding oral complications of diabetes, prevention is the most vital factor. With this publication, we hope to assist physicians and dentists to make prompt diagnoses and to help in recognizing various oral manifestations of diabetes and follow the existing guidelines.

Risk of diabetic retinopathy and retinal neurodegeneration in individuals with type 2 diabetes: Beichen Eye Study

Objective

Our aim was to evaluate associations of different risk factors with odds of diabetic retinopathy (DR) diagnosis and retinal neurodegeneration represented by macular ganglion cell-inner plexiform layer (mGCIPL).

Methods

This cross-sectional study analyzed data from individuals aged over 50 years examined between June 2020 and February 2022 in the community-based Beichen Eye Study on ocular diseases. Baseline characteristics included demographic data, cardiometabolic risk factors, laboratory findings, and medications at enrollment. Retinal thickness in both eyes of all participants was measured automatically via optical coherence tomography. Risk factors associated with DR status were investigated using multivariable logistic regression. Multivariable linear regression analysis was performed to explore associations of potential risk factors with mGCIPL thickness.

Results

Among the 5037 included participants with a mean (standard deviation, SD) age of 62.6 (6.7) years (3258 women [64.6%]), 4018 (79.8%) were control individuals, 835 (16.6%) were diabetic individuals with no DR, and 184 (3.7%) were diabetic individuals with DR. The risk factors significantly associated with DR status were family history of diabetes (odds ratio [OR], 4.09 [95% CI, 2.44-6.85]), fasting plasma glucose (OR, 5.88 [95% CI, 4.66-7.43]), and statins (OR, 2.13 [95% CI, 1.03-4.43]) relative to the control individuals. Compared with the no DR, diabetes duration (OR, 1.17 [95% CI, 1.13-1.22]), hypertension (OR, 1.60 [95% CI, 1.26-2.45]), and glycated hemoglobin A1C (HbA1c) (OR, 1.27 [95% CI, 1.00-1.59]) were significantly correlated with DR status. Furthermore, age (adjusted β = -0.19 [95% CI, -0.25 to -0.13] μm; P < 0.001), cardiovascular events (adjusted β = -0.95 [95% CI, -1.78 to -0.12] μm; P = 0.03), and axial length (adjusted β = -0.82 [95% CI, -1.29 to -0.35] μm; P = 0.001) were associated with mGCIPL thinning in diabetic individuals with no DR.

Conclusion

Multiple risk factors were associated with higher odds of DR development and lower mGCIPL thickness in our study. Risk factors affecting DR status varied among the different study populations. Age, cardiovascular events, and axial length were identified as potential risk factors for consideration in relation to retinal neurodegeneration in diabetic patients.

Physiological and Pathological Roles of Aldose Reductase

Aldose reductase (AR) is an aldo-keto reductase that catalyzes the first step in the polyol pathway which converts glucose to sorbitol. Under normal glucose homeostasis the pathway represents a minor route of glucose metabolism that operates in parallel with glycolysis. However, during hyperglycemia the flux of glucose via the polyol pathway increases significantly, leading to excessive formation of sorbitol. The polyol pathway-driven accumulation of osmotically active sorbitol has been implicated in the development of secondary diabetic complications such as retinopathy, nephropathy, and neuropathy. Based on the notion that inhibition of AR could prevent these complications a range of AR inhibitors have been developed and tested; however, their clinical efficacy has been found to be marginal at best. Moreover, recent work has shown that AR participates in the detoxification of aldehydes that are derived from lipid peroxidation and their glutathione conjugates. Although in some contexts this antioxidant function of AR helps protect against tissue injury and dysfunction, the metabolic transformation of the glutathione conjugates of lipid peroxidation-derived aldehydes could also lead to the generation of reactive metabolites that can stimulate mitogenic or inflammatory signaling events. Thus, inhibition of AR could have both salutary and injurious outcomes. Nevertheless, accumulating evidence suggests that inhibition of AR could modify the effects of cardiovascular disease, asthma, neuropathy, sepsis, and cancer; therefore, additional work is required to selectively target AR inhibitors to specific disease states. Despite past challenges, we opine that a more gainful consideration of therapeutic modulation of AR activity awaits clearer identification of the specific role(s) of the AR enzyme in health and disease.

HbA1c variability, in addition to mean HbA1c, predicts incident hip fractures in Chinese people with type 2 diabetes

Type 2 diabetes is associated with an increased risk of hip fractures. We hypothesize that long-term glycemic variability predicts incident hip fractures. We demonstrated that HbA1c variability predicted incident hip fractures independent of mean HbA1c, suggesting the potential benefits of minimizing glycemic variability in addition to optimizing mean glycemia for bone health.

INTRODUCTION

Type 2 diabetes is associated with an increased risk of hip fractures, and a linear relationship between HbA1c levels and hip fracture incidence has been observed. We hypothesize that HbA1c variability also predicts incident hip fractures in type 2 diabetes.

METHODS

Chinese individuals with type 2 diabetes aged ≥ 60 years were identified from electronic health records in Hong Kong between 2008 and 2012 and observed for incident hip fractures. Hip fracture was defined by the International Classification of Diseases (Ninth Revision) code 820. HbA1c variability was determined using standard deviation, adjusted standard deviation, and coefficient of variation of HbA1c measurements in the 5 years preceding the entry date. Multivariable Cox regression analysis was used to evaluate associations between HbA1c variability and incident hip fractures.

RESULTS

A total of 83,282 participants were included. Their mean age was 71.3 ± 7.5 years, duration of diabetes 11.7 ± 7.7 years, baseline HbA1c 56.6 ± 13.5 mmol/mol (7.33 ± 1.23%), and median follow-up 6.8 years. All indices of HbA1c variability were significant independent predictors of incident hip fractures, with an adjusted hazard ratio of up to 1.29 (all p < 0.001), and remained to be independent predictors across groups of different intensity of glycemic control. Mean HbA1c ≥ 64 mmol/mol (8.0%) was associated with a 25% increase in incident hip fractures compared with mean HbA1c < 53 mmol/mol (7.0%).

CONCLUSION

HbA1c variability is an independent positive predictor of hip fracture in type 2 diabetes, across the spectrum of varying degree of glycemic control, while a high HbA1c is also not advisable from the perspective of bone health.

Serum Urate Lowering with Allopurinol and Kidney Function in Type 1 Diabetes

BACKGROUND

Higher serum urate levels are associated with an increased risk of diabetic kidney disease. Lowering of the serum urate level with allopurinol may slow the decrease in the glomerular filtration rate (GFR) in persons with type 1 diabetes and early-to-moderate diabetic kidney disease.

METHODS

In a double-blind trial, we randomly assigned participants with type 1 diabetes, a serum urate level of at least 4.5 mg per deciliter, an estimated GFR of 40.0 to 99.9 ml per minute per 1.73 m² of body-surface area, and evidence of diabetic kidney disease to receive allopurinol or placebo. The primary outcome was the baseline-adjusted GFR, as measured with iohexol, after 3 years plus a 2-month washout period. Secondary outcomes included the decrease in the iohexol-based GFR per year and the urinary albumin excretion rate after washout. Safety was also assessed.

RESULTS

A total of 267 patients were assigned to receive allopurinol and 263 to receive placebo. The mean age was 51.1 years, the mean duration of diabetes 34.6 years, and the mean glycated hemoglobin level 8.2%. The mean baseline iohexol-based GFR was 68.7 ml per minute per 1.73 m² in the allopurinol group and 67.3 ml per minute per 1.73 m² in the placebo group. During the intervention period, the mean serum urate level decreased from 6.1 to 3.9 mg per deciliter with allopurinol and remained at 6.1 mg per deciliter with placebo. After washout, the between-group difference in the mean iohexol-based GFR was 0.001 ml per minute per 1.73 m² (95% confidence interval [CI], -1.9 to 1.9; P = 0.99). The mean decrease in the iohexol-based GFR was -3.0 ml per minute per 1.73 m² per year with allopurinol and -2.5 ml per minute per 1.73 m² per year with placebo (between-group difference, -0.6 ml per minute per 1.73 m² per year; 95% CI, -1.5 to 0.4). The mean urinary albumin excretion rate after washout was 40% (95% CI, 0 to 80) higher with allopurinol than with placebo. The frequency of serious adverse events was similar in the two groups.

CONCLUSIONS

We found no evidence of clinically meaningful benefits of serum urate reduction with allopurinol on kidney outcomes among patients with type 1 diabetes and early-to-moderate diabetic kidney disease. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; PERL ClinicalTrials.gov number, NCT02017171.).

Supported self-management for people with type 2 diabetes: a meta-review of quantitative systematic reviews

OBJECTIVES

Self-management support aims to give people with chronic disease confidence to actively manage their disease, in partnership with their healthcare provider. A meta-review can inform policy-makers and healthcare managers about the effectiveness of self-management support strategies for people with type 2 diabetes, and which interventions work best and for whom.

DESIGN

A meta-review of systematic reviews of randomised controlled trials (RCTs) was performed adapting Cochrane methodology.

SETTING AND PARTICIPANTS

Eight databases were searched for systematic reviews of RCTs from January 1993 to October 2016, with a pre-publication update in April 2017. Forward citation was performed on included reviews in Institute for Scientific Information (ISI) Proceedings. We extracted data and assessed quality with the Revised-Assessment of Multiple Systematic Reviews (R-AMSTAR).

PRIMARY AND SECONDARY OUTCOME MEASURES

Glycaemic control as measured by glycated haemoglobin (HbA1c) was the primary outcome. Body mass Index, lipid profiles, blood pressure and quality of life scoring were secondary outcomes. Meta-analyses reporting HbA1c were summarised in meta-forest plots; other outcomes were synthesised narratively.

RESULTS

41 systematic reviews incorporating data from 459 unique RCTs in diverse socio-economic and ethnic communities across 33 countries were included. R-AMSTAR quality score ranged from 20 to 42 (maximum 44). Apart from one outlier, the majority of reviews found an HbA1c improvement between 0.2% and 0.6% (2.2-6.5 mmol/mol) at 6 months post-intervention, but attenuated at 12 and 24 months. Impact on secondary outcomes was inconsistent and generally non-significant. Diverse self-management support strategies were employed; no single approach appeared optimally effective (or ineffective). Effective programmes tended to be multi-component and provide adequate contact time (>10 hours). Technology-facilitated self-management support showed a similar impact as traditional approaches (HbA1c MD -0.21% to -0.6%).

CONCLUSIONS

Self-management interventions using a range of approaches improve short-term glycaemic control in people with type 2 diabetes including culturally diverse populations. These findings can inform researchers, policy-makers and healthcare professionals re-evaluating the provision of self-management support in routine care. Further research should consider implementation and sustainability.

Review: Type 2 diabetes — implications for macrovascular mechanics and disease

Before macrovascular disease is established, type 2 diabetes is associated with structural and functional changes in large arteries that lead to increased stiffness, abnormal pulse wave travel and systolic hypertension. Structural changes result mainly from glycation of wall components. Functional changes originate in endothelial dysfunction. Increased arterial stiffness, or decreased arterial distensibility, increases pulse wave velocity and the amplitude of reflected waves, so that reflected waves arrive early and augment central systolic pressure. This promotes the development of left ventricular hypertrophy, an independent risk factor for cardiovascular mortality. One of the major mechanisms of arterial stiffening is endothelial dysfunction with reduced nitric oxide (NO)-mediated vasodilatation, the initial lesion in pre-atherosclerotic diabetes. To understand better the mechanisms of endothelial dysfunction will be vital if future therapeutic interventions are targeted to disease prevention. Protein glycation in poorly controlled diabetes is also damaging to blood vessels and must be limited by good diabetic control over the longer term.

Efficacy and safety of vildagliptin, sitagliptin, and linagliptin as add-on therapy in Chinese patients with T2DM inadequately controlled with dual combination of insulin and traditional oral hypoglycemic agent

OBJECTIVE

We aimed to evaluate the efficacy and safety of the three dipeptidyl peptidase 4 (DPP-4) inhibitors (vildagliptin, sitagliptin, and linagliptin) as add-on therapy in Chinese patients with type 2 diabetes mellitus (T2DM)inadequately controlled on dual combination of insulin and metformin or acarbose.

METHODS

A total of 535 T2DM patients who failed to achieve glycemic control with insulin and a traditional oral hypoglycemic agent were randomized to receive vildagliptin, sitagliptin, or linagliptin. Body mass index, glycosylated hemoglobin (HbA1c), fasting and postprandial plasma glucose (FPG and PPG), insulin dose, and adverse events were evaluated during the study.

RESULTS

The baseline HbA1c was 9.59 ± 1.84 % (vildagliptin group), 9.22 ± 1.60 % (sitagliptin group), and 9.58 ± 1.80 % (linagliptin group). At week 12 it was 8.16 ± 1.29 % (vildagliptin), 8.56 ± 1.96 % (linagliptin), and 8.26 ± 1.10 % (sitagliptin). The changes in HbA1c from baseline were -1.33 ± 0.11 % (vildagliptin), -0.84 ± 0.08 % (sitagliptin) and -0.81 ± 0.08 % (linagliptin), the vildagliptin group had the greatest reduction in HbA1c (P < 0.05). The proportions of patients that reached target HbA1c were 66.27 % (vildagliptin), 52.73 % (sitagliptin), and 55.49 % (linagliptin), the vildagliptin group had the highest one (P < 0.05). The baseline FPG and PPG values in the three groups were at the same level. At week 12, mean FPG levels in the vildagliptin (7.31 ± 1.50 mmol/L) and linagliptin (6.90 ± 1.55 mmol/L) groups were significantly lower than in the sitagliptin group (8.02 ± 4.48 mmol/L; P < 0.05); the linagliptin group had the lowest mean PPG followed by the vildagliptin group which was also significant lower (P = 0.000) than the sitagliptin group. Additionally, the required insulin dosage in the vildagliptin group was the lowest among the groups at weeks 6 and 12. Only mild AEs were reported during the study.

CONCLUSION

The three DPP-4 inhibitors appear to be effective and safe as add-on therapy for T2DM patients on dual combination of insulin and a traditional OHA. Vildagliptin was more effective in decreasing insulin requirement and achieving glycemic control when compared to the other two.

Implementation of guidelines for metabolic syndrome control in kidney transplant recipients: results at a single center

BACKGROUND

Cardiovascular disease is a leading cause of death among kidney transplant recipients. Metabolic syndrome increases the risk for cardiovascular events and decreases graft survival. Lately, guidelines for management of the metabolic syndrome, primarily hypertension, diabetes mellitus (DM) and hypercholesterolemia have dramatically changed in an attempt to decrease cardiovascular risks among kidney transplant recipients. In the present study we examined whether these guideline changes had impact on our management of post-transplantation patients and the subsequent treatment outcomes for these diseases.

METHODS

Data were obtained from kidney transplant clinic files from two follow-up (FU) periods-between 1994-1997 and between 2008-2011. Demographic data, monitoring and screening frequency for cardiovascular risk factors, immunosuppression regimen, treatment for hypertension, diabetes and hyperlipidemia, treatment outcomes and graft function changes were compared between the two follow-up periods.

RESULTS

There was a significant increase in the percentage of patients undergoing transplantation due to renal failure secondary to diabetes and/or hypertension. Patient monitoring and screening during the second FU period were less frequent, but more targeted, reflecting changes in clinic routines. Blood pressure was better controlled in the second FU period (p < 0.01), as was hypercholesterolemia (p < 0.001). High fasting glucose levels were more prevalent among patients in the second group (p < 0.005), although more patients received treatment for DM (p < 0.001). Significantly, fewer patients experienced deterioration of kidney functions during the second FU period (p < 0.001).

CONCLUSIONS

We found that guideline changes had impact on clinical practice, which translated to better control of the metabolic syndrome. DM control is challenging. Overall, stability of kidney function improved.

Hypothesis: Intensive insulin therapy-induced mortality is due to excessive serotonin autoinhibition and autonomic dysregulation

Action to Control Cardiovascular Risk in Diabetes (ACCORD), The Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation and the Veterans Affairs Diabetes Trial were designed to study whether older patients with type 2 diabetes mellitus could reduce the risk of heart attacks and stroke and thereby prolong their lives by maintaining their blood glucose levels at near-healthy levels but failed to demonstrate the hoped-for benefit. Why the trials failed, though, and why ACCORD saw significantly more deaths due to increased rates of cardiovascular events in the intensive therapy arm of the study are not clear. These data have now been confirmed by the results of the recently concluded NICE-SUGAR Study which again revealed that intensive glucose control increased mortality among adults in intensive care units. I propose that the negative results noted in these trials are due to altered brain serotonin concentrations and autonomic dysregulation in addition to the low-grade systemic inflammation, decreased endothelial nitric oxide and enhanced free radical generation, diminished anti-oxidant defenses and altered metabolism of essential fatty acids present in patients with type 2 diabetes.

The UKPDS and its global impact

Aim To review the world-wide impact of the United Kingdom Prospective Diabetes Study (UKPDS) on diabetes health care since publication of the main study results in 1998. Methods The major papers published by the UKPDS were reviewed, e-mails and faxes were sent to diabetes associations in various regions of the world seeking information on trends in HbA1c over the past decade and similar information was obtained from a major USA laboratory. Results The UKPDS extended to type 2 diabetes and brought to completion the case for linking the microvascular vascular complications of diabetes to control of blood glucose initially demonstrated by the Diabetes Control and Complications Trial (DCCT). This helped set the standard of care for diabetes to seek an HbA1c goal of at least < 7.0% with intensive glycemic treatment and formed a fundamental part of continuing medical education. This also helped stimulate new hypoglycemic drug development and the preferential use of metformin as first line therapy was supported by UKPDS results. In many areas of the world, including the United Kingdom and the USA, a national trend to lower HbA1c levels has been seen. Economic analyses have shown UKPDS intensive treatment to be cost-effective at 6028 Ibs. per quality life year gained, imposing a reasonable burden on the British National health care budget. Conclusions The UKPDS was a landmark study in the treatment of type 2 diabetes from the time of diagnosis that has influenced standards of care and treatment guidelines throughout the world.

Cross-sectional analysis of adult diabetes type 1 and type 2 patients with diabetic microvascular complications from a German retrospective observational study

OBJECTIVE

To obtain epidemiological data on the prevalence of predefined stages of diabetic microvascular complications from a representative cross-section of patients with existing microvascular complications of type 1 or type 2 diabetes in Germany.

RESEARCH DESIGN AND METHODS

A cross-sectional, retrospective study of medical records of 705 type 1 and 1910 type 2 adult diabetic patients with a diagnosis of retinopathy and/or peripheral neuropathy and/or nephropathy before 2002 and treated in 2002 in Germany.

RESULTS

Of 376 patients with type 1 diabetes having retinopathy, 59.3% had mild or moderate non-proliferative retinopathy without macular oedema, 27.1% had macular oedema, and 13.6% had severe retinopathy without macular oedema. In 862 patients with type 2 diabetes, the distribution of retinopathy/maculopathy classes was 56.8%, 35.5%, and 7.7%, respectively. Of 381 type 1 diabetes patients with observed peripheral neuropathy, 81.4% had sensorimotor neuropathy, 8.9% had diabetic foot conditions, and 9.7% had lower extremity amputations because of diabetes. In 1005 patients with type 2 diabetes, the distribution of neuropathy classes was 78.2%, 12.1%, and 9.7%, respectively. The proportions of patients with renal insufficiency in type 1 and type 2 diabetes groups were 15.3% versus 13.5%, respectively.

CONCLUSIONS

The study suggests that there are considerable proportions of patients with progressive stages of microvascular complications related to type 1 and type 2 diabetes in Germany. This underlines the importance of improvement of optimal quality of care and frequent screening for preventing late diabetic microvascular complications and the necessity of effective intervention strategies to tackle this major public health problem.

Lifestyle Intervention for Prevention and Treatment of Type 2 Diabetes

Evidence exists that lifestyle interventions in the prevention and treatment of type 2 diabetes are effective. The present challenge is to translate the evidence into policies and practices that maximize the potential health benefits for the largest number of individuals. Translational efforts are urgently needed to identify how best to identify individuals for lifestyle prevention efforts, prepare health care systems for treatment delivery, and design public health policies that support healthy weight through healthy opportunities for eating and physical activity.

Future alternative therapies in a quest to halt aberrations in diabetes mellitus

Under normal physiological conditions, euglycaemia is maintained principally by the homeostatic balance of insulin and glucagon which are secreted from the pancreas. In both type 1 and type 2 diabetes mellitus there is a substantial and chronic increase in the circulating glucose concentration. This elevation in glucose levels is accompanied by a plethora of other biochemical disturbances, including disruption of carbohydrate, fat and protein metabolism. Clinical manifestations of diabetes, which arise from the metabolic disturbances vary between individuals but are often a serious threat to quality and length of life. Pancreas transplantation (Tx) and islet modifications are methods used to restore endogenous insulin secretion in insulin-dependent diabetic patients. In order for this to be achieved successfully, however, some of the problems such as hyperglycemia states (> 150 mg/dl), which may harm pancreatic graft beta cells, immunorejection, the effects of immunosuppression, for example, must be overcome. Considering these problems, therefore, it seems logical that the replacement of the islet tissue itself, either by transplanting a vascularised pancreatic allograft or by transplanting modified pancreatic islet cells, provides a better alternative therapeutic approach than simply replacing insulin that has been lost. This review will show the recent development in the use of pancreatic islets and their modification in a quest to halt the aberrations seen in diabetes mellitus.

Characteristics Associated with Neuropathy and/or Retinopathy in a Hospital Outpatient Diabetic Clinic

BACKGROUND

The incidence of diabetes is increasing worldwide and with it the risk of diabetic complications. The aim of this study was to characterise parameters associated with neuropathy and/or retinopathy in a hospital outpatient diabetic clinic population.

METHOD

A structured questionnaire addressing diabetes related factors and demography was administered to a cross-sectional sample of patients (n = 290) with type 1 and type 2 diabetes attending a hospital diabetic outpatient clinic. Additional clinical measures were obtained from patient medical files and computerised records. Logistic regression analysis was used to identify characteristics associated with the presence of complications.

RESULTS

When controlling for other predictors, increasing age (P < 0.01), type 1 diabetes (P = 0.05), longer duration of diabetes (P < 0.01), increased serum triglyceride levels (P = 0.03), HbA1c (>8%; P = 0.03), self-reported low physical activity levels (P = 0.05) and being a smoker (P = 0.01) were positively related to retinopathy and/or neuropathy. Patients within the study population had reasonably well controlled BP and serum lipids, thus explaining the absence of these particular variables from the list of predictor parameters. Other factors including diabetes knowledge, home blood glucose monitoring, gender, body mass index, clinic attendance and occupational status were not significantly associated with retinopathy or neuropathy in the present study population.

CONCLUSIONS

Pharmacists and other health practitioners who are in a position to be involved in the care and management of patients with diabetes should raise awareness of complications, particularly amongst patients who present with the above risk factors and provide necessary counselling and advice as required.

Patients with uncontrolled hypertension or concomitant hypertension and benign prostatic hyperplasia

At optimal doses, individual antihypertensive agents lower blood pressure (BP) by an average of 10 mmHg. Many patients with hypertension, including those with stage 3 hypertension, target organ damage, or those at high risk for cardiovascular events and/or adverse effects of high-dose monotherapy, are likely to require combination antihypertensive drug treatment to achieve the recommended systolic/diastolic BP (< 140/90 mmHg). Two studies, a placebo-controlled, double-blind trial (n = 70) and a community-based, open-label trial (n = 491) investigated the antihypertensive efficacy of doxazosin, a long-acting selective alpha1-adrenoceptor blocker, as add-on therapy for uncontrolled hypertension with other antihypertensive medications and in patients with concomitant benign prostatic hyperplasia (BPH) and treated but inadequately controlled hypertension, respectively. The addition of doxazosin to baseline antihypertensive medication(s) significantly lowered BP and had a significantly positive effect on the serum lipid profile. In patients with concomitant BPH, doxazosin significantly improved all BPH symptom scores, regardless of initial symptom severity. Add-on doxazosin sufficiently reduced systolic/diastolic BP such that many patients whose hypertension was previously uncontrolled by other antihypertensive medications were able to reach goal BP (< 140/90 mmHg). Doxazosin as add-on therapy was well tolerated. In conclusion, doxazosin as add-on therapy improves BP control in hypertensive patients not at goal BP and improves lower urinary tract symptoms in patients with concomitant BPH.

Diagnosis of type 2 diabetes: a qualitative analysis of patients' emotional reactions and views about information provision

Research about diagnosis of chronic illness indicates this is an emotional time for patients. Information provision is especially salient for diabetes management. Yet current orthodoxy suggests that too much information at the time of diagnosis is unhelpful for patients. In this study, we used in-depth interviews with 40 newly diagnosed type 2 diabetic (T2DM) patients in Scotland, to explore their emotional reactions about diagnosis, and their views about information provision at the time of diagnosis. Data were analysed using a thematic approach. Our results showed three main 'routes' to diagnosis: 'suspected diabetes' route; 'illness' route; and 'routine' route. Those within the 'routine' route described the most varied emotional reactions to their diagnosis. We found that most patients, irrespective of their route to diagnosis, wanted more information about diabetes management at the time of diagnosis. We suggest that practitioners would benefit from being sensitive to the route patients follow to diagnosis, and prompt, simple but detailed advice about T2DM management would be helpful for newly diagnosed patients.

Evaluating the management of diabetic retinopathy in a teaching center

PURPOSE

To evaluate the efficacy of the management of diabetic retinopathy (DR) in the teaching center of the University Eye Clinic of Patras in Greece.

METHODS

From 1989 to 1999, 302 patients with type I (5.3%) and type II (94.7%) diabetes mellitus (DM) were examined. Standard examination and treatment protocols were employed. Examinations and laser treatment were done by trainee specialists, under the supervision of the head physician (N.Ph), during their rotation in the retina and vitreous disorders outpatient department.

RESULTS

At baseline examination, 17.9% of the eyes had no DR, 71.7% had nonproliferative DR, and 10.4% had proliferative DR. In 34.4%, no laser treatment followed. The other 65.6% underwent focal and/or grid laser and/or panretinal photocoagulation and/or vitrectomy. At the final examination, DR was still the same in 63.1% of the eyes, progression had occurred in 34.1%, and regression in 2.8%. Type I DM patients' eyes had a higher prevalence of proliferative DR at the final examination than type II DM eyes. There was also a significant correlation between progression of DR and duration of DM, insulin treatment for DM, and elevated glycosylated hemoglobin (HbA1c).

CONCLUSIONS

Having applied standard examination and treatment protocols, the efficacy of the management of our diabetic patients was consistent with international standards, even though patients were treated mostly by doctors in training.

Prevention of diabetic nephropathy in mice by a diet low in glycoxidation products

BACKGROUND

Reactive advanced glycation end products (AGEs), known to promote diabetic tissue damage, occur endogenously as well as in heated foods and are orally absorbed. The relative contribution of diet-derived AGEs to diabetic nephropathy (DN) remains unclear.

METHODS

We tested a standard mouse food (AIN-93G) found to be rich in AGEs (H-AGE diet) in parallel with a similar diet that contained six-fold lower AGE content (L-AGE), but equal calories, macronutrients, and micronutrients. Non-obese diabetic mice (NOD) with type 1 diabetes (T1D) and db/db mice with type 2 diabetes (T2D) were randomly assigned to each formula for either 4 or 11 months, during which time renal parameters and AGE levels were assessed.

RESULTS

Compared to the progressive DN and short survival seen in NOD mice exposed to long-term H-AGE feeding, L-AGE-fed NOD mice developed minimal glomerular pathology and a modest increase in urinary albumin:creatinine ratio (p<0.005), and a significantly extended survival (p<0.0001), consistent with lower serum (p<0.025) and kidney AGEs (p<0.01). Also, in the 4-month study, and in contrast to the H-AGE-fed mice, L-AGE-fed NOD and db/db mice exhibited low levels of renal cortex TGF beta-1 (p<0.05), laminin B1 mRNA (p<0.01) and alpha 1 IV collagen mRNA (p<0.05) and protein, in concert with reduced serum and kidney AGEs (p<0.05, respectively).

CONCLUSION

Intake of high-level, food-derived AGEs is a major contributor to DN in T1D and T2D mice. Avoidance of dietary AGEs provides sustained protection against DN in mice; providing the rationale for similar studies in human diabetic patients.

Screening for diabetes: is it warranted?

BACKGROUND

Diabetes mellitus is estimated to have a worldwide prevalence of 4.6% and afflict 200 million people. The prevalence is accelerating rapidly and the disease has reached epidemic proportions. While type 1 diabetes usually has a dramatic clinical onset, almost half of all those individuals with type 2 diabetes have not been diagnosed. This observation, coupled with the presence of complications at diagnosis and the significant reduction of microvascular complications obtained with tight glycemic control, has led to the recommendation that screening for diabetes be instituted. The American Diabetes Association recommends that adults aged 45 years or more should be evaluated for diabetes by measuring fasting plasma glucose concentrations.

CONCLUSIONS

The rationale for screening, evidence that tight glycemic control reduces complications, and the possible roles of Hb A(1c) and autoantibodies in screening strategies are addressed in this review.

Step care therapy for hypertension in diabetic patients

For diabetic patients, a goal blood pressure lower than 130/80-85 mm Hg is strongly supported by clinical trial results. We review the agents, sequence, and dosing used in clinical trials and propose a treatment algorithm. Multiagent antihypertensive therapy is required to attain goal blood pressure in most patients. Step sequences to obtain this goal are suggested. In general, we favor initial therapy with an angiotensin-converting enzyme inhibitor, followed by the addition of a diuretic. The presence of comorbid conditions may dictate variation from this scheme. The effect of antihypertensive agents on established cardiovascular diseases, proteinuria, renal function, and metabolic factors is discussed. Tailored recommendations for specific clinical scenarios are described.

Association of depression and diabetes complications: a meta-analysis

OBJECTIVE

The objective of this study was to examine the strength and consistency of the relationship between depression and diabetes complications in studies of type 1 and type 2 adult patients with diabetes.

METHOD

MEDLINE and PsycINFO databases were searched for articles examining depression and diabetes complications in type 1 and type 2 diabetes samples published between 1975 and 1999. Meta-analytic procedures were used. Studies were reviewed for diabetes type, sample size, statistical tests, and measures of diabetes complications and depression. Significance values, weighted effect sizes r, 95% confidence intervals (CI), and tests of homogeneity of variance were calculated for the overall sample (k = 27) and for subsets of interest.

RESULTS

A total of 27 studies (total combined N = 5374) met the inclusion criteria. A significant association was found between depression and complications of diabetes (p < .00001, z = 5.94). A moderate and significant weighted effect size (r = 0.25; 95% CI: 0.22-0.28) was calculated for all studies reporting sufficient data (k = 22). Depression was significantly associated with a variety of diabetes complications (diabetic retinopathy, nephropathy, neuropathy, macrovascular complications, and sexual dysfunction). Effect sizes were in the small to moderate range (r = 0.17 to 0.32).

CONCLUSIONS

These findings demonstrate a significant and consistent association of diabetes complications and depressive symptoms. Prospective, longitudinal studies are needed to identify the pathways that mediate this association.

Diabetes and endothelial dysfunction: a clinical perspective

The main etiology for mortality and a great percent of morbidity in patients with diabetes mellitus is atherosclerosis. A hypothesis for the initial lesion of atherosclerosis is endothelial dysfunction, defined pragmatically as changes in the concentration of the chemical messengers produced by the endothelial cell and/or by blunting of the nitric oxide-dependent vasodilatory response to acetylcholine or hyperemia. Endothelial dysfunction has been documented in patients with diabetes and in individuals with insulin resistance or at high risk for developing type 2 diabetes. Factors associated with endothelial dysfunction in diabetes include activation of protein kinase C, overexpression of growth factors and/or cytokines, and oxidative stress. Several therapeutic interventions have been tested in clinical trials aimed at improving endothelial function in patients with diabetes. Insulin sensitizers may have a beneficial effect in the short term, but the virtual absence of trials with cardiovascular end-points preclude any definitive conclusion. Two trials offer optimism that treatment with ACE inhibitors may have a positive impact on the progression of atherosclerosis. Although widely used, the effect of hypolipidemic agents on endothelial function in diabetes is not clear. The role of antioxidant therapy is controversial. No data have been published regarding the effects of hormonal replacement therapy on endothelial dysfunction in postmenopausal women with type 2 diabetes.