Incidence, prevalence and coronary heart disease risk level in known Type 2 diabetes: a sentinel practice network study in the Basque Country, Spain

Effect of age and dietary habits on Red Blood Cell membrane fatty acids in a Southern Europe population (Basque Country)

The levels of blood eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are very variable and, in general, low in most of the world population. In this study, the effects of age, sex, COVID-19, and dietary habits on the lipid profile of the erythrocyte membranes were assessed in a sub-cohort of healthy population (N = 203) from a large cohort of individuals from the Basque Country, Spain, (AKRIBEA). Sex did not have an effect on RBC lipid profile. COVID-19 infected participants showed higher levels of DGLA. Oldest participants showed higher oleic acid, EPA and DHA levels. Arachidonic acid in RBC correlated positively with the intake of sunflower oil, butter, eggs, processed and red meat, whereas DHA and EPA correlated positively with oily and lean fish. Basque Country population showed lipid profiles similar to other high fish consuming countries, such as Italy and Japan. Baseline levels of the whole lipidomic profile of the RBC including SFA, MUFA and PUFA should be examined to obtain a better description of the health and nutritional status.

Incidence of diabetes mellitus and associated risk factors in the adult population of the Basque country, Spain

The aim of this study was to estimate the incidence of diabetes mellitus in the Basque Country and the risk factors involved in the disease by reassessing an adult population after 7 years of follow-up. In the previous prevalence study, 847 people older than 18 years were randomly selected from all over the Basque Country and were invited to answer a medical questionnaire, followed by a physical examination and an oral glucose tolerance test. In the reassessment, the same variables were collected and the resulting cohort comprised 517 individuals of whom 43 had diabetes at baseline. The cumulative incidence of diabetes was 4.64% in 7 years and the raw incidence rate was 6.56 cases/1000 person-years (95%CI: 4.11-9.93). Among the incident cases, 59% were undiagnosed. The most strongly associated markers by univariate analyses were age > 60 years, dyslipidaemia, prediabetes and insulin resistance. We also found association with hypertension, obesity, family history of diabetes and low education level. Multivariate analysis adjusted for age and sex showed that a set of risk factors assessed together (dyslipidaemia, waist-to-hip-ratio and family history of diabetes) had great predictive value (AUC-ROC = 0.899, 95%CI: 0.846-0.953, p = 0.942), which suggests the need for early intervention before the onset of prediabetes.

Clinical characteristics of type 2 diabetic patients on basal insulin therapy with adequate fasting glucose control who do not achieve HbA1c targets

BACKGROUND

The aim of the present study was to determine the clinical characteristics of patients with type 2 diabetes mellitus (T2DM) treated with basal insulin who achieved an adequate fasting plasma glucose (FPG) level (<130 mg/dL), but were unable to achieve the HbA1c target (<7%; <53 mmol/mol).

METHODS

A cross-sectional study was performed on T2DM patients aged 31-90 years treated with basal insulin registered in the SIDIAP^Q primary healthcare electronic database during 2010.

RESULTS

In 2010, of a population of 126 811 T2DM subjects, 9899 were treated with basal insulin (neutral protamine Hagedorn [NPH], detemir, or glargine). Of these, 23.5% (n = 2322) achieved optimal FPG control levels (<130 mg/dL) but an inadequate HbA1c target (>7%). Mean HbA1c values in the contolled and uncontrolled groups were 8.15% (65.6 mmol/mol) and 6.31% (45.5 mmol/mol), respectively. Patients with controlled FPG but uncontrolled HbA1c had longer T2DM duration (11.6 vs 9.9 years), higher systolic blood pressure (138.2 vs 136.3 mmHg) and low-density lipoprotein cholesterol (104 vs 99 mg /dL), and a higher prevalence of retinopathy (24.8% vs 18.2%) than patients (17.8%) with optimal control of both glycemic targets (P < 0.05). Multivariate analysis showed that inadequate glycemic control was positively related only to younger age.

CONCLUSION

One-quarter of T2DM patients treated with basal insulin have difficulties attaining the recommended HbA1c goal despite adequate FPG levels. As some guidelines state, healthcare professionals should focus on PPG to identify and intensify treatment to control prandial glucose excursions in these patients.

A Pilot Study to Assess the Feasibility of the Spanish Diabetes Self-Management Program in the Basque Country

Purpose. The purpose of this study was to assess the feasibility of the Spanish Diabetes Self-Management Program (SDSMP) in the primary care setting of the Basque Health Service and offer initial estimations of the randomized controlled trial (RCT) effects. Methods. Ten health centers (HCs) participated in a single-arm pilot study with a 6-month follow-up period between February 2011 and June 2012. Recruitment was performed via invitation letters, health professionals, and the local media. Each intervention group consisted of 8-15 people. The ability of each HC in forming up to 2 groups, participants' compliance with the course, and coordination and data collection issues were evaluated. Glycated haemoglobin (HbA1c) was the main outcome variable. Secondary outcomes were cardiovascular risk factors, drugs consumption, medical visits, quality of life, self-efficacy, physical exercise, and diet. Results. Two HCs did not organize a course. A total of 173 patients initiated the program, 2 dropped out without baseline data, and 90% completed it. No pre-post HbA1c differences existed. Certain improvements were observed in blood pressure control, self-efficacy, physical activity, and some dietary habits. Conclusion. The SDSMP is feasible in our setting. Our experience can be of interest when planning and conducting this program in similar health settings. The trial is registered with ClinicalTrials.gov identifier NCT01642394.

Development of a prediction model for fatal and non-fatal coronary heart disease and cardiovascular disease in patients with newly diagnosed type 2 diabetes mellitus: the Basque Country Prospective Complications and Mortality Study risk engine (BASCORE)

AIMS/HYPOTHESIS

The aim of this study was to construct a model for predicting CHD and cardiovascular disease (CVD) risk in patients with newly diagnosed type 2 diabetes in a southern European region. External validation of two other cardiovascular risk models and internal validation of our model were assessed.

METHODS

We studied 65,651 people attending a primary care setting in the Basque Country Health Service. A 10-year prospective population-based cohort study was performed with 777 patients newly diagnosed with type 2 diabetes older than 24 years in a Sentinel Practice Network. Cardiovascular risk factors, CVD events and mortality were registered. Coefficients for the significant predictors of CHD and CVD were estimated using Cox models. We assessed the discrimination and calibration of the UK Prospective Diabetes Study risk engine (UKPDS-RE), the Framingham Risk Score-Regicor Study (FRS-RS) and the cardiovascular risk model we developed.

RESULTS

The incidence rate per 1,000 patients/year was calculated for microvascular and cardiovascular complications, and death. Age, the ratio of non-HDL- to HDL-cholesterol, HbA1c, systolic blood pressure and smoking were significant predictors of cardiovascular events. A risk model was developed using these predictors. The UKPDS-RE and FRS-RS showed inadequate discrimination (Uno's C statistics 0.62 and 0.58, respectively) and calibration (24% overestimation and 51% underestimation, respectively) for predicting CHD risk. The internal discrimination and calibration of the developed model were acceptable for predicting fatal/non-fatal 2- and 5-, but not 10-year CHD and CVD risk.

CONCLUSIONS/INTERPRETATION

This study is the first southern European validated population-derived model for predicting 5-year fatal/non-fatal CHD and CVD risk in patients with newly diagnosed type 2 diabetes.

Impact of a self-care education programme on patients with type 2 diabetes in primary care in the Basque Country

Background

Type 2 diabetes mellitus (DM2) is a disease with high prevalence and significant impact in terms of mortality and morbidity. The increased prevalence of the disease requires the implementation of new strategies to promote patient self-management. The Spanish Diabetes Self-Management Program (SDSMP) has proven to be effective in other settings. The objective of this study is to assess its effectiveness in terms of care for DM2 patients in primary care settings within the Basque Health Service – Osakidetza (Spain).

Method/Design

This is a randomised clinical trial in which patients diagnosed with DM2, 18–79 years of age, from four health regions within the Basque Health Service will be randomised into two groups: an intervention group, who will follow the SDSMP, and a control group, who will receive usual care in accordance with the clinical guidelines for DM2 and existing regulations in our region. The intervention consists of 2,5 hour-group sessions once a week for six weeks. The sessions cover target setting and problem solving techniques, promotion of physical exercise, basic knowledge of nutrition, proper use of medication, effective communication with relatives and health professionals, and basic knowledge about DM2 and its complications. This content is complemented by educational material: books, leaflets and CDs. The primary outcome measure will be the change in glycated haemoglobin (HbA1c), and secondary outcome measures will include changes in levels of physical activity and intake of fruit and vegetables, cardiovascular risk, quality of life, self-efficacy, number of consultations and drug prescriptions. The results will be analysed 6, 12 and 24 months after the intervention.

Discussion

If the intervention were to be effective, the programme should be spread to the entire diabetic population in the Basque Country and it could also be applied for other diseases.

Trial registration

ClinicalTrials.gov identifier NCT01642394

Costs, outcomes and challenges for diabetes care in Spain

BACKGROUND

Diabetes is becoming of increasing concern in Spain due to rising incidence and prevalence, although little information is known with regards to costs and outcomes. The information on cost of diabetes in Spain is fragmented and outdated. Our objective is to update diabetes costs, and to identify outcomes and quality of care of diabetes in Spain.

METHODS

We performed systematic searches from secondary sources, including scientific literature and government data and reports.

RESULTS

Diabetes Type II prevalence is estimated at 7.8%, and an additional 6% of the population is estimated to be undiagnosed. Four Spanish diabetes cost studies were analyzed to create a projection of direct costs in the NHS and productivity losses, estimating €5.1 billion for direct costs along with €1.5 billion for diabetes-related complications (2009) and labour productivity losses represented €2.8 billion. Glycemic control (glycolysated hemoglobin) is considered acceptable in 59% of adult Type II cases, in addition to 85% with HDL cholesterol ≥40mg/dl and 65% with blood pressure <140/90 mmHg, pointing to good intermediate outcomes. However, annual figures indicate that over half of the Type II diabetics are obese (BMI >30), 15% have diabetic retinopathy, 16% with microalbuminuria, and 15% with cardiovascular disease.

CONCLUSIONS

The direct health care costs (8% of the total National Health System expenditure) and the loss of labour productivity are high. The importance of a multi-sectoral approach in prevention and improvements in management of diabetes are discussed, along with policy considerations to help modify the disease course.

Prevalence of diabetic retinopathy in Type 2 diabetes in developing and developed countries

BACKGROUND

As the global prevalence of diabetes increases, so will the numbers of people with diabetic retinopathy. Our review aimed to provide a comprehensive picture of available studies of diabetic retinopathy and how prevalence varies around the developed and developing world.

METHODS

A detailed literature search using PubMed was undertaken. The following search term was used: 'diabetic retinopathy AND prevalence'. The titles and abstracts of all publications identified by the search were reviewed and 492 studies were retrieved. Inclusion and exclusion criteria were applied.

RESULTS

A total of 72 articles from 33 countries were included. There were only 26 population-based studies using fundus photography (12 in developing countries), of which only 16 (eight in developing countries) were published since 2000. Prevalence estimates varied from as low as 10% to as high as 61% in persons with known diabetes and from 1.5 to 31% in newly diagnosed diabetes. Across all the studies, the median (interquartile range) prevalence of any diabetic retinopathy in known diabetes was 27.9% (22-37%) and 10.5% (6-16%) in newly diagnosed diabetes. Prevalence of diabetic retinopathy was higher in developing countries.

CONCLUSION

Significant gaps exist in that reliable population-based data from developing nations and indigenous populations in particular are lacking. Major differences in study characteristics and methodologies make comparisons very difficult. More research is required and study methodologies must be better standardized. This will provide important information for prevention and treatment strategies.

Impaired fasting glucose, ancestry and waist-to-height ratio: main predictors of incident diagnosed diabetes in the Canary Islands

AIMS

To estimate the incidence rate and risk factors for diabetes in the Canary Islands.

METHODS

A total of 5521 adults without diabetes were followed for a median of 3.5 years. Incident cases of diabetes were self-declared and validated in medical records. The following factors were assessed by Cox regression to estimate the hazard ratios for diabetes: impaired fasting glucose (5.6 mmol/l ≤ fasting glucose ≤ 6.9 mmol/l), BMI, waist-to-height ratio (≥ 0.55), insulin resistance (defined as triglycerides/HDL cholesterol ≥ 3), familial antecedents of diabetes, Canarian ancestry, smoking, alcohol intake, sedentary lifestyle, Mediterranean diet, social class and the metabolic syndrome.

RESULTS

The incidence rate was 7.5/10(3) person-years (95% CI 6.4-8.8). The greatest risks were obtained for impaired fasting glucose (hazard ratio 2.6; 95% CI 1.8-3.8), Canarian ancestry (hazard ratio 1.9; 95% CI 1.0-3.4), waist-to-height ratio (hazard ratio 1.7; 95% CI 1.1-2.5), insulin resistance (hazard ratio 1.5; 95% CI 1.0-2.2) and paternal history of diabetes (hazard ratio 1.5; 95% CI 1.0-2.3). The metabolic syndrome (hazard ratio 1.9; 95% CI 1.3-2.8) and BMI ≥ 30 kg/m(2) (hazard ratio 1.7; 95% CI 1.0-2.7) were significant only when their effects were not adjusted for impaired fasting glucose and waist-to-height ratio, respectively.

CONCLUSIONS

The incidence of diabetes in the Canary Islands is 1.5-fold higher than that in continental Spain and 1.7-fold higher than in the UK. The main predictors of diabetes were impaired fasting glucose, Canarian ancestry, waist-to-height ratio and insulin resistance. The metabolic syndrome predicted diabetes only when its effect was not adjusted for impaired fasting glucose. In individuals with Canarian ancestry, genetic susceptibility studies may be advisable. In order to propose preventive strategies, impaired fasting glucose, waist-to-height ratio and triglyceride/HDL cholesterol should be used to identify subjects with an increased risk of developing diabetes.

Co-occurrence of diabetes, myocardial infarction, stroke, and cancer: quantifying age patterns in the Dutch population using health survey data

Background

The high prevalence of chronic diseases in Western countries implies that the presence of multiple chronic diseases within one person is common. Especially at older ages, when the likelihood of having a chronic disease increases, the co-occurrence of distinct diseases will be encountered more frequently. The aim of this study was to estimate the age-specific prevalence of multimorbidity in the general population. In particular, we investigate to what extent specific pairs of diseases cluster within people and how this deviates from what is to be expected under the assumption of the independent occurrence of diseases (i.e., sheer coincidence).

Methods

We used data from a Dutch health survey to estimate the prevalence of pairs of chronic diseases specified by age. Diseases we focused on were diabetes, myocardial infarction, stroke, and cancer. Multinomial P-splines were fitted to the data to model the relation between age and disease status (single versus two diseases). To assess to what extent co-occurrence cannot be explained by independent occurrence, we estimated observed/expected co-occurrence ratios using predictions of the fitted regression models.

Results

Prevalence increased with age for all disease pairs. For all disease pairs, prevalence at most ages was much higher than is to be expected on the basis of coincidence. Observed/expected ratios of disease combinations decreased with age.

Conclusion

Common chronic diseases co-occur in one individual more frequently than is due to chance. In monitoring the occurrence of diseases among the population at large, such multimorbidity is insufficiently taken into account.

Design and cohort description of the InterAct Project: an examination of the interaction of genetic and lifestyle factors on the incidence of type 2 diabetes in the EPIC Study

AIMS/HYPOTHESIS

Studying gene-lifestyle interaction may help to identify lifestyle factors that modify genetic susceptibility and uncover genetic loci exerting important subgroup effects. Adequately powered studies with prospective, unbiased, standardised assessment of key behavioural factors for gene-lifestyle studies are lacking. This case-cohort study aims to investigate how genetic and potentially modifiable lifestyle and behavioural factors, particularly diet and physical activity, interact in their influence on the risk of developing type 2 diabetes.

METHODS

Incident cases of type 2 diabetes occurring in European Prospective Investigation into Cancer and Nutrition (EPIC) cohorts between 1991 and 2007 from eight of the ten EPIC countries were ascertained and verified. Prentice-weighted Cox regression and random-effects meta-analyses were used to investigate differences in diabetes incidence by age and sex.

RESULTS

A total of 12,403 verified incident cases of type 2 diabetes occurred during 3.99 million person-years of follow-up of 340,234 EPIC participants eligible for InterAct. We defined a centre-stratified subcohort of 16,154 individuals for comparative analyses. Individuals with incident diabetes who were randomly selected into the subcohort (n = 778) were included as cases in the analyses. All prevalent diabetes cases were excluded from the study. InterAct cases were followed-up for an average of 6.9 years; 49.7% were men. Mean baseline age and age at diagnosis were 55.6 and 62.5 years, mean BMI and waist circumference values were 29.4 kg/m(2) and 102.7 cm in men, and 30.1 kg/m(2) and 92.8 cm in women, respectively. Risk of type 2 diabetes increased linearly with age, with an overall HR of 1.56 (95% CI 1.48-1.64) for a 10 year age difference, adjusted for sex. A male excess in the risk of incident diabetes was consistently observed across all countries, with a pooled HR of 1.51 (95% CI 1.39-1.64), adjusted for age.

CONCLUSIONS/INTERPRETATION

InterAct is a large, well-powered, prospective study that will inform our understanding of the interplay between genes and lifestyle factors on the risk of type 2 diabetes development.

[Cost-effectiveness of exenatide versus insulin glargine in Spanish patients with obesity and type 2 diabetes mellitus]

BACKGROUND AND OBJECTIVES

Exenatide, a GLP-1 receptor agonist for adjuvant treatment of type 2 diabetes mellitus (T2DM), has been shown to be as effective as insulin glargine (IG) for reducing glycated hemoglobin levels combined with metformin or/and sulphonylureas. Exenatide is associated to weight reduction and a higher incidence of gastrointestinal adverse events. The objective of this study was to assess the cost-effectiveness of exenatide as compared to IG in obese patients with T2DM not achieving an adequate blood glucose control from the perspective of the Spanish healthcare system.

METHODS

Pharmacoeconomic model inputs were obtained from an obese subpopulation (BMI ≥ 30 k/m(2)) of an international, randomized, controlled clinical trial comparing exenatide with IG in poorly controlled T2DM patients, and were supplemented with country-specific data.

RESULTS

Exenatide was associated to improvements in life-years gained and quality-adjusted life years (QALYs) by 0.11 and 0.62 respectively versus IG. Direct costs were € 9,306 higher as compared to IG (€ 47,010 versus € 37,704, with increased pharmacy costs as the main driver). Exenatideís incremental cost-effectiveness ratio was € 15,068 per QALY gained versus IG.

CONCLUSIONS

Exenatide was associated to greater clinical benefits and higher costs in obese T2DM patients as compared to IG. Considering a willingness-to-pay threshold of € 30,000 per QALY gained in the Spanish setting, exenatide represents an efficient option in comparison with IG.

Clustering of unhealthy lifestyle behaviors is associated with nonadherence to clinical preventive recommendations among adults with diabetes

AIM

Analyze clustering of unhealthy lifestyle behavior and its relationship with nonadherence to clinical preventive care services among Spanish diabetic adults.

METHODS

Cross-sectional study including 2156 diabetic adults from the 2006 Spanish National Health Survey. Subjects were asked about their uptake of BP measurement, lipid profile, influenza vaccination, and dental examination. Lifestyle behaviors included smoking status, physical activity, alcohol consumption, and dieting. Binary logistic regression models were built to assess the association between clustering of unhealthy lifestyle and the uptake of each preventive activity.

RESULTS

Almost 16% and 36% of the subjects had not undergone blood pressure (BP) and blood lipids measurements, respectively. Forty percent had not been vaccinated and 72% had not received dental examination. Fourteen percent of the subjects had three to four unhealthy behaviors and this increased the probability of not having BP check-up (OR 2.32, 95% CI 1.38-3.91), blood lipids testing (OR 1.63, 95% CI 1.14-2.33), and not being vaccinated (OR 1.99, 95% CI 1.37-2.89). Number of unhealthy lifestyle behaviors is linearly associated with number of preventive measures unfulfilled.

CONCLUSIONS

Adherence to recommended clinical preventive services is under desirable levels among Spanish diabetes sufferers. These preventive services are provided neither equitably nor efficiently, since subjects with unhealthier lifestyles are less likely to receive them.

Multifactorial control and treatment intensity of type-2 diabetes in primary care settings in Catalonia

BACKGROUND

Many studies on diabetes have demonstrated that an intensive control of glycaemia and the main associated risk factors (hypertension, dislipidaemia, obesity and smoking) reduce cardiovascular morbi-mortality. Different scientific societies have proposed a multifactorial approach to type 2 diabetes.The objective of this study was to identify the degree of control of glycosylated haemoglobin (HbA1c) and of cardiovascular risk factors in type 2 diabetic patients, using the GedapS 2004 guidelines, and to analyse the type and intensity of drug treatment.

METHODS

This cross-sectional, multicentre, epidemiological study was conducted in a primary care setting in Vallès Occidental South, Catalonia. Data were collected of 393 patients aged 18 and above who were diagnosed with diabetes mellitus type 2. Biodemographic and clinical data, cardiovascular risk factors, associated cardiovascular disease, and treatment were assessed. Descriptive and multivariable analysis with logistic regression was realized.

RESULTS

A total of 392 patients with a mean age of 66.8 years (SD = 10.6) (45.4% male patients) were analyzed. The duration of diabetes was 8.4 years (SD = 7.6). The degree of multifactorial control of risk factors was only 2.6%, although in more than 50% individual cardiovascular risk factor was controlled, except for LDL cholesterol (40.6%) and systolic blood pressure (29.6%). Furthermore, only 13.0% of subjects had an optimal BMI, 27.5% an optimal waist circumference. Treatment for diabetes was prescribed in 82.7% of patients, for hypertension 70.7%, for dyslipidaemia 47.2% and 40.1% were taking antiplatelets.

CONCLUSION

Over 50% of type 2 diabetic patients presented optimal control of the majority of individual cardiovascular risk factors, although the degree of multifactorial control of diabetes was insufficient (2.6%) and should be improved. Drug treatment can be intensified using a larger number of combinations, particularly in patients with target organ damage and associated clinical cardiovascular disease.

Global estimates of the prevalence of diabetes for 2010 and 2030

AIM

We estimated the number of people worldwide with diabetes for the years 2010 and 2030.

METHODS

Studies from 91 countries were used to calculate age- and sex-specific diabetes prevalences, which were applied to national population estimates, to determine national diabetes prevalences for all 216 countries for 2010 and 2030. Studies were identified using Medline, and contact with all national and regional International Diabetes Federation offices. Studies were included if diabetes prevalence was assessed using a population-based methodology, and was based on World Health Organization or American Diabetes Association diagnostic criteria for at least three separate age-groups within the 20-79 year range. Self-report or registry data were used if blood glucose assessment was not available.

RESULTS

The world prevalence of diabetes among adults (aged 20-79 years) will be 6.4%, affecting 285 million adults, in 2010, and will increase to 7.7%, and 439 million adults by 2030. Between 2010 and 2030, there will be a 69% increase in numbers of adults with diabetes in developing countries and a 20% increase in developed countries.

CONCLUSION

These predictions, based on a larger number of studies than previous estimates, indicate a growing burden of diabetes, particularly in developing countries.

Trends from 1995 to 2006 in the prevalence of self-reported cardiovascular risk factors among elderly Spanish diabetics

AIM

In this study, we examined the trends from 1995 to 2006 in cardiovascular risk factors (CVRF) in Spaniards aged 65 years or older with diabetes.

METHODS

We looked at the individual data from adults aged > or =65 years from the Spanish National Health Surveys of 1995 (n=1117), 1997 (n=1111), 2001 (n=4328), 2003 (n=6134) and 2006 (n=7835). Those classified as having diabetes had answered the two following questions in the affirmative: Has your doctor told you that you currently have diabetes? Have you taken any medication to treat diabetes in the last two weeks? The CVRF of interest included high blood pressure (HBP), high cholesterol levels, obesity (BMI > or =30 kg/m(2)), smoking and sedentarity, which were estimated and compared for prevalence by survey year, age group and gender. Progression over time was analyzed using logistic-regression models.

RESULTS

During the study period, the prevalences of all of the CVRF of interest were significantly higher among the elderly with diabetes compared with those without diabetes, except for current smoking, which was less frequent. The percentages of diabetic patients with HBP and obesity increased from 49.6 and 17.1%, respectively, in 1995 to 64 and 30.6%, respectively, in 2006 (adjusted ORs: 1.95 for HBP; 2.22 for obesity).

CONCLUSION

Overall, the self-reported prevalence of CVRF among elderly patients with diabetes did not improve during 1995-2006 but, instead, showed significant increases in self-reported obesity and HBP. This lack of improvement calls for further investigations, and the dedicated attention of both healthcare providers and the diabetic patients themselves.

Trends in cardiovascular risk factors and lifestyle behaviors among Spanish adults with diabetes (1993-2003)

Previous studies have observed high prevalences of high blood pressure (HBP), high blood cholesterol (HBC), obesity, and sedentary lifestyle among Spanish diabetic adults. These cardiovascular risk factors and unhealthy lifestyle behaviors occur more often in subjects with diabetes than in the general population. The aim of this study was to examine the trends in cardiovascular risk factors and lifestyle behaviors among Spanish adults with diabetes over the decade 1993-2003.

METHODS

We used individualized data drawn from the 1993 (N=20,880) and 2003 (N=21,650) Spanish National Health Surveys. Subjects were classified as diabetes sufferers if they answered affirmatively to either or both of the following questions: "Has your doctor told you that you are currently suffering from diabetes?" and/or, "Have you taken any medication to treat diabetes in the last two weeks?" Cardiovascular risk factors analyzed included self-reported HBP and HBC. Lifestyle behaviors included obesity (body mass index >or=30), smoking status, and physical activity. We estimated and compared the prevalences and analyzed the time trends using logistic regression models.

RESULTS

In both years studied, the prevalence of obesity and sedentary lifestyle was significantly higher among persons with than among those without diabetes, and current smoking was less frequent. The proportions of diabetes patients with HBP and obesity increased significantly from 39.5% and 20.1% in 1993 to 46.7% and 29.8% in 2003, with adjusted odds ratios of 1.32 (95% CI 1.07-1.62) for HBP and 1.88 (95% CI 1.44-2.46) for obesity.

CONCLUSIONS

The overall prevalence of cardiovascular risk factors and unhealthy lifestyle behaviors among diabetes patients has shown no improvement in the decade 1993-2003, and there have been significant setbacks, in particular the rise in obesity and HBP.

Duration of Diabetes and Screening Coverage for Retinopathy Among Patients With Type 2 Diabetes

AIMS

Despite reporting of the Wisconsin Epidemiologic Study of Diabetic Retinopathy(1) and the Diabetic Retinopathy Awareness Program(2) that diabetes duration was a significant predictor for adherence to vision care guidelines, reports of estimates of screening coverage for diabetic retinopathy taking into account diabetes duration have been lagging. This article estimates considering diabetes duration, the prevalence of diabetic retinopathy and screening coverage for diabetic retinopathy among type 2 diabetic patients.

METHODS

As part of a treatment program at a High-Resolution Diabetes Center in Spain, type 2 diabetic patients attending the center from January 2003 to January 2005 were invited to participate in the study. Data on age, sex, and diabetes were recorded into a questionnaire, as was information about previous eye examinations. Polaroid(R) photographs were taken of the eye fundus with the poorest visual acuity using a nonmydriatic retinal camera.

RESULTS

A total of 217 type 2 diabetic patients entered the program. The average age and duration of diabetes was 60.9 years and 7 years, respectively. Screening coverage for diabetic retinopathy was higher in those with a longer duration of diabetes (chi(2) = 36.5; p = 0.001). Fifty percent of patients had developed some retinopathy within the first 5 years after the diagnosis of the disease, but only 26.1% had received a previous fundus examination.

CONCLUSIONS

These results argue for screening programs for people with type 2 diabetes mellitus focused on the subgroup of patients with diabetes duration of 5 years or less.

A sampling design for a sentinel general practitioner network

OBJECTIVE

To construct a design for probabilistic sampling of reporting physicians in sentinel networks.

METHODS

We performed a multi-stage sample selection study. Data on primary care physicians and their patients were obtained from the Madrid Health Institute for 2005. The geographical unit of reference was the basic health area. A factorial analysis was performed on the basis of demographic, socio-cultural and socio-occupational variables. A cluster analysis was conducted to group the 247 basic health areas into homogeneous strata, which were then tested using a discriminant analysis. The general practitioners and pediatricians needed in each stratum were selected by simple random sampling. The representativeness of the population monitored by the selected physicians was studied with respect to the population of Madrid.

RESULTS

Factorial analysis yielded five factors. Using these, 14 strata were obtained, which were shown to be homogeneous and mutually different by discriminant analysis. The minimum population that needed to be monitored consisted of 146,946 adults and 24,518 children, proportionally distributed among the respective strata. Eighty-eight general practitioners and 32 pediatricians were selected, who respectively covered populations of 154,610 and 31,336 persons representative of the general population.

CONCLUSIONS

Obtaining samples through suitable designs improves the accuracy of the information gathered by health sentinel networks in epidemiologic surveillance. Ensuring the representativeness of the study population vis-à-vis the general population is essential; cluster analysis and simple random sampling are methods that meet this need. Selecting physicians by means of probabilistic methods enables the accuracy of estimates to be ascertained.

Socio-economic differences in the prevalence of diabetes in Italy: the population-based Turin study

BACKGROUND AND AIMS

A surveillance programme on diabetes based on administrative data is being implemented in the city of Turin, Italy. The aim of this study is to assess socio-economic differences in the prevalence of diabetes in this large Italian population-based cohort.

METHODS AND RESULTS

People with known diabetes resident in Turin on July 31, 2003 were identified through three data sources: the regional register of persons with diabetes, hospital discharges and prescriptions for antidiabetic drugs. Data sources were linked to the Turin population register to obtain individual data on educational level and census tract median income. Missing cases were estimated by using the capture-recapture method. We identified 34,420 persons with diabetes; prevalence adjusted for undercount was 4.91% (95% Confidence Intervals: 4.69-5.22) among men and 4.68% (4.41-5.08) among women. Age adjusted prevalence ratios between low and high educational levels were 2.32 (2.23-2.41) in men, and 3.45 (3.28-3.62) in women. Social inequalities were larger in women than in men and in people aged 21-65 years than in those age >65 years.

CONCLUSION

This population-based study shows that there are socio-economic inequalities in the prevalence of the disease, particularly in women, and in young people. Our findings indicate that: (1) prevention of diabetes should be mainly focused on the socially disadvantaged strata of the population; (2) a low cost surveillance programme of diabetes using routinely collected data is feasible to better assist public health policies.

Screening coverage for diabetic retinopathy using a three-field digital non-mydriatic fundus camera

AIMS

Guidelines for regular screening of diabetic retinopathy (DR) have been published in the Spanish and European literature since 1992, but screening for DR is still in its early stages in Spain. The aim of this paper is to estimate the prevalence of screening coverage for DR and prevalence of DR itself using three-field digital non-mydriatic fundus photography to determine whether these guidelines had been implemented.

METHODS

Data on age, gender, diabetes and previous eye examinations were recorded on a specially designed questionnaire. Three 45 degrees digital images per eye were taken using a three-field digital non-mydriatic fundus camera with two photographic procedures (both eyes versus the eye with the poorer visual acuity).

RESULTS

A total of 183 patients with diabetes participated. The median age and duration of diabetes was 63 years and 10 years, respectively. Only six patients (3.3%) could not be completely graded. Screening coverage for DR was 38.5% in patients with type 2 diabetes and a duration less than 5 years versus those with longer diabetes duration (P=0.007); 20.5% of these patients had DR.

CONCLUSIONS

This study highlights the need for heightened awareness of the importance of screening for retinopathy in people with type 2 diabetes and duration of diabetes under 5 years.

Prevalence and incidence of chronic complications and mortality in a cohort of type 2 diabetic patients in Spain

AIMS

To evaluate the prevalence, incidence of micro- and macrovascular complications, final events, and mortality in type 2 diabetic patients, followed over a period of 10 years in Spain.

METHODS

Prospective, population-based cohort study. 317 type 2 diabetic patients treated at a Primary Care Centre, followed for 10 years. Variables were described by means of ratios, mean values and standard deviation. The chi(2) test was used to compare ratios and the Student's t test to compare mean values.

RESULTS

Mean age in women (61%) was 61.2 years; men 66.7 years. With regard to the prevalence of complications, the following was observed: an increase in nephropathy (12%), in retinopathy (6.2%) and in neuropathy (2.1%), a decrease in ischemic cardiomyopathy (-6.2%), an increase in peripheral vascular disease (5.6%). Cerebrovascular event and diabetic foot remaining unchanged. The highest incidence rates (1000 subjects/year) were: nephropathy 43, neuropathy 39 and ischemic cardiomyopathy 32. The prevalence of cardiovascular risk factors increased over the follow-up; being high blood pressure the most noticeable (30%). Overall mortality was 28/1000 subjects/year, being cardiovascular disease the main cause (31.2%).

CONCLUSIONS

Our study determines the prevalence and incidence of chronic complications and risk factors in Spain.

Cost-effectiveness of insulin aspart versus human soluble insulin in type 2 diabetes in four European countries: subgroup analyses from the PREDICTIVE study

OBJECTIVES

To evaluate the long-term health economic outcomes associated with insulin aspart (IAsp) compared to human soluble insulin (HI) in type 2 diabetes patients on basal-bolus therapy in Sweden, Spain, Italy and Poland.

METHODS

A published computer simulation model of diabetes was used to predict life expectancy, quality-adjusted life expectancy and incidence of diabetes-related complications. Baseline cohort characteristics (age 61.6 years, duration of diabetes 13.2 years, 45.1% male, HbA(1c) 8.2%, BMI 29.8 kg/m(2)) and treatment effects were derived from the PREDICTIVE observational study. Country-specific complication costs were derived from published sources. The analyses were run over 35-year time horizons from third-party payer perspectives in Spain, Italy and Poland and from a societal perspective in Sweden. Future costs and clinical benefits were discounted at country-specific discount rates. Sensitivity analyses were performed.

RESULTS

IAsp was associated with improvements in discounted life expectancy and quality-adjusted life expectancy, and a reduced incidence of most diabetes-related complications versus HI in all four settings. IAsp was associated with societal cost-savings in Sweden (SEK 2470), direct medical cost-savings in Sweden and Spain (SEK 8248 and euro 1382, respectively), but increased direct costs in Italy (euro 2235) and Poland (euro 743). IAsp was associated with improved quality-adjusted life expectancy in Sweden (0.077 QALYs), Spain (0.080 QALYs), Italy (0.120 QALYs) and Poland (0.003 QALYs).

CONCLUSIONS

IAsp was dominant versus HI in both Sweden and Spain, would be considered cost-effective in Italy with an incremental cost-effectiveness ratio of euro 18,597 per QALY gained, but would not be considered cost-effective in Poland.

Control of diabetes and cardiovascular risk factors in patients with type 2 diabetes in primary care. The gap between guidelines and reality in Spain

To evaluate the level and factors affecting control of diabetes and cardiovascular risk factors in type 2 diabetes (TYPE 2 DM) patients. Multicentre cross-sectional study: a sample of 430 primary care practices across Spain selected 1907 type 2 diabetic patients. The first five consecutive ambulatory patients with TYPE 2 DM were eligible for the inclusion into the survey. Patients were free of known cardiovascular disease (CVD). Control criteria were defined based on 2002 American Diabetes Association (ADA) clinical practice recommendations. A total of 1907 patients (51% women) aged 63 +/- 9 years. Smoking prevalence was 22.6%, 50.6% had levels of A1c < 7%. Mean blood pressure (BP) was 148 +/- 17/86 +/- 10 mmHg. Only 7.8% have achieved the target of BP < 130/80 mmHg. Among the 1180 patients (65%) treated for hypertension, this target was attained in only 4.4% of patients. A measurement for low-density lipoprotein (LDL) cholesterol was available in 1669 patients (88%). Only 5.9% of patients achieved the target of LDL < 100 mg/dl. Among the 638 patients (41.6%) on drug treatment for dyslipidaemia, this target was attained in only 5.6% of patients. Among type 2 diabetic patients in Spain the prevalence of cardiovascular risk factors is high. Control of glycaemia, smoking, BP and LDL are far from optimal despite the widespread use of guidelines for the management of diabetes and CVD. The application of published recommendations needs to be reinforced.

Cardiovascular disease risk in subjects with type 2 diabetes mellitus in a population in southern Spain

To calculate overall 10-year cardiovascular disease (CVD) risk for patients with type 2 diabetes we applied the UKPDS and SCORE prediction models to data derived from clinical notes of 1846 patients (mean age 65.5 years; 55.8% women) with type 2 diabetes attending eight Primary-Care Centres serving a catchment population of 200,000 citizens in Andalusia. The results showed obesity and high blood pressure present in >50%, established CVD in 24%, retinopathy in 30%, and nephropathy in 17%. Mean HbAlc level was 7.3%. Compliance with therapeutic goals was 54% for systolic blood pressure <130 mmHg, 39% for HbA1c <7% and 9% for LDL cholesterol <2.58 mmol/L. Approximately 33% were receiving treatment with metformin, statins, renin-angiotensin system inhibitors and anti-aggregation agents. UKPDS risk for coronary heart disease (CHD) was 23% and 16% for stroke. The SCORE 10-year mortality risk was 5%. Correlation coefficient between the two models predicting CVD risk was 0.68 (p<0.001). We conclude that, despite the European consensus that CVD is low in Mediterranean countries, the CVD risk factors in the type 2 diabetes sub-population in southern Spain is relatively high. Specific measures of health-care intervention are needed if CVD-associated morbido-mortality rates in these diabetic patients are to be reduced.

Prevalence of nonalcoholic fatty liver disease and its association with cardiovascular disease among type 2 diabetic patients

OBJECTIVE

To determine the prevalence of nonalcoholic fatty liver disease (NAFLD) in type 2 diabetic population and to compare the prevalence of cardiovascular disease (CVD) and its risk factors between people with and without NAFLD.

RESEARCH DESIGN AND METHODS

The entire sample of type 2 diabetic outpatients (n = 2,839) who regularly attended our clinic was screened. Main outcome measures were NAFLD (by patient history and liver ultrasound) and manifest CVD (by patient history, review of patient records, electrocardiogram, and echo-Doppler scanning of carotid and lower limb arteries).

RESULTS

The unadjusted prevalence of NAFLD was 69.5% among participants, and NAFLD was the most common cause (81.5%) of hepatic steatosis on ultrasound examination. The prevalence of NAFLD increased with age (65.4% among participants aged 40-59 years and 74.6% among those aged > or = 60 years; P < 0.001) and the age-adjusted prevalence of NAFLD was 71.1% in men and 68% in women. NAFLD patients had remarkably (P < 0.001) higher age and sex-adjusted prevalences of coronary (26.6 vs. 18.3%), cerebrovascular (20.0 vs. 13.3%), and peripheral (15.4 vs. 10.0%) vascular disease than their counterparts without NAFLD. In logistic regression analysis, NAFLD was associated with prevalent CVD independent of classical risk factors, glycemic control, medications, and metabolic syndrome features.

CONCLUSIONS

NAFLD is extremely common in people with type 2 diabetes and is associated with a higher prevalence of CVD. Follow-up studies are needed to determine whether NAFLD predicts the development and progression of CVD.

Redes centinela sanitarias en España. Consenso para una guía de principios y métodos

Since the eighties, health sentinel networks have been active in our country, but with a variety of objectives, methods and different development levels in the autonomous communities. The necessity of standardising the management and harmonising the indicators has concluded in a research project on the Spanish health sentinel networks, one of whose objectives is to establish a guide for work principles and methods. A panel of 23 experts has made a study using the Delphi method to agree, in three consecutive phases, a definition of sentinel network, the objectives and the management principles and other aspects related to the organisation and functioning. Altogether, 41 questions were gathered from a previous draft which needed 80% of consensus in the first phase and 70% in the second. All the experts participated in the first phase, 22 in the second and 20 in the third. A consensus was achieved on 36 questions in the first phase and in 4 of the remaining ones in the second. In the third phase the shape of the guide document was given. The Delphi consensus method has been extremely useful in the resolution of discrepancies and divergences. The experts who were selected outside of the sentinel networks contributed with a wider vision on the objectives and applicability of the health sentinel networks in Spain.

Increased prevalence of cardiovascular disease in Type 2 diabetic patients with non-alcoholic fatty liver disease

AIMS

To estimate the prevalence of cardiovascular disease (CVD) in Type 2 diabetic patients with and without non-alcoholic fatty liver disease (NAFLD), and to assess whether NAFLD is independently related to prevalent CVD.

METHODS

We studied 400 Type 2 diabetic patients with NAFLD and 400 diabetic patients without NAFLD who were matched for age and sex. Main outcome measures were prevalent CVD (as ascertained by medical history, physical examination, electrocardiogram and echo-Doppler scanning of carotid and lower limb arteries), NAFLD (by ultrasonography) and presence of the metabolic syndrome (MetS) as defined by the World Health Organization or Adult Treatment Panel III criteria.

RESULTS

The prevalences of coronary (23.0 vs. 15.5%), cerebrovascular (17.2 vs. 10.2%) and peripheral (12.8 vs. 7.0%) vascular disease were significantly increased in those with NAFLD as compared with those without NAFLD (P < 0.001), with no differences between sexes. The MetS (by any criteria) and all its individual components were more frequent in NAFLD patients (P < 0.001). In logistic regression analysis, male sex, age, smoking history and MetS were independently related to prevalent CVD, whereas NAFLD was not.

CONCLUSIONS

The prevalence of CVD is increased in patients with Type 2 diabetes and NAFLD in association with an increased prevalence of MetS as compared with diabetic patients without NAFLD. Follow-up studies are necessary to determine whether this higher prevalence of CVD among diabetic patients with NAFLD affects long-term mortality.

Prevalencia y consumo de medicación antidiabética en la Comunidad de Madrid (1996-2002)

OBJECTIVES/AIMS

To determine the prevalence of diabetes mellitus treated with drugs and the prescription of drugs in diabetes (oral anti-diabetics and insulin) in the Community of Madrid between 1996-2002.

METHODS

We used the indirect method for estimating the rate of prevalence of diabetes based on antidiabetic drug in the Madrid Community. We studied the consumption or oral antidiabetics (OH) and insulin (IN) in all the Madrid Community Area from 1996 to 2002. To make consumption uniform we used the daily doses/1,000 inhabitants/day (DHD). The total consumption was obtained using the official billing data and the annual population data provided by the "Institute Madrileño de Salud".

RESULTS

The prevalence of diabetes mellitus increased 62.5% in the period studied, ranging from 1.6% in 1996 up to 2.6% in 2002. The DHD of oral drugs increased 87.8% from 12.2 in 1996 to 23.07 in 2002. The DHD of insulin decreased 28.2% from 3.99 in 1996 down to 3.11 in 2002. The OH/IN ratio increased 138%, from 3.11 to 7.42 in 2002. There is a tendency to increase biguanide and sulfonilureas with low risk of hypoglycemia. The total cost of insulin and oral medication increase every year, the increase of diabetic patients and the cost/DDD of the new drugs are factors that increase the total cost of diabetes.

CONCLUSIONS

The prevalence of diabetes mellitus treated with drugs increased in the Community of Madrid. There is a progressive use of oral drugs versus insulin, and a tendency to prescribe biguanide, sulfonylureas, especially gliclazide and glimepiride. A tendency to substitute insulin with insulin analogues is also seen in the use of insulin. The cost of diabetes increases yearly.

Lifetime health consequences and cost-effectiveness of rosiglitazone in combination with metformin for the treatment of type 2 diabetes in Spain

OBJECTIVE

To assess the lifetime diabetes health consequences and cost-effectiveness in Spain of rosiglitazone in combination with metformin for the treatment of type 2 diabetes in overweight and obese patients failing to maintain glycaemic control with metformin monotherapy compared with conventional care of metformin in combination with either sulfonylureas or bedtime insulin.

RESEARCH DESIGN AND METHODS

The Diabetes Decision Analysis of Cost--Type 2 was adapted for clinical practice and healthcare funding in Spain, and was calibrated with Spanish epidemiological, healthcare resource use and cost data, taking the perspective of the Spanish National Health System. The model simulates lifetime treatment histories, complications and consequences of type 2 diabetes, and associated health outcomes and costs for age and sex-matched cohorts of 1000 overweight and obese patients. The primary health outcome measures compared are glycaemic control, time to insulin, incidence and prevalence of coronary heart disease, stroke, clinical nephropathy, ulceration and amputation, and severe visual loss, and incremental life-years and quality-adjusted life-years (QALYs).

RESULTS

Rosiglitazone in combination with metformin produces better glycaemic control than conventional care of metformin in combination with either sulfonylureas or bedtime insulin in most patients, and extends the viability of combination therapy by between 6 and 13 years before requiring insulin. Rosiglitazone patients have a longer life expectancy, gaining between 106 and 175 additional life-years per 1000 patients, experience fewer episodes of coronary disease and clinical nephropathy, and live for longer periods free of complications. The improvements in morbidity and mortality are projected to yield between 134 and 238 additional QALY per 1000 patients over their lifetime. Discounted incremental cost-effectiveness ratios range from euro 9406 to euro 23,514 per QALY gained.

CONCLUSION

The model predicts that rosiglitazone in combination with metformin is a cost-effective intervention for the treatment of both overweight and obese patients with type 2 diabetes when compared with conventional care in Spain.

Utilization of oral antihyperglycemic drugs over a 7–year period (1998–2004) in a Hungarian population and adherence to drug therapy

OBJECTIVE

To describe the quantitative and qualitative changes in the utilization of oral antihyperglycemic drugs (OAHDs) between 1998 and 2004 and to analyze patients' adherence to OAHD therapy.

METHODS

We conducted a retrospective analysis of the electronic database of the Hungarian National Health Fund Administration for the years 1998 through 2004. All 912,620 prescriptions for OAHDs dispensed for the 38,855 patients in Csongrád County (430,000 inhabitants) were retrieved and analyzed according to the ATC/DDD (World Health Organization) methodology. Nonadherence was set as medication possession ratio <80%.

RESULTS

The number of patients using OAHDs significantly increased (P<0.001); the yearly prevalence of 2.88% in 1998 increased to 4.32% in 2004. The overall consumption of OAHDs increased by 76%, from 20.85 defined daily doses per 1,000 inhabitants per day (DDD/TID) in 1998 to 36.83 DDD/TID in 2004. While in 1998 glibenclamide was the most often prescribed agent, received by 61.7% of patients, its share dropped to 16.1% in 2004, and metformin became the leading agent prescribed for 43.0% of patients. During the study period, the adherence rate varied between 47.9% and 49.2%. Women had a significantly better (P<0.001) adherence rate than men, 51.3% vs. 45.5%. The adherence rate peaked in patients between 60 and 79 years and was lowest in patients in their 30s.

CONCLUSIONS

The utilization pattern of OAHDs considerably changed, but there were no significant changes in patients' adherence. The significant increase in the utilization of OAHDs is not the result of increased adherence but of increased patient number.

Socio-economic inequalities in the prevalence of Type 2 diabetes, cardiovascular risk factors and chronic diabetic complications in the Basque Country, Spain

AIMS

To establish the relationship between socio-economic status and the prevalence of known Type 2 diabetes, cardiovascular risk factors and chronic diabetic complications.

METHODS

In 2000, a cross-sectional survey was conducted among 61 general practitioners (GPs) who studied 65 651 people older than 24 years. Of those, 2985 known Type 2 diabetic patients were registered. The main outcome measures were: diabetes prevalence, major cardiovascular risk factors, chronic diabetic complications and primary care services utilization in Type 2 diabetic patients. Socio-economic status was based on area-based socio-economic measures.

RESULTS

The prevalence of known Type 2 diabetes was higher in patients of lower socio-economic status (OR: 2.17, 95% CI: 1.77-2.28), especially among women (OR: 2.28, 95% CI: 1.91-2.73). In Type 2 diabetes patients, obesity, sedentary lifestyle, and abnormal levels of low-density lipoprotein (LDL) cholesterol and HbA(1c) were more prevalent among those from lower socio-economic status. Macroangiopathy was inversely associated with socio-economic status after adjustment for clinical and demographic variables. Patients of lower socio-economic status more frequently visited primary care services than those of higher status.

CONCLUSIONS

This study shows an association between deprivation and Type 2 diabetes prevalence, cardiovascular risk factors and chronic diabetic complications in Type 2 diabetes patients. Despite a greater use of health services by less wealthy patients, they showed worse glycaemic control and more chronic complications. Besides clinical variables, socio-economic status and environmental information need to be considered in the assessment of risk profile of diabetic patients by health professionals and by health service planners.