An association of adverse psychosocial factors with diabetes mellitus: a meta-analytic review of longitudinal cohort studies

Interactions between physical activity and psychological factors in the association with the risk of lean type 2 diabetes mellitus

Background: The extent to which physical activity and psychological factors may affect the risk of diabetes mellitus among lean individuals remains unclear.Purpose: This study aimed to investigate the associations of total physical activity (TPA) and psychological factors with lean type 2 diabetes mellitus (T2DM) risk.Research Design: A prospective cohort study.Study Sample: The study population included 1,945 Korean adults who maintained a body mass index <23 kg/m2.Data Collection and Analysis: Baseline data on TPA and psychological factors were collected and T2DM incidence was assessed for 10 years. For analysis, a multivariable Cox proportional hazards regression model was used.Results: TPA was inversely associated with T2DM risk and this association was more pronounced in participants who were depressed or distressed; the top TPA quartile exhibited significant reductions in T2DM risk of 66% (95% confidence interval [CI]: 0.15, 0.78) and 65% (95% CI: 0.14, 0.88) among participants who reported depressed mood and those who perceived high distress, respectively, compared with the bottom TPA quartile.Conclusions: The current study demonstrated the preventive effects of physical activity on T2DM in lean adults through its interaction with psychological factors.

Mental health and periodontal and peri-implant diseases

Mental health disorders, particularly depression and anxiety, affect a significant number of the global population. Several pathophysiological pathways for these disorders have been identified, including the hypothalamic-pituitary-adrenal axis, autonomic nervous system, and the immune system. In addition, life events, environmental factors, and lifestyle affect the onset, progression, and recurrence of mental health disorders. These may all overlap with periodontal and/or peri-implant disease. Mental health disorders are associated with more severe periodontal disease and, in some cases, poorer healing outcomes to nonsurgical periodontal therapy. They can result in behavior modification, such as poor oral hygiene practices, tobacco smoking, and alcohol abuse, which are also risk factors for periodontal disease and, therefore, may have a contributory effect. Stress has immunomodulatory effects regulating immune cell numbers and function, as well as proinflammatory cytokine production. Stress markers such as cortisol and catecholamines may modulate periodontal bacterial growth and the expression of virulence factors. Stress and some mental health disorders are accompanied by a low-grade chronic inflammation that may be involved in their relationship with periodontal disease and vice versa. Although the gut microbiome interacting with the central nervous system (gut-brain axis) is thought to play a significant role in mental illness, less is understood about the role of the oral microbiome. The evidence for mental health disorders on implant outcomes is lacking, but may mainly be through behaviourial changes. Through lack of compliance withoral hygiene and maintenance visits, peri-implant health can be affected. Increased smoking and risk of periodontal disease may also affect implant outcomes. Selective serotonin reuptake inhibitors have been linked with higher implant failure. They have an anabolic effect on bone, reducing turnover, which could account for the increased loss.

Influence of Literacy, Self-Efficacy, and Social Support on Diabetes-Related Outcomes Following Hospital Discharge

OBJECTIVE

To evaluate the relationship between health literacy, social support, and self-efficacy as predictors of change in A1c and readmission among hospitalized patients with type 2 diabetes (T2D).

METHODS

This is a secondary analysis of patients with T2D (A1c >8.5%) enrolled in a randomized trial in which health literacy (Newest Vital Sign), social support (Multidimensional Scale of Perceived Social Support), and empowerment (Diabetes Empowerment Scale-Short Form) was assessed at baseline. Multivariable models evaluated whether these concepts were associated with A1c reduction at 12 weeks (absolute change, % with >1% reduction, % reaching individualized target) and readmission (14 and 30 days).

RESULTS

A1c (N=108) decreased >1% in 60%, while individualized A1c target was achieved in 31%. After adjustment for baseline A1c and potential confounders, health literacy was associated with significant reduction in A1c (Estimate -0.21, 95% CI -0.40, -0.01, p=0.041) and >1% decrease in A1c (OR 1.37, 95% CI 1.08, 1.73, p=0.009). However, higher social support was associated with greater adjusted odds of reaching the individualized A1c target (OR 1.63, 95% CI 1.04, 2.55, p=0.32). Both higher empowerment (OR 0.23, 95% CI 0.08, 0.64, p=0.005) and social support (OR 0.57, 95% CI 0.36, 0.91, p=0.018) were associated with fewer readmissions by 14 days, but not 30 days.

CONCLUSION

The study indicates that health literacy and social support may be important predictors of A1c reduction post-discharge among hospitalized patients with T2D. Social support and diabetes self-management skills should be addressed and early follow-up may be critical for avoiding readmissions.

CLINICAL TRIAL

NCT03455985.

A Systematic Review of the Associations of Adult Sexual Abuse in Women with Cardiovascular Diseases and Selected Risk Factors

Aim

To systematically assess the association between adult sexual abuse (ASA) and cardiovascular diseases (CVDs) of heart attack and stroke, and their risk factors of hypertension, diabetes, dyslipidaemia and obesity.

Methods

Two authors conducted a PubMed, Scopus and Web of Science review of the literature published prior to 1 October 2019. Relevant English language studies irrespective of study design and data collection techniques were included. Included articles needed to have examined ASA per se independent of physical or psychological/emotional abuse, and childhood sexual abuse.

Results

Of the 3260 articles identified, nine were selected from 97 full-text articles assessed for eligibility (n = 855 206 women). Six studies were cross-sectional in design while three articles were from longitudinal studies; all emanated from the United States. One study only (n = 867) performed clinical assessments (heights and weights) to determine the relevant outcome (obesity), four presented self-reported outcomes (heart attack, stroke, hypertension, diabetes, obesity), two reviewed clinical records and two did not provide details on outcome assessments (obesity). Sexual abuse by an intimate partner was examined in five articles, three assessed military sexual trauma and a single study evaluated any perpetrator. A meta-analysis could not be conducted because of the heterogeneity across studies. The available evidence was insufficient to quantify the relationship, if any, between ASA and CVDs and their risk factors.

Conclusions

Currently, no longitudinal studies of ASA in general populations have objectively investigated the development of CVDs and their risk factors using clinical and biochemical measurements. In view of the high CVD burden, and the frequency of ASA, it is important to fully understand the relationship between the two.

Cumulative psychosocial factors are associated with cardiovascular disease risk factors and management among African Americans in the Jackson Heart Study

BACKGROUND

Racial disparities in cardiovascular disease (CVD) have been attributed in part to negative psychosocial factors. Prior studies have demonstrated associations between individual psychosocial factors and CVD risk factors, but little is known about their cumulative effects.

METHODS

Using the Jackson Heart Study, we examined the cross-sectional associations of cumulative psychosocial factors with CVD risk factors among 5306 African Americans. We utilized multivariable Poisson regression to estimate sex-stratified prevalence ratios (PR 95% confidence interval-CI) of obesity, hypertension and diabetes prevalence and hypertension and diabetes control with negative affect (cynicism, anger-in, anger-out, depressive symptoms and cumulative negative affect) and stress (global stress, weekly stress, major life events-MLEs and cumulative stress), adjusting for demographics, socioeconomic status, and behaviors.

RESULTS

After full adjustment, high (vs. low) cumulative negative affect was associated with prevalent obesity among men (PR 1.36 95% CI 1.16-1.60), while high (vs. low) cumulative stress was similarly associated with obesity among men and women (PR 1.24 95% CI 1.01-1.52 and PR 1.13 95% CI 1.03-1.23, respectively). Psychosocial factors were more strongly associated with prevalent hypertension and diabetes among men than women. For example, men who reported high cynicism had a 12% increased prevalence of hypertension (PR 1.12, 95% CI 1.03-1.23). Psychosocial factors were more strongly associated with lower hypertension and diabetes control for women than men. Women who reported high (vs. low) cynicism had a 38% lower prevalence of hypertension control (PR 0.62, 95% CI 0.46-0.84).

CONCLUSIONS

Cumulative psychosocial factors were associated with CVD risk factors and disease management among African Americans. The joint accumulation of psychosocial factors was more associated with risk factors for men than women.

Individuals With Type 2 Diabetes: An Exploratory Study of Their Experience of Family Relationships and Coping With the Illness

PURPOSE

The purpose of this qualitative study is to explore familial patterns that may be related to type 2 diabetes (T2DM) and to patients' ways of coping with the illness.

METHODS

A purposive sample of 32 Israeli Jewish (n = 12) and Arab (n = 20) individuals with T2DM were recruited from a community population and interviewed about their familial experiences and their illness. Interview data were analyzed using Colaizzi's phenomenological method.

RESULTS

Many participants, particularly from the Arab society, reported familial patterns that suggest fused relationships and emotional cutoff. They described highly close and positive family relationships, on one hand, but demonstrated unwillingness to share their difficulties with their family members, on the other hand. Precipitating stressful or traumatic events and day-to-day stress appeared as leading perceived causes of the illness. Maintaining an appropriate lifestyle, stress reduction, and family support were the main coping strategies with the illness.

CONCLUSIONS

The findings suggest a possible avenue in which fusion with family members and inability to attenuate emotional distress by sharing difficulties with others may contribute to the development of T2DM. Assessment of such family dynamics and ways of coping with stress could lead to more appropriately nuanced treatment for individuals with T2DM and prediabetes.

Death and Chronic Disease Risk Associated With Poor Life Satisfaction: A Population-Based Cohort Study

Life satisfaction is increasingly recognized as an important determinant of health; however, prospective population-based studies on this topic are limited. We estimated the risk of chronic disease and death according to life satisfaction among a population-based cohort in Ontario, Canada (n = 73,904). The cohort included 3 pooled cycles of the Canadian Community Health Survey (2003–2008) linked to 6 years of follow-up (to 2015), using population-based health databases and validated disease-specific registries. The databases capture incident and prevalent cases of diabetes, cancer, chronic obstructive pulmonary disease, heart disease, and death. Multivariable Cox proportional hazard models were used to estimate hazards of incident chronic disease and death, and were adjusted for sociodemographic, behavioral, and clinical confounders, including age, sex, comorbidity, mood disorder, smoking, alcohol consumption, physical activity, body mass index, immigrant status, education, and income. In the fully adjusted models, risk of both death and incident chronic disease was highest for those most dissatisfied with life (for mortality, hazard ratio = 1.59, 95% confidence interval: 1.15, 2.19; for chronic disease, hazard ratio = 1.70, 95% confidence interval: 1.16, 2.51). In this population-based cohort, poor life satisfaction was an independent risk factor for incident chronic disease and death, supporting the idea that interventions and programs that improve life satisfaction will affect population health.

Amygdalar activity predicts future incident diabetes independently of adiposity

While it is established that psychosocial stress increases the risk of developing diabetes mellitus (DM), two key knowledge gaps remain: 1) the neurobiological mechanisms that are involved in mediating that risk, and 2) the role, if any, that adiposity plays in that mechanism. We tested the hypotheses that: 1) metabolic activity in the amygdala (AmygA), a key center involved in the neurobiological response to stress, associates with subsequent DM risk, and 2) this association is independent of adiposity. AmygA and adipose tissue volumes were measured, and serial blood assessments for DM were obtained in 232 subjects who underwent combined ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG-PET/CT) imaging. Higher baseline AmygA predicted subsequent, new-onset DM, independently of adiposity and other DM risk factors. Furthermore, higher adiposity only increased DM risk in the presence of higher AmygA. In a separate cross-sectional cohort, higher AmygA associated with higher insulin resistance. Accordingly, the current study shows, for the first time, that activity in a stress-responsive neural region predicts the onset of DM. Further, we observed that this neurobiological activity acts independently of, but also synergistically with adiposity to increase DM risk. These findings suggest novel therapeutic targets to help manage and possibly prevent DM.

Modifiable and emerging risk factors for type 2 diabetes in Africa: a systematic review and meta-analysis protocol

BACKGROUND

Type 2 diabetes mellitus (T2DM) remains a public health problem in low-income countries, including African countries. Risk factors of this disease in Africa are still unclear. This study will examine the modifiable and emerging risk factors associated with T2DM in Africa.

METHODOLOGY

The study will include a systematic review and meta-analysis of published and unpublished empirical studies, reporting quantitative data only. We will conduct a search on scientific databases (e.g. Global Health), general online search engines (e.g. Google Scholar) and key websites for grey literature using a combination of key countries/geographic terms, risk factors (e.g. overweight/obesity) and T2DM (including a manual search of the included reference lists). We will use the Comprehensive Meta-Analysis Software (CMA) version 2.0 for data management and analysis. This protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P).

DISCUSSION

The systematic review and meta-analysis will provide a robust and reliable evidence base for policy makers and future research. This may help with identifying and implementing more cost-effective diabetes prevention strategies and improved resource allocation.

SYSTEMATIC REVIEW REGISTRATION

This protocol has been registered with the PROSPERO international prospective register of systematic reviews. The reference number is CRD42016043027 .

Life satisfaction is a protective factor against the onset of Type 2 diabetes in men but not in women: findings from the MONICA/KORA cohort study

AIMS

To investigate the association of high life satisfaction with incident Type 2 diabetes separately in men and women.

METHODS

A longitudinal analysis was conducted among the 7107 participants (3664 men, 51.5%; 3443 women, 48.5%) aged 25-74 years (mean ± sd age 47.8 ±13.7 years) of two population-based MONICA/KORA surveys conducted in 1989-1995 and followed up until 2009. Life satisfaction was assessed using a one-item instrument with a six-order response level, which was dichotomized into high vs medium or low. Sex-specific hazard ratios were estimated using Cox proportional hazards models.

RESULTS

Crude incidence rates for Type 2 diabetes per 10 000 person-years were lower in participants with high than in those with medium or low life satisfaction (men: 57 vs 73; women: 37 vs 48). In men with high life satisfaction, there was a 27% risk reduction in incident Type 2 diabetes (hazard ratio 0.73, 95% CI 0.56-0.94; P=0.02) in a model adjusted for sociodemographic, behavioural and clinical risk factors. The association lost statistical significance after further adjusting for depressed mood (hazard ratio 0.79, 95% CI 0.61-1.03). Life satisfaction was not significantly associated with incident Type 2 diabetes in women.

CONCLUSION

Life satisfaction may be a valuable asset in assessing risk of Type 2 diabetes, especially in men, and in the development of more effective prevention strategies to deter onset of diabetes. More research is needed to investigate the underlying potential causal pathways that may link life satisfaction to the development of Type 2 diabetes.

Time spent outdoors, activity levels, and chronic disease among American adults

Chronic diseases-including cancer, cardiovascular diseases, and metabolic conditions such as diabetes and obesity-account for over 60% of overall global mortality. Sedentary time increases the risk for chronic disease incidence and mortality, while moderate to vigorous physical activity is known to decrease risk. Most Americans spend at least half of their time sedentary, with a trend toward increasingly sedentary lifestyles, and few Americans achieve recommended levels of physical activity. Time spent outdoors has been associated with reduced sedentary time and increased physical activity among children/youth and the elderly, but few population-based studies have examined this relationship among working age adults who may face greater constraints on active, outdoor time. This study examines the relationship between time spent outdoors, activity levels, and several chronic health conditions among a population-based sample of working age American adults in the National Health and Nutrition Examination Survey (NHANES) for 2009-2012. Findings provide evidence that time spent outdoors, on both work days and non-work days, is associated with less time spent sedentary and more time spent in moderate to vigorous physical activity. Further, findings indicate that time spent outdoors is associated with lower chronic disease risk; while these associations are partially explained by activity levels, controlling for activity levels does not fully attenuate the relationship between time outdoors and chronic disease risk. While cross-sectional, study findings support the notion that increasing time spent outdoors could result in more active lifestyles and lower chronic disease risk. Future work should examine this relationship longitudinally to determine a causal direction. Additional work is also needed to identify mechanisms beyond physical activity, such as psychosocial stress, that could contribute to explaining the relationship between time spent outdoors and chronic disease risk.

Impact of quality of life (QoL) on glycemic control (HbA1c) among adolescents and emerging adults with long-duration type 1 diabetes: A prospective cohort-study

OBJECTIVE

To evaluate the impact of self-reported chronic-generic and condition-specific quality of life (QoL) on glycemic control among adolescents and emerging adults with long-duration type 1 diabetes (T1D) in a longitudinal design.

METHODS

The database used was a nationwide cohort study of patients with ≥10 years T1D duration at baseline in Germany. The baseline questionnaire survey was conducted in 2009-2010, the follow-up survey in 2012-2013; additional clinical data of routine care procedures were linked. QoL was assessed by the DISABKIDS chronic generic module (DCGM-12) and diabetes module (DM) with treatment and impact scales. Regression analyses were conducted for the outcome hemoglobin A1c (HbA1c) at follow up with baseline DISABKIDS scores as predictors and sociodemographic and health-related covariates.

RESULTS

At baseline, the included 560 patients had a mean age of 15.9 (SD 2.3) years, a diabetes duration of 13.0 (2.0) years, and an HbA1c of 67 (14.2) mmol/mol. Mean follow-up time was 3.0 (0.6) years. Univariate analyses indicated associations between baseline QoL scores and HbA1c at follow-up (β[DCGM-12] = -0.174 (SE 0.038), β[DM treatment] = -0.100 (0.022), β[DM impact] = -0.177 (0.030), p < .001). The associations remained significant after adjustment for sociodemographic and illness-related factors, but dissolved (p > .60) when additionally adjusting for baseline HbA1c. In patients with poor baseline HbA1c (>75 mmol/mol), significant associations were observed between DCGM-12 and DM impact scores and follow-up HbA1c (β[DCGM-12] = -0.144 (0.062), p = .021; β[DM impact] = -0.139 (0.048), p = .004).

CONCLUSIONS

QoL was inversely associated with HbA1c after 3 years in the course of T1D only in patients poorly controlled at baseline.

Multivariable Adaptive Artificial Pancreas System in Type 1 Diabetes

PURPOSE OF REVIEW

The review summarizes the current state of the artificial pancreas (AP) systems and introduces various new modules that should be included in future AP systems.

RECENT FINDINGS

A fully automated AP must be able to detect and mitigate the effects of meals, exercise, stress and sleep on blood glucose concentrations. This can only be achieved by using a multivariable approach that leverages information from wearable devices that provide real-time streaming data about various physiological variables that indicate imminent changes in blood glucose concentrations caused by meals, exercise, stress and sleep. The development of a fully automated AP will necessitate the design of multivariable and adaptive systems that use information from wearable devices in addition to glucose sensors and modify the models used in their model-predictive alarm and control systems to adapt to the changes in the metabolic state of the user. These AP systems will also integrate modules for controller performance assessment, fault detection and diagnosis, machine learning and classification to interpret various signals and achieve fault-tolerant control. Advances in wearable devices, computational power, and safe and secure communications are enabling the development of fully automated multivariable AP systems.

Is Type 1 Diabetes Mellitus More Prevalent Than Expected in Transgender Persons? A Local Observation

The International Diabetes Federation estimates that approximately 0.4% of the Belgian population is diagnosed with type 1 diabetes mellitus, which is similar to other industrialized countries. The prevalence of transgenderism is estimated at 0.6% to 0.7% of all adults in Western populations. In this study, we evaluated whether there was an increased prevalence of type 1 diabetes mellitus in transgender people in the local cohort. Medical records of transgender patients were analyzed retrospectively. From January 1, 2007 until October 10, 2016, 1,081 transgender patients presented at a tertiary reference center to start hormonal treatment. Nine of these 1,081 patients were previously diagnosed with type 1 diabetes mellitus and 1 was diagnosed with latent autoimmune diabetes in adults. A 2.3-fold higher prevalence of type 1 diabetes mellitus was observed in transgender patients. We concluded that type 1 diabetes mellitus was more prevalent in transgender patients than one would expect from population prevalences. This could be a spurious result in a local cohort, because a causal relation seems unlikely, but our finding might encourage other centers to investigate this putative association.

Defreyne J, De Bacquer D, Shadid S, et al. Is Type 1 Diabetes Mellitus More Prevalent Than Expected in Transgender Persons? A Local Observation. Sex Med 2017;5:e215–e218.

Social support and coping in adults with type 2 diabetes

Background

The diagnosis of diabetes has been described as a lifelong psychological burden on the patient and his or her family. Social support plays a pivotal role in patients with diabetes and is important in enabling them to cope effectively with the disease. There is a dearth of research on social support and coping in patients with diabetes in South Africa.

Objectives

The aim of this study was to explore whether patients with poor perceived social support have lower levels of well-being and coping than patients with good social support.

Method

A cross-sectional study was conducted at both public and private facilities on the north coast of KwaZulu-Natal, South Africa. The Diabetes Care Profile (DCP), the General Health Questionnaire (GHQ), the Social Support Questionnaire (SSQ) and the WHO-5 Well-being Index (WHO-5) were administered to 401 participants.

Results

The findings indicate that there is an inverse relationship between social support and coping, which suggests that an increase in social support is associated with a decrease in emotional distress. There was a small positive correlation between the SSQ and the WHO-5, which suggests participants who had good support endorsed better levels of well-being. Although participants indicated that they were satisfied with their level of support, they had poor coping as indicated by the high mean score on the GHQ and the high HbA1c level. There was a small positive correlation between GHQ and HbA1c. There was no association between social support and HbA1c.

Conclusion

Social support is important in helping the patient with diabetes cope with the disease and to improve adherence to treatment. Health care providers should take cognisance of psychosocial factors in the treatment regime of the patient. Family members should be educated about diabetes, the importance of adherence and long-term complications of the disease.

Type 2 diabetes in a Senegalese rural area

AIM

To estimate the prevalence of diabetes in the rural population of Tessekere (Senegal) and investigate associated risk factors.

METHODS

Data from a 2015 survey of 500 individuals age 20 and over representative of the population of the municipality of Tessekere were used. Sociodemographic characteristics, health related variables, capillary whole blood glucose, and weight and height measurements of individuals were collected during face-to-face interviews. Statistical analyses used were bivariate tests and binary logistic regressions.

RESULTS

The percentage of individuals having impaired fasting glucose (IFG) is 6.6%. Those with fasting blood glucose (FBG) levels ≥ 126 mg/dL and/or currently being treated for diabetes is 4.2%. Only mean body mass index (BMI) is significantly higher among diabetic individuals and among those having FBG levels ≥ 110 mg/dL. After adjustment for sex, age, educational level, BMI and hypertension, only BMI is associated with diabetes.

CONCLUSION

Prevalence of diabetes and IFG in our study correspond to the high range of rural sub-Saharan Africa prevalence. Diabetes is thus becoming a pressing public health concern, even in rural areas. But the risk factors identified in Tessekere suggest that the diabetes epidemic is still in the early stages, such that concerted action would make it possible to contain the devastating impact of this chronic condition.

Positive Psychosocial Factors in Childhood Predicting Lower Risk for Adult Type 2 Diabetes: The Cardiovascular Risk in Young Finns Study, 1980-2012

INTRODUCTION

Type 2 diabetes is a public health concern, but psychosocial factors that may protect against the disease are unknown. This study examines whether a positive psychosocial environment in childhood is associated with lower risk for Type 2 diabetes in adulthood or healthier glucose trajectories over the life course, and whether BMI mediates the associations.

METHODS

A cohort of 3,596 Finnish children was followed into adulthood over 32 years. An overall positive psychosocial score, consisting of six subdomains, was measured at study baseline (1980). Relative risk ratios and multilevel growth curve modeling were used to examine associations of the psychosocial score with Type 2 diabetes (2012) and glucose trajectories (1986-2012). The mediating effect by BMI was examined using mediation analysis. The analyses were conducted between June 2015 and January 2016.

RESULTS

There was a 21% decrease in the rate of Type 2 diabetes (relative risk ratio, 0.79; 95% CI=0.66, 0.94) for each 1-SD increase in the positive psychosocial score after adjustment for childhood cardiovascular risk factors and dietary behaviors. Adult BMI mediated 52% and weight gain mediated 25% of the association. The growth curve model showed healthier glucose trajectories (age X psychosocial score interaction, b= -0.01; p=0.010) for participants with higher versus lower positive psychosocial score in childhood.

CONCLUSIONS

Positive psychosocial environment in childhood seems to have beneficial influences on the risk for Type 2 diabetes over the life span. RCTs will be required to see if interventions directed at early-life circumstances are warranted.

Education achievement and type 2 diabetes-what mediates the relationship in older adults? Data from the ESTHER study: a population-based cohort study

OBJECTIVE

The study aims to identify the mediating factors of the relationship between education achievement and incident type 2 diabetes mellitus (T2DM) in older adults.

DESIGN

Population-based cohort study.

SETTING

Participants were recruited from the German federal state of Saarland.

PARTICIPANTS

Participants were excluded if they had prevalent T2DM or missing data on prevalent T2DM, missing or zero follow-up time for incident T2DM or were under 50 years of age. The total sample consisted of 7462 individuals aged 50-75 years (42.8% men, mean age 61.7 years) at baseline (2000-02). The median follow-up time was 8.0 years.

METHODS

Cox proportional hazards regression was initially used to determine the direct association between education achievement and incident T2DM. Using the Baron and Kenny approach, we then investigated the associations between education achievement and incident T2DM with the potential mediators. The contribution of each of the putative mediating variables was then calculated.

RESULTS

A clear socioeconomic gradient was observed with regard to T2DM incidence with the lowest educated individuals at a greater risk of developing the disease during the follow-up period: HR (95% CI) high education: 0.52 (0.34 to 0.80); medium education: 0.80 (0.66 to 0.96). Seven of the variables considered explained a proportion of the education-T2DM relationship (body mass index, alcohol consumption, hypertension, fasting triglycerides, high-density lipoprotein (HDL) cholesterol, physical activity and smoking status), where the contribution of the variables ranged from 1.0% to 17.7%. Overall, the mediators explained 31.7% of the relationship.

CONCLUSION

By identifying the possible mediating factors of the relationship between education achievement and incident T2DM in older adults, the results of this study can be used to assist with the development of public health strategies that aim to reduce socioeconomic inequalities in T2DM.

Type 2 diabetes, depressive symptoms and trajectories of cognitive decline in a national sample of community-dwellers: A prospective cohort study

We examined the individual and synergistic effects of type 2 diabetes and elevated depressive symptoms on memory and executive function trajectories over 10 and eight years of follow-up, respectively. Our sample comprised 10,524 community-dwellers aged ≥50 years in 2002–03 from the English Longitudinal Study of Ageing. With respect to memory (word recall), participants with either diabetes or elevated depressive symptoms recalled significantly fewer words compared with those free of these conditions (reference category), but more words compared with those with both conditions. There was a significant acceleration in the rate of memory decline in participants aged 50–64 years with both conditions (-0.27, 95% CI, -0.45 to -0.08, per study wave), which was not observed in those with either condition or aged ≥65 years. With respect to executive function (animal naming), participants aged ≥65 years with diabetes or those with elevated depressive symptoms named significantly fewer animals compared with the reference category, while those with both conditions named fewer animals compared with any other category. The rate of executive function decline was significantly greater in participants with both conditions (-0.54, 95% CI, -0.99 to -0.10; and –0.71, 95% CI, -1.16 to -0.27, per study wave, for those aged 50–64 and ≥65 years, respectively), but not in participants with either condition. Diabetes and elevated depressive symptoms are inversely associated with memory and executive function, but, individually, do not accelerate cognitive decline. The co-occurrence of diabetes and elevated depressive symptoms significantly accelerates cognitive decline over time, especially among those aged 50–64 years.

Invited Commentary: Foreclosures and Health in a Neighborhood Context

Recent systematic reviews link foreclosure to worse health at both the individual and population levels. In this issue of the Journal, Downing et al. (Am J Epidemiol. 2017;185(6):429-435) add to what is known about foreclosure and health by examining annual measures of glycemic control in relation to local foreclosure activity. They provided evidence that between 2007 and 2010, glycemic control was not associated with rates of completed foreclosure among a continuously insured managed-care population of persons with type 2 diabetes living in 9 California counties. In this commentary, I consider 5 possible interpretations of the null results: 1) foreclosures do not affect health in general, 2) glycated hemoglobin is insensitive to local foreclosure activity, 3) the presence of real estate owned foreclosures (rather than the competed foreclosure rate) affects health, 4) an integrated health-care delivery system buffers patients from the effects of the foreclosure crisis, and 5) community conditions and responses to the foreclosure crisis buffer patients from the effects of the foreclosure crisis. I close by arguing that research on the contextual effects of foreclosure on health should continue despite the ongoing recovery of the housing market.

Beyond the Great Recession: Was the Foreclosure Crisis Harmful to the Health of Individuals With Diabetes?

The housing foreclosure crisis was harmful to the financial well-being of many households. In the present study, we investigated the health effects of the housing foreclosure crisis on glycemic control within a population of patients with diabetes. We hypothesized that an increase in the neighborhood foreclosure rate could worsen glycemic control by activating stressors such as higher neighborhood crime, lower housing prices, and erosion of neighborhood social cohesion. To test this, we linked public foreclosure records at the census-block level with clinical records from 2006 to 2009 of patients with diabetes. We specified individual fixed-effects models and controlled for individual time-invariant confounders and area-level time-varying confounders, including housing prices and unemployment rate, to estimate the effect of the foreclosure rate per census-block group on glycated hemoglobin. We found no statistically significant relationship between changes in the neighborhood foreclosure rate per block group in the prior year and changes in glycated hemoglobin. There is no evidence that increased foreclosure rates worsened glycemic control in this continuously insured population with diabetes. More research is needed to inform our knowledge of the role of insurance and health-care delivery systems in protecting the health of diabetic patients during times of economic stress.

Cortisol dysregulation: the bidirectional link between stress, depression, and type 2 diabetes mellitus

Controversy exists over the role of stress and depression in the pathophysiology of type 2 diabetes mellitus. Depression has been shown to increase the risk for progressive insulin resistance and incident type 2 diabetes mellitus in multiple studies, whereas the association of stress with diabetes is less clear, owing to differences in study designs and in forms and ascertainment of stress. The biological systems involved in adaptation that mediate the link between stress and physiological functions include the hypothalamic-pituitary-adrenal (HPA) axis and the autonomic nervous and immune systems. The HPA axis is a tightly regulated system that represents one of the body's mechanisms for responding to acute and chronic stress. Depression is associated with cross-sectional and longitudinal alterations in the diurnal cortisol curve, including a blunted cortisol awakening response and flattening of the diurnal cortisol curve. Flattening of the diurnal cortisol curve is also associated with insulin resistance and type 2 diabetes mellitus. In this article, we review and summarize the evidence supporting HPA axis dysregulation as an important biological link between stress, depression, and type 2 diabetes mellitus.

Commentary: Reconsidering the Role of Context in Diabetes Prevention

A substantial gap remains between what we know about type 2 diabetes prevention and our ability to apply that knowledge in socially disadvantaged populations at highest risk. This gap results, in part, from a lack of integration between epidemiologic science and social psychology theory, particularly regarding the intersections of stress, self-regulatory health behaviors, and the biological mechanisms underlying the development of diabetes. In this commentary, we describe the utility of a theoretical framework that focuses on the intersection of biological, psychosocial, and environmental contexts as they apply to diabetes disparities, and how such a framework could inform a translational research agenda to reorient prevention efforts to address these inequalities. Such reorientation is needed to ensure that the implementation of prevention efforts does not inadvertently widen diabetes disparities.

Effect of individualized diabetes education for type 2 diabetes mellitus: a single-center randomized clinical trial

BACKGROUND

To evaluate the effect of individualized education for patients with type 2 diabetes mellitus (T2DM).

METHODS

A total of 280 patients (158 males, mean age 63 ± 10 years) with T2DM were randomly divided into study and control group. Eysenck Personality questionnaire was used to assess the personality of the patients in the study group, which was provided us one-on-one counseling and individualized management plan. Group education was provided to the control group.

RESULTS

At the end of the study, the body mass index (21.5±2.5 vs 23.6±1.6 kg/m², P =0.002), waist circumference (83.7±6.4 vs 85.7±7.7 cm, P =0.03), fasting blood glucose (6.0±0.8 vs 6.9±2.1 mmol/L, P =0.004), HbA1c (6.2±0.6% vs 6.9±3.1%, P =0.03), systolic blood pressure (130.1±8.8 vs 135.1±8.4 mmHg, P =0.003),triglyceride (1.21±0.66 vs 1.46±0.58 mmol/L) and low-density lipoprotein (2.36±0.44 vs 2.84±0.64 mmol/L, P =0.03) in the study group was lower than in the control group.

CONCLUSION

Individualized diabetes education is more effective than group education in facilitating the control of type 2 diabetes.

Prediction of the 20-year incidence of diabetes in older Chinese: Application of the competing risk method in a longitudinal study

The competing risk method has become more acceptable for time-to-event data analysis because of its advantage over the standard Cox model in accounting for competing events in the risk set. This study aimed to construct a prediction model for diabetes using a subdistribution hazards model.We prospectively followed 1857 community residents who were aged ≥ 55 years, free of diabetes at baseline examination from August 1992 to December 2012. Diabetes was defined as a self-reported history of diabetes diagnosis, taking antidiabetic medicine, or having fasting plasma glucose (FPG) ≥ 7.0 mmol/L. A questionnaire was used to measure diabetes risk factors, including dietary habits, lifestyle, psychological factors, cognitive function, and physical condition. Gray test and a subdistribution hazards model were used to construct a prediction algorithm for 20-year risk of diabetes. Receiver operating characteristic (ROC) curves, bootstrap cross-validated Wolber concordance index (C-index) statistics, and calibration plots were used to assess model performance.During the 20-year follow-up period, 144 cases were documented for diabetes incidence with a median follow-up of 10.9 years (interquartile range: 8.0-15.3 years). The cumulative incidence function of 20-year diabetes incidence was 11.60% after adjusting for the competing risk of nondiabetes death. Gray test showed that body mass index, FPG, self-rated heath status, and physical activity were associated with the cumulative incidence function of diabetes after adjusting for age. Finally, 5 standard risk factors (poor self-rated health status [subdistribution hazard ratio (SHR) = 1.73, P = 0.005], less physical activity [SHR = 1.39, P = 0.047], 55-65 years old [SHR = 4.37, P < 0.001], overweight [SHR = 2.15, P < 0.001] or obesity [SHR = 1.96, P = 0.003], and impaired fasting glucose [IFG] [SHR = 1.99, P < 0.001]) were significantly associated with incident diabetes. Model performance was moderate to excellent, as indicated by its bootstrap cross-validated discrimination C-index (0.74, 95% CI: 0.70-0.79) and calibration plot.Poor self-rated health, physical inactivity, being 55 to 65 years of age, overweight/obesity, and IFG were significant predictors of incident diabetes. Early prevention with a goal of achieving optimal levels of all risk factors should become a key element of diabetes prevention.

Influence of Race, Ethnicity and Social Determinants of Health on Diabetes Outcomes

BACKGROUND

There is strong evidence that race, ethnicity and social determinants of health significantly influence outcomes for patients with diabetes. A better understanding of the mechanisms of these relationships or associations would improve development of cost-effective, culturally tailored programs for patients with diabetes.

METHODS

This article reviews the current state of the literature on the influence of race and ethnicity and social determinants of health on process of care, quality of care and outcomes for diabetes, with particular emphasis on the rural South to give an overview of the state of the literature.

RESULTS

The literature review shows that racial or ethnic differences in the clinical outcomes for diabetes, including glycemic, blood pressure (BP) and lipid control, continue to persist. In addition, the literature review shows that the role of social determinants of health on outcomes, and the possible role these determinants play in disparities have largely been ignored. Psychosocial factors, such as self-efficacy, depression, social support and perceived stress, show consistent associations with self-care, quality of life and glycemic control. Neighborhood factors, such as food insecurity, social cohesion and neighborhood esthetics have been associated with glycemic control. Perceived discrimination has also been associated with self-care and the psychological component of quality of life.

CONCLUSION

Healthcare professionals need to be skilled in assessing social determinants of health and taking them into consideration in clinical care. In addition, more research is needed to identify the separate and combined influence of race and ethnicity and social determinants of health on process of care, quality of care and outcomes in diabetes, especially in the South, where the burden of disease is particularly high.

Childhood maltreatment as a risk factor for diabetes: findings from a population-based survey of Canadian adults

BACKGROUND

It is well established that childhood maltreatment (CM) is a risk factor for various mental and substance use disorders. To date, however, little research has focused on the possible long-term physical consequences of CM. Diabetes is a chronic disease, for which an association with CM has been postulated.

METHODS

Based on data from a sample of 21,878 men and women from the 2012 Canadian Community Health Survey - Mental Health (CCHS - MH), this study examines associations between three types of CM (childhood physical abuse (CPA), childhood sexual abuse (CSA), and childhood exposure to intimate partner violence (CEIPV)) and diabetes in adulthood. Multiple logistic regression models were used to examine associations between CM and diabetes controlling for the effects of socio-demographic characteristics and risk factors for type 2 diabetes.

RESULTS

When controlling socio-demographic characteristics, diabetes was significantly associated with reports of severe and frequent CPA (OR = 1.8) and severe and frequent CSA (OR = 2.2). A dose-response relationship was observed when co-occurrence of CSA and CPA was considered with the strongest association with diabetes being observed when both severe and frequent CSA and CPA were reported (OR = 2.6). Controlling for type 2 diabetes risk factors attenuated associations particularly for CPA. CEIPV was not significantly associated with having diabetes in adulthood.

CONCLUSION

CPA and CSA are risk factors for diabetes. For the most part, associations between CPA and diabetes are mediated via risk factors for type 2 diabetes. Failure to consider severity and frequency of abuse may limit our understanding of the importance of CM as a risk factor for diabetes.

Evidence of perceived psychosocial stress as a risk factor for stroke in adults: a meta-analysis

BACKGROUND

Several studies suggest that perceived psychosocial stress is associated with increased risk of stroke; however results are inconsistent with regard to definitions and measurement of perceived stress, features of individual study design, study conduct and conclusions drawn and no meta-analysis has yet been published. We performed a systematic review and meta-analysis of studies assessing association between perceived psychosocial stress and risk of stroke in adults.The results of the meta-analysis are presented.

METHODS

Systematic searches of MEDLINE, EMBASE, CINAHL, PsycInfo, and Cochrane Database of Systematic Reviews were undertaken between 1980 and June 2014. Data extraction and quality appraisal was performed by two independent reviewers. Hazard ratios (HR) and odds ratios (OR) were pooled where appropriate.

RESULTS

14 studies were included in the meta-analysis, 10 prospective cohort, 4 case-control design. Overall pooled adjusted effect estimate for risk of total stroke in subjects exposed to general or work stress or to stressful life events was 1.33 (95 % confidence interval [CI], 1.17, 1.50; P < 0.00001). Sub-group analyses showed perceived psychosocial stress to be associated with increased risk of fatal stroke (HR 1.45 95 % CI, 1.19,1.78; P = 0.0002), total ischaemic stroke (HR 1.40 95 % CI, 1.00,1.97; P = 0.05) and total haemorrhagic stroke (HR 1.73 95 % CI, 1.33,2.25; P > 0.0001).A sex difference was noted with higher stroke risk identified for women (HR 1.90 95 % CI, 1.4, 2.56: P < 0.0001) compared to men (HR 1.24 95 % CI, 1.12, 1.36; P < 0.0001).

CONCLUSIONS

Current evidence indicates that perceived psychosocial stress is independently associated with increased risk of stroke.

Diabetes IN develOpment (DINO): the bio-psychosocial, family functioning and parental well-being of youth with type 1 diabetes: a longitudinal cohort study design

Background

Strict glycemic control during adolescence decreases the risk of developing complications later in life, even if this level of control is not maintained afterwards. However, the majority of adolescents with type 1 diabetes (T1D) are in poor control and so far medical or psychological interventions have shown limited success. Adolescence is characterized by major biological, psychosocial, cognitive and parent–child relationship changes and the complex interaction between these developmental trajectories, and its impact on health outcomes is still poorly understood. A specific topic of interest in this context is the timing of diagnosis. The longitudinal study DINO (Diabetes IN develOpment) aims to examine:

If and how the onset of T1D before vs. during puberty results in different outcomes of glycemic control, self-management, psychological functioning and diabetes-related quality of life.

The timing of onset of disturbed eating behavior, its risk factors and its prospective course in relation to glycemic and psychological consequences.

If and how the onset of T1D before vs. during puberty results in different family functioning and parental well-being.

If and how the cognitive development of youth with T1D relates to glycemic control and diabetes self-management.

Methods/design

DINO, a longitudinal multi-center cohort study is conducted in youth with T1D in the age range 8–15 years at baseline. Participants will be divided into two subgroups: pre-pubertal and pubertal. Both groups will be followed for 3 years with assessments based on a bio-psychosocial model of diabetes, scheduled at baseline, 12 months, 24 months and 36 months examining the biological, psychosocial -including disturbed eating behaviors- and cognitive development, family functioning and parental well-being.

Discussion

A better understanding of how the different trajectories affect one another will help to gain insight in the protective and risk factors for glycemic outcomes and in who needs which support at what moment in time. First results are expected in 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0400-1) contains supplementary material, which is available to authorized users.

Prevalence of diabetes and pre-diabetes and assessments of their risk factors in urban slums of Bangalore

BACKGROUND

To determine the prevalence of diabetes and pre-diabetes and to assess the risk factors associated with diabetes and pre-diabetes in the urban slums of Bangalore.

MATERIALS AND METHODS

A cross-sectional study was conducted in four slums of Bangalore in the age group of 35 years and above comprising of total 2013 subjects. Risk factors like age, sex, family history, behavior, physical activity, BMI, waist hip ration, diet habits were assessed to find their association with diabetes.

RESULTS

Prevalence of diabetes was 12.33% and of pre-diabetes was 11.57%. Prevalence was more among the females compared to males. Increasing age, over weight and obesity, sedentary life style, tobacco consumption, diet habits showed statistically significant association with prevalence of diabetes and pre-diabetes.

CONCLUSION

Physical activity like regular exercises both at the office and at home, fibers-rich diet, blood sugar estimation after 35 years are some of the recommendations which can control diabetes.

Association between major depression and type 2 diabetes in midlife: findings from the Screening Across the Lifespan Twin Study

OBJECTIVE

Cohort studies suggest that the relationship between major depression (MD) and Type 2 diabetes (T2DM) is bidirectional. However, this association may be confounded by shared genetic or environmental factors. The objective of this study was to use a twin design to investigate the association between MD and T2DM.

METHODS

Data come from the Screening Across the Lifespan Twin Study, a sample of monozygotic and dizygotic twins 40 years or older sampled from the Swedish Twin Registry (n = 37,043). MD was assessed by using the Composite International Diagnostic Inventory. Structural equation twin modeling and Cox proportional hazards modeling were used to assess the relationship between MD and T2DM.

RESULTS

Approximately 19% of respondents had a history of MD and 5% had a history of T2DM. MD was associated with 32% increased likelihood of T2DM (95% confidence interval = 1.00-1.80) among twins aged 40 to 55 years, even after accounting for genetic risk, but was not associated with T2DM among twins older than 55 years. T2DM was associated with 33% increased likelihood of MD (95% confidence interval = 1.02-1.72) among younger, but not older twins. Cholesky decomposition twin modeling indicated that common unique environmental factors contribute to the association between MD and T2DM.

CONCLUSIONS

Environmental factors that are unique to individuals (i.e., not shared within families) but common to both MD and T2DM contribute to their co-occurrence in midlife. However, we cannot exclude the possibility of bidirectional causation as an alternate explanation. It is likely that multiple processes are operating to effect the relation between psychiatric and medical conditions in midlife.

Risk factors of incident type 2-diabetes mellitus over a 3-year follow-up: Results from a large Australian sample

AIMS

To describe the incidence of type 2 diabetes mellitus (T2DM) among middle-aged and older Australian adults and to examine a broad range of risk factors of T2DM.

METHODS

A large cohort of Australian adults aged 45 and up was sampled from the general population and was followed up for approximately 3 years (n=60,404). Physician-diagnosed T2DM was self-reported at baseline (2006-2008) and follow-up (2010). Incident T2DM was determined as not reporting T2DM at baseline, but reporting T2DM at follow-up. A broad range of risk factors, including socio-demographic characteristics, health status, family history, and lifestyle behaviors were examined at baseline. Multiple logistic regression was used for selecting potential predictors of incident T2DM, and age and reported family history of T2DM were tested as potential effect modifiers.

RESULTS

Of the 54,997 without T2DM at baseline, 888 reported T2DM at follow-up (cumulative incidence 1.6% over 3.4 years, annual incidence rate 0.44%). Adjusted for other risk factors, being male, older age, higher relative socio-economic disadvantage, being born in Asia, lower educational attainment, medical history of hypertension and dyslipidemia, family history of T2DM, overweight/obese, smoking, long sleeping hours, and psychological distress were significantly associated with higher odds of developing T2DM. Particularly, hypertension, dyslipidemia, and overweight/obesity were stronger predictors of T2DM among middle-aged than older adults (≥60 years).

CONCLUSIONS

Understanding risk factors for incident T2DM could help identify at-risk populations and develop upstream preventive strategies to combat the epidemic of diabetes.

The prospective association between positive psychological well-being and diabetes

OBJECTIVE

Positive psychological well-being has protective associations with cardiovascular outcomes, but no studies have considered its association with diabetes. This study investigated links between well-being and incident diabetes.

METHODS

At study baseline (1991-1994), 7,800 middle-aged British men and women without diabetes indicated their life satisfaction, emotional vitality, and optimism. Diabetes status was determined by self-reported physician diagnosis and oral glucose tolerance test (screen detection) at baseline and through 2002-2004. Incident diabetes was defined by physician-diagnosed and screen-detected cases combined and separately. Logistic regression estimated the odds of developing diabetes controlling for relevant covariates (e.g., demographics, depressive symptoms). Models were also stratified by gender and weight status.

RESULTS

There were 562 combined cases of incident diabetes during follow-up (up to 13 years). Well-being was not associated with incident diabetes for combined physician-diagnosed and screen-detected cases. However, when examining the 288 physician-diagnosed cases, life satisfaction and emotional vitality were associated with up to a 15% decrease in the odds of physician-diagnosed diabetes, controlling for demographics (results were similar with other covariates). Optimism was not associated with physician-diagnosed diabetes, and no well-being indicator was associated with screen-detected diabetes. Gender and weight status were not moderators.

CONCLUSIONS

Life satisfaction and emotional vitality, but not optimism, were associated with reduced risk of physician-diagnosed diabetes. These findings suggest that well-being may contribute to reducing risk of a prevalent and burdensome condition, although intervention studies are needed to confirm this. It is unclear why findings differed for physician-diagnosed versus study-screened diabetes. (PsycINFO Database Record

Blunted glucocorticoid and mineralocorticoid sensitivity to stress in people with diabetes

Psychological stress may contribute to type 2 diabetes but mechanisms are still poorly understood. In this study, we examined whether stress responsiveness is associated with glucocorticoid and mineralocorticoid sensitivity in a controlled experimental comparison of people with type 2 diabetes and non-diabetic participants. Thirty-seven diabetes patients and 37 healthy controls underwent psychophysiological stress testing. Glucocorticoid (GR) and mineralocorticoid sensitivity (MR) sensitivity were measured by dexamethasone- and prednisolone-inhibition of lipopolysaccharide (LPS)-induced interleukin (IL) 6 levels, respectively. Blood pressure (BP) and heart rate were monitored continuously, and we periodically assessed salivary cortisol, plasma IL-6 and monocyte chemotactic protein (MCP-1). Following stress, both glucocorticoid and mineralocorticoid sensitivity decreased among healthy controls, but did not change in people with diabetes. There was a main effect of group on dexamethasone (F(1,74)=6.852, p=0.013) and prednisolone (F(1,74)=7.295, p=0.010) sensitivity following stress at 45 min after tasks. People with diabetes showed blunted stress responsivity in systolic BP, diastolic BP, heart rate, IL-6, MCP-1, and impaired post-stress recovery in heart rate. People with Diabetes had higher cortisol levels as measured by the total amount excreted over the day and increased glucocorticoid sensitivity at baseline. Our study suggests that impaired stress responsivity in type-2 diabetes is in part due to a lack of stress-induced changes in mineralocorticoid and glucocorticoid sensitivity.

Diabetes and ischemic heart disease: double jeopardy with regard to depressive mood and reduced quality of life

The aim of this study was to test i) whether patients having diabetes and ischemic heart disease (IHD), i.e., patients suffering from two chronic diseases, demonstrate a higher degree of chronic stress when compared with patients suffering from IHD alone, and ii) whether suffering from the two chronic diseases results in an elevation in specific elements of the chronic stress concept. A total of 361 participants with IHD were included, of whom 47 suffered from concomitant diabetes. Stress was measured by pressure pain sensitivity (PPS) and by the following questionnaires: the Major Depression Inventory (MDI), the SF-36 Quality of Life questionnaire (SF-36 QOL), the WHO-5 Well-being Index, and the clinical stress signs (CSSs) scale. Participants with diabetes and IHD had a higher MDI score, a lower SF-36 physical component summary score, and a lower score of several sub-measurements of the SF-36 mental component score when compared with patients with IHD without diabetes. No significant differences were observed regarding stress measured by the PPS measure, the WHO-5 Well-being Index, or the number of CSSs. In conclusion, the combination of diabetes and IHD seems to be associated with increased depressive symptoms, lower overall physical QOL, and reduced mental QOL on several sub-elements of the questionnaire. This should be recognized in the management of patients with double diagnoses.

Association of diurnal patterns in salivary cortisol with type 2 diabetes in the Whitehall II study

CONTEXT

The hypothalamic pituitary-adrenal axis is thought to play a role in Type 2 Diabetes (T2D). However, the evidence for an association between diurnal cortisol patterns and T2D is equivocal.

OBJECTIVE

The aim was to examine the association of cortisol patterns throughout the day with T2D status in a community-dwelling population.

DESIGN

This was a cross-sectional study of T2D status and salivary cortisol from phase 7 (2002-2004) of the Whitehall II study, United Kingdom.

SETTING

The occupational cohort was originally recruited in 1985-1988.

PARTICIPANTS

Three-thousand, five-hundred eight white men and women including 238 participants with T2D aged 50-74 years with complete information on cortisol secretion participated.

OUTCOME MEASURES

We measured diurnal cortisol (nmol/L) patterns from six saliva samples obtained over the course of a normal day: at waking, +30 min, +2.5, +8, +12 hours, and bedtime. The cortisol awakening response and slope in diurnal secretion were calculated.

RESULTS

T2D status was associated with a flatter slope in cortisol decline across the day (b = 0.004; confidence interval [CI], 0.001-0.007; P = .014) and greater bedtime cortisol (b = 0.063; CI, 0.010-0.117; P = 0.020) independent of a wide range of covariates measured at the time of cortisol assessment. There was no association between morning cortisol, the cortisol awakening response, and T2D (P > .05).

CONCLUSIONS

In this nonclinical population, T2D was associated with a flatter slope in cortisol levels across the day and raised bedtime cortisol values.

Psychological distress and incidence of type 2 diabetes in high-risk and low-risk populations: the Whitehall II Cohort Study

OBJECTIVE

We examined whether psychological distress predicts incident type 2 diabetes and if the association differs between populations at higher or lower risk of type 2 diabetes.

RESEARCH DESIGN AND METHODS

This was a prospective cohort of 5,932 diabetes-free adults (4,189 men and 1,743 women, mean age 54.6 years) with three 5-year data cycles (1991-2009): a total of 13,207 person-observations. Participants were classified into four groups according to their prediabetes status and Framingham Offspring Type 2 Diabetes Risk Score: normoglycemia with a risk score of 0-9, normoglycemia with a risk score of 10-19, prediabetes with a risk score of 10-19, and prediabetes with a risk score of >19. Psychological distress was assessed by the General Health Questionnaire. Incident type 2 diabetes was ascertained by 2-h oral glucose tolerance test, doctor diagnosis, or use of antihyperglycemic medication at the 5-year follow-up for each data cycle. Adjustments were made for age, sex, ethnicity, socioeconomic status, antidepressant use, smoking, and physical activity.

RESULTS

Among participants with normoglycemia and among those with prediabetes combined with a low risk score, psychological distress did not predict type 2 diabetes. Diabetes incidence in these groups varied between 1.6 and 15.6%. Among participants with prediabetes and a high risk score, 40.9% of those with psychological distress compared with 28.5% of those without distress developed diabetes during the follow-up. The corresponding adjusted odds ratio for psychological distress was 2.07 (95% CI 1.19-3.62).

CONCLUSIONS

These data suggest that psychological distress is associated with an accelerated progression to manifest diabetes in a subpopulation with advanced prediabetes.

Associations of chronic stress burden, perceived stress, and traumatic stress with cardiovascular disease prevalence and risk factors in the Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study

OBJECTIVE

The current study examined multiple stress indicators (chronic, perceived, traumatic) in relation to prevalent coronary heart disease, stroke, and major cardiovascular disease (CVD) risk factors (i.e., diabetes, dyslipidemia, hypertension, and current smoking) in the multisite Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study (2010-2011).

METHODS

Participants were 5313 men and women 18 to 74 years old, representing diverse Hispanic/Latino ethnic backgrounds, who underwent a comprehensive baseline clinical examination and sociocultural examination with measures of stress.

RESULTS

Chronic stress burden was related to a higher prevalence of coronary heart disease after adjusting for sociodemographic, behavioral, and biological risk factors (odds ratio [OR; 95% confidence interval], 1.22 [1.10-1.36]) and related to stroke prevalence in the model adjusted for demographic and behavioral factors (OR [95% confidence interval], 1.26 [1.03-1.55]). Chronic stress was also related to a higher prevalence of diabetes (OR = 1.20 [1.11-1.31]) and hypertension (OR = 1.10 [1.02-1.19]) in individuals free from CVD (n = 4926). Perceived stress (OR = 1.03 [1.01-1.05]) and traumatic stress (OR = 1.15 [1.05-1.26]) were associated with a higher prevalence of smoking. Participants who reported a greater number of lifetime traumatic events also unexpectedly showed a lower prevalence of diabetes (OR = 0.89 [0.83-0.97]) and hypertension (OR = 0.88 [0.82-0.93]). Effects were largely consistent across age and sex groups.

CONCLUSIONS

The study underscores the advantages of examining multiple indicators of stress in relation to health because the direction and consistency of associations may vary across distinct stress conceptualizations. In addition, the study suggests that chronic stress is related to higher CVD risk and prevalence in Hispanics/Latinos, the largest US ethnic minority group.

Perceived psychosocial stress and glucose intolerance among pregnant Hispanic women

AIM

Prior literature suggests a positive association between psychosocial stress and the risk of diabetes in non-pregnant populations, but studies during pregnancy are sparse. We evaluated the relationship between stress and glucose intolerance among 1115 Hispanic (predominantly Puerto Rican) prenatal care patients in Proyecto Buena Salud, a prospective cohort study in Western Massachusetts (2006-2011).

METHODS

Cohen's Perceived Stress Scale (PSS-14) was administered in early (mean = 12.3 weeks gestation; range 4.1-18 weeks) and mid- (mean = 21.3 weeks gestation; range 18.1-26 weeks) pregnancy. Participants were classified as having a pregnancy complicated by gestational diabetes mellitus, impaired glucose tolerance, and abnormal glucose tolerance, based on the degree of abnormality on glucose tolerance testing between 24 and 28 weeks of gestation.

RESULTS

The prevalence of gestational diabetes mellitus, impaired glucose tolerance, and abnormal glucose tolerance was 4.1%, 7.2%, and 14.5%, respectively. Absolute levels of early or mid-pregnancy stress were not significantly associated with glucose intolerance. However, participants with an increase in stress from early to mid-pregnancy had a 2.6-fold increased odds of gestational diabetes mellitus (95% confidence intervals: 1.0-6.9) as compared to those with no change or a decrease in stress after adjusting for age and pre-pregnancy body mass index. In addition, every one-point increase in stress scores was associated with a 5.5mg/dL increase in screening glucose level (β=5.5; standard deviation=2.8; P=0.05), after adjusting for the same variables.

CONCLUSION

In this population of predominantly Puerto Rican women, stress patterns during pregnancy may influence the risk of glucose intolerance.

Work stress is associated with diabetes and prediabetes: cross-sectional results from the MIPH Industrial Cohort Studies

BACKGROUND

Diabetes is rapidly rising globally, and the relation of psychosocial stress in workplace to diabetes and prediabetes is not well investigated.

PURPOSE

The aim of the study was to examine the association of work stress with diabetes and prediabetes in a sample of German industrial workers.

METHOD

In this cross-sectional survey of an occupational cohort (n = 2,674, 77 % male), work stress was measured by the Effort-Reward Imbalance (ERI) Questionnaire. Diabetic status, i.e., diabetes and prediabetes, were diagnosed by glycated hemoglobin A1c criterion or fasting plasma glucose criterion supplemented by self-reports.

RESULTS

The overall prevalence rates of diabetes and prediabetes were 3.5 and 42.2 %, respectively. Using ordinal logistic regression with adjustment for potential confounding factors, high ERI at work was associated with diabetes-related ordinal variable (odds ratio [OR], 1.27; 95 % confidence interval [95 % CI], 1.02-1.58) and prediabetes-related ordinal variable (OR, 1.26; 95 % CI, 1.01-1.58) in men, whereas the associations in women were somewhat less pronounced and did not reach statistical significance.

CONCLUSION

The findings indicate that work stress in terms of ERI is associated with diabetes and prediabetes in German industrial male workers. If supported by prospective evidence, results point to a new approach towards primary prevention of diabetes.

Position paper on the importance of psychosocial factors in cardiology: Update 2013

Background: The rapid progress of psychosomatic research in cardiology and also the increasing impact of psychosocial issues in the clinical daily routine have prompted the Clinical Commission of the German Heart Society (DGK) to agree to an update of the first state of the art paper on this issue which was originally released in 2008.

Methods: The circle of experts was increased, general aspects were implemented and the state of the art was updated. Particular emphasis was dedicated to coronary heart diseases (CHD), heart rhythm diseases and heart failure because to date the evidence-based clinical knowledge is most advanced in these particular areas. Differences between men and women and over the life span were considered in the recommendations as were influences of cognitive capability and the interactive and synergistic impact of classical somatic risk factors on the affective comorbidity in heart disease patients.

Results: A IA recommendation (recommendation grade I and evidence grade A) was given for the need to consider psychosocial risk factors in the estimation of coronary risks as etiological and prognostic risk factors. Furthermore, for the recommendation to routinely integrate psychosocial patient management into the care of heart surgery patients because in these patients, comorbid affective disorders (e.g. depression, anxiety and post-traumatic stress disorder) are highly prevalent and often have a malignant prognosis. A IB recommendation was given for the treatment of psychosocial risk factors aiming to prevent the onset of CHD, particularly if the psychosocial risk factor is harmful in itself (e.g. depression) or constrains the treatment of the somatic risk factors. Patients with acute and chronic CHD should be offered anti-depressive medication if these patients suffer from medium to severe states of depression and in this case medication with selective reuptake inhibitors should be given. In the long-term course of treatment with implanted cardioverter defibrillators (ICDs) a subjective health technology assessment is warranted. In particular, the likelihood of affective comorbidities and the onset of psychological crises should be carefully considered.

Conclusions: The present state of the art paper presents an update of current empirical evidence in psychocardiology. The paper provides evidence-based recommendations for the integration of psychosocial factors into cardiological practice and highlights areas of high priority. The evidence for estimating the efficiency for psychotherapeutic and psychopharmacological interventions has increased substantially since the first release of the policy document but is, however, still weak. There remains an urgent need to establish curricula for physician competence in psychodiagnosis, communication and referral to ensure that current psychocardiac knowledge is translated into the daily routine.

Diabetes in the Africa Region: an update

The Africa Region (AFR), where diabetes was once rare, has witnessed a surge in the condition. Estimates for type 1 diabetes suggest that about 39,000 people suffer from the disease in 2013 with 6.4 new cases occurring per year per 100,000 people in children <14 years old. Type 2 diabetes prevalence among 20-79-year-olds is 4.9% with the majority of people with diabetes <60 years old; the highest proportion (43.2%) is in those aged 40-59 years. Figures are projected to increase with the numbers rising from 19.8 million in 2013 to 41.5 million in 2035, representing a 110% absolute increase. There is an apparent increase in diabetes prevalence with economic development in AFR with rates of 4.4% in low-income, 5.0% in lower-middle income and 7.0% in upper-middle income countries. In addition to development and increases in life-expectancy, the likely progression of people at high risk for the development of type 2 diabetes will drive the expected rise of the disease. This includes those with impaired glucose tolerance, the prevalence of which is 7.3% among 20-79-year-olds in 2013. Mortality attributable to diabetes in 2013 in AFR is expected to be over half a million with three-quarter of these deaths occurring in those <60 years old. The prevalence of undiagnosed diabetes remains unacceptably high at 50.7% and is much higher in low income (75.1%) compared to lower- and upper-middle income AFR countries (46.0%). This highlights the inadequate response of local health systems which need to provide accessible, affordable and optimal care for diabetes.