Prevalence of hypertension in patients with type II diabetes in referral versus primary care clinics

Prevalence of hypertension in Type-2 diabetes mellitus

Background

Cardiovascular disease is the most prevalent cause of morbidity and mortality in diabetic patients. Hypertension (HTN) has been confirmed as a major risk factor for cardiovascular disease, which is frequently associated with diabetes mellitus (DM). Therefore, the detection and management of elevated blood pressure (BP) is a critical component of the comprehensive clinical management of diabetics. Since the rates of hypertension in diabetics are lacking in Afghanistan, this study aimed to evaluate the prevalence of elevated blood pressure in type-2 diabetic patients.

Materials and methods

This is a descriptive cross-sectional study, which included 321 type −2 diabetic patients (119 males, 202 females) with a mean age of 53.86 ± 11.54 years who were presented to the Noble OPD center from November 2019 to January 2020.

Results

The elevated blood pressure was detected in 70.5% of the patients. It was more prevalent in women than men (76.8% and 59.7% respectively). The mean systolic blood pressure was 146.94 ± 23.19 mmHg and mean diastolic blood pressure was 89.61 ± 11.59 mmHg. The mean pulse pressure was 57.32 ± 15.58 mmHg and the mean arterial pressure was 48.98 ± 7.73 mmHg. The mean body weight was 73.09 ± 13.75 Kg. The mean duration of diabetes mellitus was 7.08 ± 5.95 years with the average HbA1c of 9.27 ± 2.41%. The mean body mass index (BMI) of the patients was noted 28.77 ± 5.58 kg/m2.

Conclusion

This study showed high prevalence of hypertension in type-2 diabetes patients with a significant difference in the rate of elevated blood pressure between males and females (it was higher in females than males). The systolic blood pressure had a positive correlation with age. However, it was insignificant for diastolic blood pressure. Healthcare providers and other health sector should work in collaboration for designing appropriate preventive strategies targeting the modifiable risk factors associated with hypertension.

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The hypertension is more prevalent in type- 2 diabetes mellitus.

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Females diabetics are more likely to have hypertension than males patients.

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The control of hypertension among diabetics may be a critical component of the comprehensive clinical management.

The Healthy Hearts and Kidneys (HHK) study: Design of a 2×2 RCT of technology-supported self-monitoring and social cognitive theory-based counseling to engage overweight people with diabetes and chronic kidney disease in multiple lifestyle changes

Patients with complex chronic diseases usually must make multiple lifestyle changes to limit and manage their conditions. Numerous studies have shown that education alone is insufficient for engaging people in lifestyle behavior change, and that theory-based behavioral approaches also are necessary. However, even the most motivated individual may have difficulty with making lifestyle changes because of the information complexity associated with multiple behavior changes. The goal of the current Healthy Hearts and Kidneys study was to evaluate, different mobile health (mHealth)-delivered intervention approaches for engaging individuals with type 2 diabetes (T2D) and concurrent chronic kidney disease (CKD) in behavior changes. Participants were randomized to 1 of 4 groups, receiving: (1) a behavioral counseling, (2) technology-based self-monitoring to reduce information complexity, (3) combined behavioral counseling and technology-based self-monitoring, or (4) baseline advice. We will determine the impact of randomization assignment on weight loss success and 24-hour urinary excretion of sodium and phosphorus. With this report we describe the study design, methods, and approaches used to assure information security for this ongoing clinical trial. Clinical Trials.gov Identifier: NCT02276742.

Dietary Sodium Intake in People with Diabetes in Korea: The Korean National Health and Nutrition Examination Survey for 2008 to 2010

BACKGROUND

Diabetics are likely to receive advice from their physicians concerning lifestyle changes. To understand how much sodium is consumed by diabetics in Korea, we compared the average daily sodium intake between diabetics and non-diabetics after controlling for confounding factors.

METHODS

We obtained the sodium intake data for 13,957 individuals who participated in the Korean National Health and Nutrition Examination Survey (KNHANES), 2008 to 2010, which consisted of a health interview and behavioral and nutritional surveys. The KNHANES uses a stratified, multistage, probability-sampling design, and weighting adjustments were conducted to represent the entire population.

RESULTS

Our analysis revealed that, overall, diabetics tended to have lower sodium intake (4,910.2 mg) than healthy individuals (5,188.2 mg). However, both diabetic and healthy individuals reported higher sodium intake than is recommended by the World Health Organization (WHO). Stratified subgroup analyses revealed that the sodium intake (4,314.2 mg) among newly diagnosed diabetics was higher among women when compared to patients with known diabetes (3,812.5 mg, P=0.035). Female diabetics with cardiovascular disease had lower average sodium intake compared to those without cardiovascular disease after adjusting for sex, age, body mass index, and total energy intake (P=0.058). Sodium intake among male diabetics with hypercholesterolemia (P=0.011) and female diabetics with hypertriglyceridemia (P=0.067) tended to be higher than that among those who without dyslipidemia.

CONCLUSION

The average sodium intake of diabetics in Korea was higher than the WHO recommends. Sodium intake in newly diagnosed diabetics was significantly higher than that in non-diabetics and previously diagnosed diabetics among females. Prospective studies are needed to identify the exact sodium intake.

Dietary Sodium Intake in Type 2 Diabetes

Patients with type 2 diabetes have an increased risk for cardiovascular and chronic kidney disease. Superimposed hypertension further increases the risk and is associated with increased dietary sodium intake. There are few data available on dietary sodium intake in type 2 diabetes. The aim of this study was to quantify dietary sodium intake in a cohort of self-referred patients with type 2 diabetes and to identify sociodemographic characteristics associated with it. Sodium intake in this cohort was far greater than current recommendations. Increased awareness of sodium intake in this population might lead to target interventions to reduce sodium intake and potentially improve long-term outcomes.

Prevalence of Diabetes Mellitus and Its Risk Factors among Permanently Settled Tribal Individuals in Tribal and Urban Areas in Northern State of Sub-Himalayan Region of India

Background. Effect of urban environment on the development of DM and its risk factors is studied with an ecological fallacy due to their study designs that formulate the background for the present study. Objective. To study the prevalence of DM and associated lifestyle related risk factors in traditional tribal individuals residing in tribal area and migrating persons of the same tribe to urban area of sub-Himalayan northern state of India. Methodology. Population based cross-sectional study. Results. A total of 8000 individuals (tribal: 4000; urban: 4000) were recruited. Overall, among urban tribes the prevalence of central obesity (59.0%), overweight (29.3%), stage 1 (22.8%) and stage 2 (5.3%) hypertension, and DM (fasting: 7.8%; OGTT: 8.5%) (P = 0.00) was significantly higher than the tribes of tribal area. Based on OGTT, the prevalence of DM was found to be 9.2% among central obese tribes of urban area and 6.7% of tribal area (P = 0.00). DM showed a significant high prevalence among urban tribes with prehypertension (urban: 8.3%; tribal: 2.9%; P = 0.00), and stage 1 (urban: 14.1%; tribal: 8.7%; P = 0.00) and stage 2 (urban: 17.5%; tribal: 13.9%; P = 0.59) hypertension. Conclusion. Urban environment showed a changing lifestyle and high prevalence of DM among tribal migrating urban tribes as compared to traditional tribes.

Is there benefit in dual renin-angiotensin-aldosterone system blockade? No, yes and maybe: a guide for the perplexed

Since the initial discovery of Angiotensin converting enzyme inhibitors (ACEI) in the 1960s and the launch of Captopril as the first available for clinical use in the 1970s, there now exist three other classes of drugs that block the renin angiotensin aldosterone system (RAAS): the angiotensin II receptor blockers (ARB), aldosterone antagonists (AA) and direct renin inhibitors (DRI). With the proven efficacy of RAAS blockers as monotherapy in many arenas there has been considerable interest in the use of dual therapy combinations of these medications that target different points in the pathway. By potentially offering a more complete RAAS blockade with a commensurate enhanced clinical effect, the strong biological rationale for dual therapy has led to it being embraced by clinicians as a treatment option, for hypertension and nephroprotection in particular. However, the initial enthusiasm for this treatment has been tempered by the recent results from several large trials such as ONTARGET and ALTITUDE, which do not support a specific dual therapy approach. In contrast, there is supportive evidence for dual blockade of specific combinations in selected patient groups and data are lacking for others. In the wake of this complex contemporary evidence, the conundrum now faced by clinicians committed to individualised care is, for which patients dual therapy could still be of benefit. This review examines for the practising clinician the current 'state of play' for dual blockade of various combinations and a perspective on its use in cardio-renal disease and diabetic complications.

Prevalence of diagnosed and undiagnosed diabetes and hypertension in India--results from the Screening India's Twin Epidemic (SITE) study

OBJECTIVE

Despite the rising number of patients with diabetes and hypertension in India, there is a dearth of nationwide, comprehensive prevalence data on these diseases. Our study aimed at collecting data on the prevalence of diabetes and hypertension and the underlying risk factors in various outpatient facilities throughout India.

METHODS

This cross-sectional study was planned to be conducted in 10 Indian states, one state at a time. It was targeted to enroll about 2,000 patients from 100 centers in each state. Each center enrolled the first 10 patients (≥18 years of age, not pregnant, signed consent) per day on two consecutive days. "Diabetes" and "hypertension" were defined by the 2008 American Diabetes Association and the Joint National Committee's 7(th) Report guidelines, respectively. Patient data (demographics, lifestyle factors, medical history, and laboratory diagnostic results) were collected and analyzed.

RESULTS

During 2009-2010, in total, 15,662 eligible patients (54.8% males; mean age, 48.9±13.9 years) from eight states were enrolled. Diabetes was prevalent in 5,427 (34.7%) patients, and 7,212 (46.0%) patients had hypertension. Diabetes and hypertension were coexistent in 3,227 (20.6%) patients. Among those whose disease status was not known at enrollment, 7.2% (793 of 11,028) and 22.2% (2,408 of 10,858) patients were newly diagnosed with diabetes and hypertension, respectively; additionally, 18.4% (2,031 of 11,028) were classified as having prediabetes and 60.1% (6,521 of 10,858) as having prehypertension. A positive association (P<0.05) was observed between diabetes/hypertension and age, familial history of either, a medical history of cardiovascular disorders, alcohol consumption, and diet.

CONCLUSIONS

Our study demonstrates that the substantial burden of diabetes and hypertension is on the rise in India. Patient awareness and timely diagnosis and intervention hold the key to limiting this twin epidemic.

Duloxetine in the management of diabetic peripheral neuropathic pain

Diabetic neuropathy affects up to 70% of diabetics, and diabetic peripheral neuropathic pain (DPNP) is the most common and debilitating of the diabetic neuropathies. DPNP significantly reduces quality of life and increases management costs in affected patients. Despite the impact of DPNP, management is poor with one-quarter of patients receiving no treatment and many treated with medications having little or no efficacy in managing DPNP. Duloxetine is one of two drugs approved by the United States Food and Drug Administration for DPNP management. Duloxetine is a serotonin and norepinephrine reuptake inhibitor (SNRI) proven safe, effective, and cost-saving in reducing DPNP symptoms at a dose of 60 mg/day. Duloxetine doses greater than 60 mg/day for DPNP management are not recommended since they are no more efficacious and associated with more side effects; addition of pregabalin or gabapentin for these patients may be beneficial. Side effects of duloxetine are generally mild and typical for the SNRI class including nausea, dizziness, somnolence, fatigue, sweating, dry mouth, constipation, and diarrhea. Given its other indications, duloxetine is a particularly good choice for DPNP treatment in patients with coexisting depression, anxiety, fibromyalgia, or chronic musculoskeletal pain. Duloxetine treatment had no clinically significant effect on glycemic control and did not increase the risk of cardiovascular events in diabetes patients. However, duloxetine use should be avoided in patients with hepatic disease or severe renal impairment. Given its safety, efficacy, and tolerability, duloxetine is an excellent choice for DPNP treatment in many patients.

Feline Systemic Hypertension

Practical relevance The increased availability of indirect blood pressure monitoring devices in clinical practice over the past decade has highlighted the significance of systemic hypertension in the feline population. Without routine monitoring and appropriate intervention, cats with undiagnosed systemic hypertension may first be presented with sudden-onset blindness as a consequence of either hyphaema or retinal detachment.

Clinical challenges The primary aim in the early diagnosis and treatment of systemic hypertension is prevention of hypertensive target organ damage (with respect to the eye, kidney, cardiovascular and central nervous systems, in particular). A prerequisite is a knowledge of the pathophysiological mechanisms and disease conditions that may contribute to the development of hypertension. This allows the clinician to determine those cases in which blood pressure assessment and longitudinal monitoring is essential and can assist in determining appropriate therapeutic strategies for control of blood pressure. Recent studies have also begun to explore the relationship that systemic hypertension may have with proteinuria and the progression of kidney disease.

Patient group The geriatric cat appears most susceptible to the development of systemic hypertension, and monitoring of systolic blood pressure is often advocated as part of a routine health screen in cats over 9–12 years old. Consideration must also be given to cats suspected of having an underlying disease such as chronic kidney disease or hyperthyroidism, or which are receiving therapeutic agents, irrespective of their age.

Evidence base Much of our understanding of the pathogenesis of feline hypertension is extrapolated from studies performed in experimental animal models or in human patients, and interspecies differences are often poorly understood.

Beyond ONTARGET: angiotensin-converting enzyme inhibition and angiotensin II receptor blockade in combination, a lesser evil in some?

AIM

Following the recent Ongoing Telmistartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET) finding of adverse renal outcomes, dual renin-angiotensin blockade has fallen out of favour, despite antihypertensive and antiproteinuric efficacy. However, in high-risk severe hypertension, not studied in ONTARGET, whether combination treatment should be withheld or withdrawn is not clear. We examine the renal effects of angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin II receptor blocker (ARB) monotherapy versus combination therapy in patients with type 2 diabetes and varying degrees of hypertension.

METHODS

Subjects attending a hospital diabetes centre were selected as case (combination therapy, n = 120) and control (monotherapy, n = 480). Subjects were matched for age, gender, ethnicity, estimated glomerular filtration rate (eGFR), blood pressure (BP) and study duration. Patients were stratified by BP, hypertension stage 1 (BP < 160/100, n = 506) and stage 2 (≥160/100, n = 94), and by treatment group. Data were analysed for the primary renal outcome of eGFR decline ≥20 ml/min, over a median of 3.7 years.

RESULTS

In keeping with the ONTARGET study, for stage 1 hypertension, combination treatment is significantly worse than monotherapy for the primary outcome of eGFR decline ≥20 ml/min (20 vs. 10.7%, p = 0.01). In contrast, for stage 2 hypertension, this endpoint was reached less often for combination versus monotherapy (12.0 vs. 23.2%, p = 0.2). Combination treatment was also not detrimental in patients with proteinuria or eGFR < 60 ml/min and was associated with fewer macrovascular events.

CONCLUSION

Given that hypertension control is paramount and in the spirit of primum non nocere, these data are reassuring should clinicians choose to use ACE-I and ARB combination therapy in the very hypertensive diabetic patient.

Safety and tolerability of duloxetine treatment of diabetic peripheral neuropathic pain between patients with and without cardiovascular conditions

BACKGROUND

Diabetic patients are predisposed to cardiovascular (CV) disease and other chronic medical conditions. We compared the safety of duloxetine in patients with (CV-positive) and without (CV-negative) historical/comorbid cardiovascular conditions at study entry.

METHODS

Data were pooled from three double-blind studies in which patients (age > or =18 years) with diabetic peripheral neuropathic pain (DPNP) were randomized to 12 weeks of duloxetine (DLX) 60 mg qd (n=344), 60 mg bid (n=341), or placebo (PBO, n=339). Safety assessments included discontinuation rates, spontaneously reported treatment-emergent adverse events (TEAEs), changes in vital signs, and changes in lab analytes.

RESULTS

Mean age of CV-positive patients (n=762) vs. CV-negative patients (n=262) was 61.1 vs. 56.1 years. The most common historical or comorbid CV conditions were hypertension, coronary artery disease, and myocardial infarction. Discontinuation due to adverse events was higher for DLX than for PBO in both CV-positive and CV-negative patients (13.5% DLX, 6.0% PBO, and 14.3% DLX, 3.4% PBO, respectively). Rates of CV-related TEAEs in CV-positive (8.4% DLX; 9.9% PBO) and CV-negative (8.6% DLX; 5.7% PBO) patients were similar (P>.1). Mean changes in blood pressure for each DLX dose vs. PBO between CV-positive and CV-negative patients were not statistically significant (P>.1), nor were sustained hypertension rates between CV-positive (2.4% DLX; 2.8% PBO) and CV-negative (2.9% DLX; 4.7% PBO) patients.

CONCLUSIONS

In this analysis, the safety of duloxetine in patients with DPNP was not found to be significantly different between patients with and without historical or comorbid CV conditions.

The Ontario printed educational message (OPEM) trial to narrow the evidence-practice gap with respect to prescribing practices of general and family physicians: a cluster randomized controlled trial, targeting the care of individuals with diabetes and hypertension in Ontario, Canada

Background

There are gaps between what family practitioners do in clinical practice and the evidence-based ideal. The most commonly used strategy to narrow these gaps is the printed educational message (PEM); however, the attributes of successful printed educational messages and their overall effectiveness in changing physician practice are not clear. The current endeavor aims to determine whether such messages change prescribing quality in primary care practice, and whether these effects differ with the format of the message.

Methods/design

The design is a large, simple, factorial, unblinded cluster-randomized controlled trial. PEMs will be distributed with informed, a quarterly evidence-based synopsis of current clinical information produced by the Institute for Clinical Evaluative Sciences, Toronto, Canada, and will be sent to all eligible general and family practitioners in Ontario. There will be three replicates of the trial, with three different educational messages, each aimed at narrowing a specific evidence-practice gap as follows: 1) angiotensin-converting enzyme inhibitors, hypertension treatment, and cholesterol lowering agents for diabetes; 2) retinal screening for diabetes; and 3) diuretics for hypertension.

For each of the three replicates there will be three intervention groups. The first group will receive informed with an attached postcard-sized, short, directive "outsert." The second intervention group will receive informed with a two-page explanatory "insert" on the same topic. The third intervention group will receive informed, with both the above-mentioned outsert and insert. The control group will receive informed only, without either an outsert or insert.

Routinely collected physician billing, prescription, and hospital data found in Ontario's administrative databases will be used to monitor pre-defined prescribing changes relevant and specific to each replicate, following delivery of the educational messages. Multi-level modeling will be used to study patterns in physician-prescribing quality over four quarters, before and after each of the three interventions. Subgroup analyses will be performed to assess the association between the characteristics of the physician's place of practice and target behaviours.

A further analysis of the immediate and delayed impacts of the PEMs will be performed using time-series analysis and interventional, auto-regressive, integrated moving average modeling.

Trial registration number

Current controlled trial ISRCTN72772651.

Treatment and blood pressure control in 47,964 people with diabetes and hypertension: a systematic review of observational studies

BACKGROUND

Many patients with diabetes also have hypertension, greatly increasing their risk for cardiovascular disease. It has been suggested that hypertension is poorly treated in those with diabetes.

OBJECTIVE

To examine treatment and control of hypertension in people with diabetes.

DATA SOURCES

Data sources included MEDLINE, EMBASE, HealthSTAR, CINAHL, Web of Science, clinical evidence and government health and statistical Web sites.

METHOD

Databases were systematically reviewed and hand searches of the bibliographies of relevant studies (1990 to 2004) were conducted. Two investigators selected studies and extracted the data independently.

RESULTS

A total of 44 studies (77,649 subjects with diabetes, 47,964 [62%] of whom also had hypertension) were included. While 83% (range 32% to 100%) of patients with hypertension received drug therapy, only 12% (range 6% to 30%) had their blood pressure (BP) controlled to 130/85 mmHg or less. While BP control rates differed by definition of control (those studies with the least stringent definitions for BP control--160/90 mmHg or less--reported mean control rates of 37%), treatment and control rates did not differ appreciably between countries or health care settings.

CONCLUSIONS

Fewer than one in eight people with diabetes and hypertension have adequately controlled BP, with remarkable uniformity across studies conducted in a variety of settings. There is an urgent need for multidisciplinary, community-based approaches to manage these high-risk patients.

The prevalence of calcified carotid artery atheromas on the panoramic radiographs of patients with type 2 diabetes mellitus

BACKGROUND

People with type 2 diabetes mellitus are disproportionately at risk of experiencing stroke, because hyperglycemia and other risk factors associated with diabetes accelerate development of cervical carotid artery atheromas. Removal of these atheromas may reduce the incidence of stroke. The authors conducted a study to ascertain if those treated without insulin (noninsulin-treated, or NIT) would have a lower prevalence of atheromas on their radiographs and a lower prevalence of risk factors than those treated with insulin (insulin-treated, or IT).

METHODS

The authors evaluated the panoramic radiographs and medical records of 46 neurologically asymptomatic men (n = 34) and women (n = 12) (age range 62-77 years, mean age 68.5 years) with type 2 diabetes. They used Fisher exact test to perform a statistical comparison of the prevalence of atherogenic atheromas and risk factors between groups.

RESULTS

The radiographs showed that 24 percent of the NIT patients and 36 percent of the IT patients had atheromas; this difference was not statistically significant (P = .52). The groups had similar risk factors--that is, high levels of glycosylated hemoglobin A, or HbA1c; smoking; hypertension; and obesity (P > .05). When compared with the 4 percent atheroma prevalence rate among healthy people of similar age, the rates were significantly higher in both the NIT (P = .02) and IT (P = .0006) patients.

CONCLUSION

These results demonstrate that people with type 2 diabetes, irrespective of treatment modality, have high rates of atheromas as visualized on their panoramic radiographs.

CLINICAL IMPLICATIONS

Dentists treating patients with type 2 diabetes mellitus must review their panoramic radiographs carefully for evidence of atheroma formation. Patients with atheromatous lesions must be referred to their physicians for further evaluation and treatment, because the modification of atherogenic risk factors and the surgical removal of atheromas in certain people have been shown to reduce the likelihood of stroke.