Screening for diabetes and prediabetes should be cost-saving in patients at high risk

Evaluation of the effectiveness and cost-effectiveness of the chronic disease co-care (CDCC) Pilot Scheme: a study protocol

BACKGROUND

The Chronic Disease Co-Care (CDCC) Pilot Scheme is a government-subsidized program that aims to provide targeted copayment for the screening and management of hypertension, diabetes mellitus and pre-diabetes in the private healthcare sector. Studies have found that concurrent screening and management with a multi-disciplinary intervention is cost-saving because of the reduction in the rates of premature mortality, complications and utilization of public health services. This study aims to evaluate the quality of care, acceptability, effectiveness and cost-effectiveness of the CDCC Pilot Scheme.

METHODS

Quality of care will be evaluated by the standards achieved by the program in each criterion in the domains of structure, process and outcomes of care. Site visits and two serial questionnaire surveys at 6 and 12 months will be conducted for the structure of care. Operational data, including the provision of diagnosis and treatment, as well as participants' health status will be extracted to evaluate the process and outcomes of care. Participants' acceptability will be evaluated on experience (accessibility, facility, continuity of care and communication), satisfaction (perceived usefulness, continuation and recommendation) and enablement in 548 CDCC participants at 3 and 12 months by telephone surveys. Evaluation of the effectiveness and cost-effectiveness is a 1-year comparative cohort study using longitudinal data on changes in disease control parameters between CDCC and non-CDCC participants at baseline and 12 months. Costing questionnaires on the set-up and operation costs of the Scheme among service providers, and direct medical costs incurred from public and private service utilization among participants within 12 months from enrolment will be assessed. The incremental costs incurred for an additional participant in the CDCC Pilot Scheme to achieve target disease control outcomes after 12 months will be reported as an indicator for cost-effectiveness.

DISCUSSION

The quality of care and effectiveness of the CDCC Pilot Scheme in enhancing the health outcomes of the Scheme participants will be examined. Standards of good practice and recommendations for quality enhancement will be established to inform service planning in similar cross-sector screening and management programme.

TRIAL REGISTRATION

NCT06310148; 2024-03-22.

Cross-sectional study on prevalence and risk factors of undiagnosed type 2 diabetes among patients with hypertension attending St. Orsola Catholic Mission Hospital, Tharaka Nithi County, Kenya

Introduction

according to the World Health Organization (WHO), Non-Communicable Diseases (NCD) were a major cause of death in 2022 accounting for 4 million (74%) of deaths worldwide. Diabetes mellitus and hypertension are the two illnesses that are not contagious but linked closely. The objective of the research was to establish the prevalence and risk factors of undiagnosed diabetes among patients with hypertension attending St. Orsola Hospital in Tharaka Nithi County, Kenya.

Methods

the study utilized a descriptive cross-sectional design with random sampling. Data were collected from 384 patients with hypertension attending outpatient medical from October to December 2022 using a structured questionnaire. Analysis was conducted using the Statistical Package for the Social Sciences (SPSS). The chi-square test was used at the bivariable level and multiple logistic regression at the multivariable level, with a significance level set at P<0.05.

Results

the findings revealed that the age of the participants ranged between 20-89 years, with majority (62%) being below 60 years, where of these participants (66%) were women. Seventy-five percent (288/384) of participants were found to be with no diabetes, with 21 (5.5%) with undiagnosed diabetes mellitus and 75 (19.5%) being pre-diabetes. Significant associations were found between diabetes status and socio-demographic factors, with higher body mass index (BMI > 24.9) showing a strong correlation with undiagnosed diabetes (AOR 3.794 95% CI: 1.345-4.705). Education level was also significant, with lower education levels (primary or below) associated with a higher risk of undiagnosed diabetes (AOR 1.821 95% CI: 2.134-8.567). Employment status played a critical role, with unemployed individuals more likely to have undiagnosed diabetes (AOR 2.845 95% CI: 1.211-6.683). Additionally, lower frequency of vegetable consumption (less than three times per week) was linked to a higher likelihood of undiagnosed diabetes (AOR 2.937 95% CI: 1.135-7.602). Gender disparities were evident, with 62% of undiagnosed diabetes cases occurring in women. These findings underscore the importance of addressing both socio-economic and behavioral factors in the prevention and management of undiagnosed diabetes among patients with hypertension.

Conclusion

the study highlights a substantial prevalence of undiagnosed diabetes among patients with hypertension. These findings underscore the need for integrated screening programs, targeted health education, and lifestyle modification interventions.

Deep learning-based long-term risk evaluation of incident type 2 diabetes using electrocardiogram in a non-diabetic population: a retrospective, multicentre study

Background

Diabetes is a major public health concern. We aimed to evaluate the long-term risk of incident type 2 diabetes in a non-diabetic population using a deep learning model (DLM) detecting prevalent type 2 diabetes using electrocardiogram (ECG).

Methods

In this retrospective study, participants who underwent health checkups at two tertiary hospitals in Seoul, South Korea, between Jan 1, 2001 and Dec 31, 2022 were included. Type 2 diabetes was defined as glucose ≥126 mg/dL or glycated haemoglobin (HbA1c) ≥ 6.5%. For survival analysis on incident type 2 diabetes, we introduced an additional variable, diabetic ECG, which is determined by the DLM trained on ECG and corresponding prevalent diabetes. It was assumed that non-diabetic individuals with diabetic ECG had a higher risk of incident type 2 diabetes than those with non-diabetic ECG. The one-dimensional ResNet-based model was adopted for the DLM, and the Guided Grad-CAM was used to localise important regions of ECG. We divided the non-diabetic group into the diabetic ECG group (false positive) and the non-diabetic ECG (true negative) group according to the DLM decision, and performed a Cox proportional hazard model, considering the occurrence of type 2 diabetes more than six months after the visit.

Findings

190,581 individuals were included in the study with a median follow-up period of 11.84 years. The areas under the receiver operating characteristic curve for prevalent type 2 diabetes detection were 0.816 (0.807-0.825) and 0.762 (0.754-0.770) for the internal and external validations, respectively. The model primarily focused on the QRS duration and, occasionally, P or T waves. The diabetic ECG group exhibited an increased risk of incident type 2 diabetes compared with the non-diabetic ECG group, with hazard ratios of 2.15 (1.82-2.53) and 1.92 (1.74-2.11) for internal and external validation, respectively.

Interpretation

In the non-diabetic group, those whose ECG was classified as diabetes by the DLM were at a higher risk of incident type 2 diabetes than those whose ECG was not. Additional clinical research on the relationship between the phenotype of ECG and diabetes to support the results and further investigation with tracked data and various ECG recording systems are suggested for future works.

Funding

National Research Foundation of Korea.

Consensus on potential interventions for improving glycaemic control among patients with type 2 diabetes in Kinshasa, Democratic Republic of the Congo: a Delphi study

BACKGROUND

Poor glycaemic control is a multifactorial and complex problem with dire clinical and economic implications. In the Democratic Republic of the Congo, recent studies have shown alarming poor control rates. There is no policy framework to guide corrective actions.

OBJECTIVES

To build a consensus on interventions to improve glycaemic control among patients with type 2 diabetes in Kinshasa, Democratic Republic of the Congo.

METHODS

This was a two-round electronic Delphi study involving 31 local and 5 international experts. The experts rated proposed interventions from previous studies on glycaemic control in sub-Saharan Africa and Kinshasa on a 4-Likert scale questionnaire. Additionally, the experts were asked to suggest other recommendations useful for the purpose. The mode, mean and standard deviation of each statement were calculated for each round.

RESULTS

Participants reached consensus in five domains that included 39 statements on how to improve glycaemic control in Kinshasa: strengthening the health system, enhancing the awareness of diabetes, alleviating the financial burden of diabetes, enhancing the adoption of lifestyle modifications, and reducing the proportion of undiagnosed diabetes.

CONCLUSIONS

Improved glycaemic control needs to be considered within the broader framework of managing noncommunicable diseases in a more integrated, coordinated and better financed healthcare system. Further studies are needed to operationalise the interventions identified for successful implementation.

A Systematic Approach to Treating Early Metabolic Disease and Prediabetes

At least 70% of US adults have metabolic disease. However, less is done to address early disease (e.g., overweight, obesity, prediabetes) versus advanced disease (e.g., type 2 diabetes mellitus, coronary artery disease). Given the burden of advanced metabolic disease and the burgeoning pandemics of obesity and prediabetes a systematic response is required. To accomplish this, we offer several recommendations: (A) Patients with overweight, obesity, and/or prediabetes must be consistently diagnosed with these conditions in medical records to enable population health initiatives. (B) Patients with early metabolic disease should be offered in-person or virtual lifestyle interventions commensurate with the findings of the Diabetes Prevention Program. (C) Patients unable to participate in or otherwise failing lifestyle intervention must be screened to assess if they require pharmacotherapy. (D) Patients not indicated for, refusing, or failing pharmacotherapy must be screened to assess if they need bariatric surgery. (E) Regardless of treatment approach or lack of treatment, patients must be consistently screened for the progression of early metabolic disease to advanced disease to enable early control. Progression of metabolic disease from an overweight yet otherwise healthy person includes the development of prediabetes, obesity ± prediabetes, dyslipidemia, hypertension, type 2 diabetes, chronic kidney disease, coronary artery disease, and heart failure. Systematic approaches in health systems must be deployed with clear protocols and supported by streamlined technologies to manage their population's metabolic health from early through advanced metabolic disease. Additional research is needed to identify and validate optimal system-level interventions. Future research needs to identify strategies to roll out systematic interventions for the treatment of early metabolic disease and to improve the metabolic health among the progressively younger patients being impacted by obesity and diabetes.

Risk prediction models for type 2 diabetes using either fasting plasma glucose or HbA1c in Chinese, Malay, and Indians: Results from three multi-ethnic Singapore cohorts

AIMS

To assess three well-established type 2 diabetes (T2D) risk prediction models based on fasting plasma glucose (FPG) in Chinese, Malays, and Indians, and to develop simplified risk models based on either FPG or HbA1c.

METHODS

We used a prospective multiethnic Singapore cohort to evaluate the established models and develop simplified models. 6,217 participants without T2D at baseline were included, with an average follow-up duration of 8.3 years. The simplified risk models were validated in two independent multiethnic Singapore cohorts (N = 12,720).

RESULTS

The established risk models had moderate-to-good discrimination (area under the receiver operating characteristic curves, AUCs 0.762 - 0.828) but a lack of fit (P-values < 0.05). Simplified risk models that included fewer predictors (age, BMI, systolic blood pressure, triglycerides, and HbA1c or FPG) showed good discrimination in all cohorts (AUCs ≥ 0.810), and sufficiently captured differences between the ethnic groups. While recalibration improved fit the simplified models in validation cohorts, there remained evidence of miscalibration in Chinese (p ≤ 0.012).

CONCLUSIONS

Simplified risk models including HbA1c or FPG had good discrimination in predicting incidence of T2D in three major Asian ethnic groups. Risk functions with HbA1c performed as well as those with FPG.

Prevalence of Undiagnosed Dysglycaemias and their Correlates amongst Hypertensive Patients in a Tertiary Health Facility in Abuja, North Central Nigeria

Background

Dysglycaemia, (diabetes mellitus, DM, and Prediabetes) and Hypertension (HTN) are two common non-communicable diseases that are closely linked. Cardiovascular risk profile and cardiovascular-related death rise significantly when they co-exist. A third of cases of diabetes mellitus amongst hypertensive patients are undiagnosed and most people who are newly diagnosed have a low level of awareness. This study is therefore designed to assess the prevalence of dysglycaemia and associated factors, among hypertensive patients attending our facility.

Methodology

Clinical and laboratory information on 858 patients was extracted and analyzed. This includes sociodemographic variables such as age, sex, socioeconomic status, and level of physical activity. Also, family history of diabetes mellitus, the duration of hypertension as well as types of antihypertensives used by those already attending the clinic for hypertension care. Other variables were blood pressure, height, weight, waist and hip circumferences, and body mass index (BMI). Blood glucose and plasma lipid profile as well.

Results

More than a quatre of the patients had prediabetes. Between 2% and 6.1% had diabetes mellitus using 2HPP and FBG respectively. Following cross-tabulation, dysglycaemia was significantly associated with age, duration of hypertension, body mass index, BMI, elevated total cholesterol, LDL as well as the use of beta blockers and thiazides.

Conclusion

Dysglycaemias are common among hypertensive patients in Abuja. Age, duration of hypertension, body mass index, dyslipidemias, beta blocker, and thiazide use were positively associated with dysglycaemia. Screening for dysglycaemia is recommended for all hypertensive patients at the point of entry to care.

2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Development and validation of a diabetes mellitus and prediabetes risk prediction function for case finding in primary care in Hong Kong: a cross-sectional study and a prospective study protocol paper

INTRODUCTION

Diabetes mellitus (DM) is a major non-communicable disease with an increasing prevalence. Undiagnosed DM is not uncommon and can lead to severe complications and mortality. Identifying high-risk individuals at an earlier disease stage, that is, pre-diabetes (pre-DM), is crucial in delaying progression. Existing risk models mainly rely on non-modifiable factors to predict only the DM risk, and few apply to Chinese people. This study aims to develop and validate a risk prediction function that incorporates modifiable lifestyle factors to detect DM and pre-DM in Chinese adults in primary care.

METHODS AND ANALYSIS

A cross-sectional study to develop DM/Pre-DM risk prediction functions using data from the Hong Kong's Population Health Survey (PHS) 2014/2015 and a 12-month prospective study to validate the functions in case finding of individuals with DM/pre-DM. Data of 1857 Chinese adults without self-reported DM/Pre-DM will be extracted from the PHS 2014/2015 to develop DM/Pre-DM risk models using logistic regression and machine learning methods. 1014 Chinese adults without a known history of DM/Pre-DM will be recruited from public and private primary care clinics in Hong Kong. They will complete a questionnaire on relevant risk factors and blood tests on Oral Glucose Tolerance Test (OGTT) and haemoglobin A1C (HbA1c) on recruitment and, if the first blood test is negative, at 12 months. A positive case is DM/pre-DM defined by OGTT or HbA1c in any blood test. Area under receiver operating characteristic curve, sensitivity, specificity, positive predictive value and negative predictive value of the models in detecting DM/pre-DM will be calculated.

ETHICS AND DISSEMINATION

Ethics approval has been received from The University of Hong Kong/Hong Kong Hospital Authority Hong Kong West Cluster (UW19-831) and Hong Kong Hospital Authority Kowloon Central/Kowloon East Cluster (REC(KC/KE)-21-0042/ER-3). The study results will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

US ClinicalTrial.gov: NCT04881383; HKU clinical trials registry: HKUCTR-2808; Pre-results.

American Diabetes Association Professional Practice Committee. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The Effect of Traditional Aerobic Exercise and Sprint Interval Training on Insulin Resistance in Men With Prediabetes: A Randomised Controlled Trial

Introduction

Prediabetes is an intermediate stage with hyperglycaemia below the threshold of diabetes mellitus. Insulin resistance is a significant factor in its pathogenesis. Lifestyle modifications are suggested and found to be more beneficial in this stage. Moderate-intensity exercise for 30 to 45 minutes a day is routinely recommended but has low compliance, and lack of time is a significant deterrent. Sprint interval training (SIT) is an alternate exercise regimen with higher intensity and less time requirement. The present study compares the effect of a three-month intervention of traditional aerobic exercise and sprint interval training on insulin resistance in prediabetic men.

Methods

The study subjects were males aged 25 to 40 years with prediabetes as per the American Diabetes Association criteria of fasting and two-hour plasma glucose levels. The study is a parallel-group randomised trial with one arm (AE group) involved in the traditional aerobic exercise (brisk walking) for 30 minutes, five days a week. The other arm was the sprint interval training (SIT) group performing an ‘all-out’ run effort for one minute followed by a recovery rest period of one and a half minutes, completing one cycle of two and half minutes. Four such cycles were completed in each session. Thus, the exercise sessions were just 10 minutes daily, three days a week. The duration of the intervention was three months. One hundred and sixty participants were recruited after screening and randomly assigned in a 1:1 ratio to the two groups. The primary outcome measure was insulin resistance estimated by homeostasis model assessment -estimated insulin resistance (HOMA-IR). The secondary outcome measures were fasting plasma glucose and serum insulin, glycated haemoglobin, body mass index and waist-hip ratio.

Results

The mean age of the AE group was 30.7 ± 3.3 years, and the SIT group was 31 ± 3.4 years. Seventy-two men from the AE group and 74 from the SIT group completed the study. After the three-month AE and SIT exercise, the per-protocol analysis reflected a significant reduction in insulin resistance, i.e., HOMA-IR (3.6 ± 1.1 to 3 ± 1.2, p<0.0001) after traditional aerobic exercise. Similarly, the HOMA-IR was significantly reduced after sprint interval training (3.3 ± 1.2 to 2.5 ± 1, p<0.0001). The intention-to-treat analysis also found that the reductions in HOMA-IR after both exercise protocols were statistically significant. The change in insulin resistance compared for the SIT vs AE group was not statistically significant. Secondary outcome measures HbA1c, fasting glucose, fasting insulin, BMI, and waist-hip ratio showed significant improvement with AE and SIT. 

Conclusions

The sprint interval training similarly improved insulin resistance and other parameters compared to the traditional exercise group. SIT can be a time-efficient exercise protocol suggested as a part of lifestyle modification for men with prediabetes.

Risk Stratification for Early Detection of Diabetes and Hypertension in Resource-Limited Settings: Machine Learning Analysis

Background

The impending scale up of noncommunicable disease screening programs in low- and middle-income countries coupled with limited health resources require that such programs be as accurate as possible at identifying patients at high risk.

Objective

The aim of this study was to develop machine learning–based risk stratification algorithms for diabetes and hypertension that are tailored for the at-risk population served by community-based screening programs in low-resource settings.

Methods

We trained and tested our models by using data from 2278 patients collected by community health workers through door-to-door and camp-based screenings in the urban slums of Hyderabad, India between July 14, 2015 and April 21, 2018. We determined the best models for predicting short-term (2-month) risk of diabetes and hypertension (a model for diabetes and a model for hypertension) and compared these models to previously developed risk scores from the United States and the United Kingdom by using prediction accuracy as characterized by the area under the receiver operating characteristic curve (AUC) and the number of false negatives.

Results

We found that models based on random forest had the highest prediction accuracy for both diseases and were able to outperform the US and UK risk scores in terms of AUC by 35.5% for diabetes (improvement of 0.239 from 0.671 to 0.910) and 13.5% for hypertension (improvement of 0.094 from 0.698 to 0.792). For a fixed screening specificity of 0.9, the random forest model was able to reduce the expected number of false negatives by 620 patients per 1000 screenings for diabetes and 220 patients per 1000 screenings for hypertension. This improvement reduces the cost of incorrect risk stratification by US $1.99 (or 35%) per screening for diabetes and US $1.60 (or 21%) per screening for hypertension.

Conclusions

In the next decade, health systems in many countries are planning to spend significant resources on noncommunicable disease screening programs and our study demonstrates that machine learning models can be leveraged by these programs to effectively utilize limited resources by improving risk stratification.

Monitoring Prediabetes Screening in Two Primary Care Offices in Rural Appalachia: A Quality Improvement Process

BACKGROUND

One-third of the U.S. population has prediabetes, but 90% remain undiagnosed because healthcare providers are not screening for this condition.

OBJECTIVE

The purpose of this quality improvement project was to monitor prediabetes screening and identification, and implement evidence-based recommendations including registered dietician referral.

METHODS

This project involved using an evidence-based screening tool to measure individual risk of prediabetes. Aggregate data was collected to evaluate screening implementation, evidence-based recommendations offered by providers, and assess patient risk factors.

RESULTS

The percentage of patients at risk for prediabetes was 41.3% (n = 111). The most frequent risks were identified as overweight, history of hypertension, family history of type 2 diabetes mellitus (T2DM), and older age. Providers offered education on weight loss 68.5% (n = 76) and exercise 76.6% (n = 85) but referred 33.3% (n = 37) patients for nutrition education. The screening rates were 52.3% (n = 176) and 72.5% (n = 244) in clinics A and B respectively.

CONCLUSIONS

A gap remains in using evidence-based recommendations to decrease risk of prediabetes. Prediabetes screening identified a greater percentage of persons in this population.

IMPLICATIONS FOR NURSING

There is a need for consistent practice of evidence-based recommendations. This project set the benchmark for future efforts to educate, encourage, and measure providers successes.

Assessment of simple strategies for identifying undiagnosed diabetes and prediabetes in the general population

BACKGROUND AND AIMS

The rising tide of diabetes mellitus (DM) and prediabetes (PDM) is urgently calling for strategies easily applicable to anticipate diagnosis. We assessed the effectiveness of random capillary blood glucose (RCBG), administration of a validated DM risk questionnaire, or the combination of both.

MATERIALS AND METHODS

RCBG measurement and/or questionnaire administration were offered to all individuals presenting at gazebos organized during the World Diabetes Day or similar public initiatives on diabetes awareness. Subjects with suspicious DM or PDM were invited to the Diabetes Center (DC) for laboratory confirmation (fasting plasma glucose and HbA1c).

RESULTS

Among 8563 individuals without known diabetes undergoing RCBG measurement, 341 (4%) had suspicious values. Diagnosis of DM was confirmed in 36 (41.9%) of the 86 subjects who came to the DC and PDM was found in 40 (46.5%). Among 3351 subjects to whom the questionnaire was administered, 480 (14.3%) had suspicious scores. Diagnosis of DM was confirmed in 40 (10.1%) of the 397 who came to the DC and PDM was found in 214 (53.9%). These 3351 subjects also had RCBG measurement and 30 out of them had both tests positive. Among them, 27 subjects came to DC and DM was diagnosed in 17 (63.0%) and PDM was found in 9 (33.3%).

CONCLUSIONS

These data suggest that RCBG definitely outperforms the questionnaire to identify unknown DM and PDM. RCBG measurement, with questionnaire as an adjunctive tool, appears to be a simple, fast, and feasible opportunistic strategy in detecting undiagnosed DM and PDM.

2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Early detection of type 2 diabetes in socioeconomically disadvantaged areas in Stockholm - comparing reach of community and facility-based screening

BACKGROUND

Type 2 diabetes and its high-risk stage, prediabetes, are often undiagnosed. Early detection of these conditions is of importance to avoid organ complications due to the metabolic disturbances associated with diabetes. Diabetes screening can detect persons unaware of diabetes risk and the elevated glucose levels can potentially be reversed through lifestyle modification and medication. There are mainly two approaches to diabetes screening: opportunistic facility-based screening at health facilities and community screening.

OBJECTIVE

To determine the difference in population reach and participant characteristics between community- and facility-based screening for detection of type 2 diabetes and persons at high risk of developing diabetes.

METHODS

Finnish diabetes risk score (FINDRISC) is a risk assessment tool used by two diabetes projects to conduct community- and facility-based screenings in disadvantaged suburbs of Stockholm. In this study, descriptive and limited inferential statistics were carried out analyzing data from 2,564 FINDRISC forms from four study areas. Community- and facility-based screening was compared in terms of participant characteristics and with population data from the respective areas to determine their reach.

RESULTS

Our study found that persons born in Africa and Asia were reached through community screening to a higher extent than with facility-based screening, while persons born in Sweden and other European countries were reached more often by facility-based screening. Also, younger persons were reached more frequently through community screening compared with facility-based screening. Both types of screening reached more women than men.

CONCLUSION

Community-based screening and facility-based screening were complementary methods in reaching different population groups at high risk of developing type 2 diabetes. Community screening in particular reached more hard-to-reach groups with unfavorable risk profiles, making it a critical strategy for T2D prevention. More men should be recruited to intervention studies and screening initiatives to achieve a gender balance.

Effect of Vitamin D3 Supplementation on Insulin Sensitivity in Prediabetes With Hypovitaminosis D: A Randomized Placebo-Controlled Trial

Introduction The interplay of vitamin D and glucose metabolism is an area of ongoing research. The need for vitamin D supplementation trials in individuals with prediabetes and hypovitaminosis D has been stressed by earlier research studies. The objective of this study was to assess the effect of vitamin D3 supplementation on oral glucose insulin sensitivity (OGIS) index in patients with prediabetes and hypovitaminosis D. Methods  We enrolled 120 individuals with prediabetes (ADA definition) and hypovitaminosis D (vitamin D < 30 ng/mL) and randomized them into the vitamin D supplementation (60,000 IU weekly) group and the placebo group. Primary outcome measure (i.e., 2-hour OGIS index) and secondary outcome measures (i.e., fasting and postprandial blood glucose, glycosylated hemoglobin, body mass index, and insulin sensitivity indices, i.e., quantitative insulin sensitivity check index [QUICKI] and homeostatic model assessment for insulin resistance [HOMA-IR]) were analyzed for change with the 12 weeks of intervention. Results  A total of 52 subjects in the vitamin D group and 49 in the placebo group completed the study. Serum vitamin D levels (10.11 ± 2.73 to 52.2 ± 13.14 ng/mL; p < 0.0001) and OGIS index (376.4 ± 39.7 to 391.7 ± 40.7 mL/min/m2; p = 0.011) increased significantly on per-protocol analysis in the vitamin D group. There was no significant change observed in vitamin D levels and OGIS index in the placebo group. Between-group comparison showed a rise in OGIS index (15.3 ± 47.1 mL/min/m2) in the vitamin D group and decrease in OGIS index (-10.4 ± 44.7 mL/min/m2) in the placebo group, and the difference was statistically significant (p = 0.0029). The inter-group comparison showed relative fall in fasting glucose levels in the vitamin D group, with no significant change observed in the other secondary outcome measures. Conclusions The correction of hypovitaminosis D in subjects with prediabetes led to improved insulin sensitivity as assessed by OGIS index at 120 minutes, signifying the role of vitamin D in glucose homeostasis.

Alternative type 2 diabetes screening tests may reduce the number of U.S. adults with undiagnosed diabetes

AIM

To evaluate the U.S. population-level impact of two alternatives for initial type 2 diabetes screening [opportunistic random plasma glucose (RPG) > 6.7 mmol/l and a 1-h 50-g glucose challenge test (GCT) > 8.9 mmol/l] compared with American Diabetes Association (ADA)-recommended tests.

METHODS

Using a sample (n = 1471) from the National Health and Nutrition Examination Survey (NHANES) 2013-2014 that represented 145 million U.S. adults at high risk for developing type 2 diabetes, we simulated a two-test screening process. We compared ADA-recommended screening tests [fasting plasma glucose (FPG), 2-h 75-g oral glucose tolerance test (OGTT), HbA1c ] vs. initial screening with opportunistic RPG or GCT (followed by FPG, OGTT or HbA1c ). After simulation, participants were entered into an individual-level Monte Carlo-based Markov lifetime outcomes model. Primary outcomes were representative number of U.S. adults correctly identified with type 2 diabetes, societal lifetime costs and quality-adjusted life years (QALYs).

RESULTS

In NHANES 2013-2014, 100 individuals had undiagnosed diabetes [weighted estimate: 8.4 million, standard error (se): 1.1 million]. Among ADA-recommended screening tests, FPG followed by OGTT (FPG-OGTT) was most sensitive, identifying 35 individuals with undiagnosed diabetes (weighted estimate: 3.2 million, se: 0.9 million). Four alternative screening strategies performed superior to FPG-OGTT, with RPG followed by OGTT being the most sensitive overall, identifying 72 individuals with undiagnosed diabetes (weighted estimate: 6.1 million, se: 1.0 million). There was no increase in average lifetime costs and comparable QALYs.

CONCLUSIONS

Initial screening using opportunistic RPG or a GCT may identify more U.S. adults with type 2 diabetes without increasing societal costs.

The Oral Glucose Tolerance Test: 100 Years Later

For over 100 years, the oral glucose tolerance test (OGTT) has been the cornerstone for detecting prediabetes and type 2 diabetes (T2DM). In recent decades, controversies have arisen identifying internationally acceptable cut points using fasting plasma glucose (FPG), 2-h post-load glucose (2-h PG), and/or HbA1c for defining intermediate hyperglycemia (prediabetes). Despite this, there has been a steadfast global consensus of the 2-h PG for defining dysglycemic states during the OGTT. This article reviews the history of the OGTT and recent advances in its application, including the glucose challenge test and mathematical modeling for determining the shape of the glucose curve. Pitfalls of the FPG, 2-h PG during the OGTT, and HbA1c are considered as well. Finally, the associations between the 30-minute and 1-hour plasma glucose (1-h PG) levels derived from the OGTT and incidence of diabetes and its complications will be reviewed. The considerable evidence base supports modifying current screening and diagnostic recommendations with the use of the 1-h PG. Measurement of the 1-h PG level could increase the likelihood of identifying high-risk individuals when the pancreatic ß-cell function is substantially more intact with the added practical advantage of potentially replacing the conventional 2-h OGTT making it more acceptable in the clinical setting.

Review of methods for detecting glycemic disorders

Prediabetes (intermediate hyperglycemia) consists of two abnormalities, impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) detected by a standardized 75-gram oral glucose tolerance test (OGTT). Individuals with isolated IGT or combined IFG and IGT have increased risk for developing type 2 diabetes (T2D) and cardiovascular disease (CVD). Diagnosing prediabetes early and accurately is critical in order to refer high-risk individuals for intensive lifestyle modification. However, there is currently no international consensus for diagnosing prediabetes with HbA1c or glucose measurements based upon American Diabetes Association (ADA) and the World Health Organization (WHO) criteria that identify different populations at risk for progressing to diabetes. Various caveats affecting the accuracy of interpreting the HbA1c including genetics complicate this further. This review describes established methods for detecting glucose disorders based upon glucose and HbA1c parameters as well as novel approaches including the 1-hour plasma glucose (1-h PG), glucose challenge test (GCT), shape of the glucose curve, genetics, continuous glucose monitoring (CGM), measures of insulin secretion and sensitivity, metabolomics, and ancillary tools such as fructosamine, glycated albumin (GA), 1,5- anhydroglucitol (1,5-AG). Of the approaches considered, the 1-h PG has considerable potential as a biomarker for detecting glucose disorders if confirmed by additional data including health economic analysis. Whether the 1-h OGTT is superior to genetics and omics in providing greater precision for individualized treatment requires further investigation. These methods will need to demonstrate substantially superiority to simpler tools for detecting glucose disorders to justify their cost and complexity.

Random plasma glucose predicts the diagnosis of diabetes

Aims/Hypothesis

Early recognition of those at high risk for diabetes as well as diabetes itself can permit preventive management, but many Americans with diabetes are undiagnosed. We sought to determine whether routinely available outpatient random plasma glucose (RPG) would be useful to facilitate the diagnosis of diabetes.

Methods

Retrospective cohort study of 942,446 U.S. Veterans without diagnosed diabetes, ≥3 RPG in a baseline year, and ≥1 primary care visit/year during 5-year follow-up. The primary outcome was incident diabetes (defined by diagnostic codes and outpatient prescription of a diabetes drug).

Results

Over 5 years, 94,599 were diagnosed with diabetes [DIAB] while 847,847 were not [NONDIAB]. Baseline demographics of DIAB and NONDIAB were clinically similar, except DIAB had higher BMI (32 vs. 28 kg/m²) and RPG (150 vs. 107 mg/dl), and were more likely to have Black race (18% vs. 15%), all p<0.001. ROC area for prediction of DIAB diagnosis within 1 year by demographic factors was 0.701, and 0.708 with addition of SBP, non-HDL cholesterol, and smoking. These were significantly less than that for prediction by baseline RPG alone (≥2 RPGs at/above a given level, ROC 0.878, p<0.001), which improved slightly when other factors were added (ROC 0.900, p<0.001). Having ≥2 RPGs ≥115 mg/dl had specificity 77% and sensitivity 87%, and ≥2 RPGs ≥130 mg/dl had specificity 93% and sensitivity 59%. For predicting diagnosis within 3 and 5 years by RPG alone, ROC was reduced but remained substantial (ROC 0.839 and 0.803, respectively).

Conclusions

RPG levels below the diabetes “diagnostic” range (≥200 mg/dl) provide good discrimination for follow-up diagnosis. Use of such levels–obtained opportunistically, during outpatient visits–could signal the need for further testing, allow preventive intervention in high risk individuals before onset of disease, and lead to earlier identification of diabetes.

Trajectory of Excess Medical Expenditures 10 Years Before and After Diabetes Diagnosis Among U.S. Adults Aged 25-64 Years, 2001-2013

OBJECTIVE

We assessed the excess medical expenditures for adults newly diagnosed with diabetes, for up to 10 years before and after diabetes diagnosis.

RESEARCH DESIGN AND METHODS

Using the 2001-2013 MarketScan data, we identified people with newly diagnosed diabetes among adults aged 25-64 years (diabetes cohort) and matched them with people who did not have diagnosed diabetes (control cohort) using 1:1 propensity score matching. We followed these two cohorts up to ±10 years from the index date, with annual matched cohort sizes ranging from 3,922 to 39,726 individuals. We estimated the yearly and cumulative excess medical expenditures of the diabetes cohorts before and after the diagnosis of diabetes.

RESULTS

The per capita annual total excess medical expenditure for the diabetes cohort was higher for the entire 10 years prior to their index date, ranging between $1,043 in year -10 and $4,492 in year -1. Excess expenditure spiked in year 1 ($8,109), declined in year 2, and then increased steadily, ranging from $4,261 to $6,162 in years 2-10. The cumulative excess expenditure for the diabetes cohort during the entire 20 years of follow-up was $69,177 ($18,732 before and $50,445 after diagnosis).

CONCLUSIONS

People diagnosed with diabetes had higher medical expenditures compared with their counterparts, not only after diagnosis but also up to 10 years prior to diagnosis. Managing risk factors for type 2 diabetes and cardiovascular disease before diagnosis, and for diabetes-related complications after diagnosis, could alleviate medical expenditure in people with diabetes.

Implementation of a prediabetes identification algorithm for overweight and obese Veterans

Type 2 diabetes prevention is an important national goal for the Veteran Health Administration (VHA): one in four Veterans has diabetes. We implemented a prediabetes identification algorithm to estimate prediabetes prevalence among overweight and obese Veterans at Department of Veterans Affairs (VA) medical centers (VAMCs) in preparation for the launch of a pragmatic study of Diabetes Prevention Program (DPP) delivery to Veterans with prediabetes. This project was embedded within the VA DPP Clinical Demonstration Project conducted in 2012 to 2015. Veterans who attended orientation sessions for an established VHA weight-loss program (MOVE!) were recruited from VAMCs with geographically and racially diverse populations using existing referral processes. Each site implemented and adapted the prediabetes identification algorithm to best fit their local clinical context. Sites relied on an existing referral process in which a prediabetes identification algorithm was implemented in parallel with existing clinical flow; this approach limited the number of overweight and obese Veterans who were assessed and screened. We evaluated 1,830 patients through chart reviews, interviews, and/or laboratory tests. In this cohort, our estimated prevalence rates for normal glycemic status, prediabetes, and diabetes were 29% (n = 530), 28% (n = 504), and 43% (n = 796), respectively. Implementation of targeted prediabetes identification programs requires careful consideration of how prediabetes assessment and screening will occur.

Inpatient Glucose Values: Determining the Nondiabetic Range and Use in Identifying Patients at High Risk for Diabetes

BACKGROUND

Many individuals with diabetes remain undiagnosed, leading to delays in treatment and higher risk for subsequent diabetes complications. Despite recommendations for diabetes screening in high-risk groups, the optimal approach is not known. We evaluated the utility of inpatient glucose levels as an opportunistic screening tool for identifying patients at high risk for diabetes.

METHODS

We retrospectively examined 462,421 patients in the US Department of Veterans Affairs healthcare system, hospitalized on medical/surgical services in 2000-2010, for ≥3 days, with ≥2 inpatient random plasma glucose (RPG) measurements. All had continuity of care: ≥1 primary care visit and ≥1 glucose measurement within 2 years before hospitalization and yearly for ≥3 years after discharge. Glucose levels during hospitalization and incidence of diabetes within 3 years after discharge in patients without diabetes were evaluated.

RESULTS

Patients had a mean age of 65.0 years, body mass index of 29.9 kg/m², and were 96% male, 71% white, and 18% black. Pre-existing diabetes was present in 39.4%, 1.3% were diagnosed during hospitalization, 8.1% were diagnosed 5 years after discharge, and 51.3% were never diagnosed (NonDM). The NonDM group had the lowest mean hospital RPG value (112 mg/dL [6.2 mmol/L]). Having at least 2 RPG values >140 mg/dL (>7.8 mmol/L), the 95th percentile of NonDM hospital glucose, provided 81% specificity for identifying incident diabetes within 3 years after discharge.

CONCLUSIONS

Screening for diabetes could be considered in patients with at least 2 hospital glucose values at/above the 95th percentile of the nondiabetic range (141 mg/dL [7.8 mmol/L]).

Glucose challenge test screening for prediabetes and early diabetes

AIMS

To test the hypothesis that a 50-g oral glucose challenge test with 1-h glucose measurement would have superior performance compared with other opportunistic screening methods.

METHODS

In this prospective study in a Veterans Health Administration primary care clinic, the following test performances, measured by area under receiver-operating characteristic curves, were compared: 50-g oral glucose challenge test; random glucose; and HbA1c level, using a 75-g oral glucose tolerance test as the 'gold standard'.

RESULTS

The study population was comprised of 1535 people (mean age 56 years, BMI 30.3 kg/m2 , 94% men, 74% black). By oral glucose tolerance test criteria, diabetes was present in 10% and high-risk prediabetes was present in 22% of participants. The plasma glucose challenge test provided area under receiver-operating characteristic curves of 0.85 (95% CI 0.78-0.91) to detect diabetes and 0.76 (95% CI 0.72-0.80) to detect high-risk dysglycaemia (diabetes or high-risk prediabetes), while area under receiver-operating characteristic curves for the capillary glucose challenge test were 0.82 (95% CI 0.75-0.89) and 0.73 (95% CI 0.69-0.77) for diabetes and high-risk dysglycaemia, respectively. Random glucose performed less well [plasma: 0.76 (95% CI 0.69-0.82) and 0.66 (95% CI 0.62-0.71), respectively; capillary: 0.72 (95% CI 0.65-0.80) and 0.64 (95% CI 0.59-0.68), respectively], and HbA1c performed even less well [0.67 (95% CI 0.57-0.76) and 0.63 (95% CI 0.58-0.68), respectively]. The cost of identifying one case of high-risk dysglycaemia with a plasma glucose challenge test would be $42 from a Veterans Health Administration perspective, and $55 from a US Medicare perspective.

CONCLUSIONS

Glucose challenge test screening, followed, if abnormal, by an oral glucose tolerance test, would be convenient and more accurate than other opportunistic tests. Use of glucose challenge test screening could improve management by permitting earlier therapy.

Gender-related different effects of a combined therapy of Exenatide and Metformin on overweight or obesity patients with type 2 diabetes mellitus

BACKGROUND

Although men and women have similar diabetes prevalence, the same medicine will cause different therapeutic results in different genders. To understand the molecular mechanism, we explored the effects of a combined therapy of Exenatide and Metformin on obesity and overweight female and male patients with newly diagnosed type 2 diabetes mellitus (T2DM).

METHODS

One hundred and five overweight and obesity patients with newly diagnosed T2DM (n=54 female in a female group and n=51 males in a male group) received the therapy: 5 μg Exenatide+0.5 g MET twice daily for 4 weeks, then 10 μg Exenatide+0.5 g MET twice daily for 24 weeks.

RESULTS

There was an average of 8.2 ± 2.4 kg and 4.6 ± 2.3 kg weight loss in female and male patients, respectively. The combined therapy showed better effects on female than male patients for improving insulin sensitivity and serum lipid profile, reducing insulin resistance, increasing adiponectin levels, and decreasing the levels of HbA1c, BMI, resistin, TNF-alpha and C-reactive protein (P<0.05).

CONCLUSIONS

The combined therapy of Exenatide and MET shows better therapeutic results in female patients than in male patients. Therefore, the dual therapy is more suitable for female patients.

Simple non-laboratory- and laboratory-based risk assessment algorithms and nomogram for detecting undiagnosed diabetes mellitus

BACKGROUND

The aim of the present study was to develop a simple nomogram that can be used to predict the risk of diabetes mellitus (DM) in the asymptomatic non-diabetic subjects based on non-laboratory- and laboratory-based risk algorithms.

METHODS

Anthropometric data, plasma fasting glucose, full lipid profile, exercise habits, and family history of DM were collected from Chinese non-diabetic subjects aged 18-70 years. Logistic regression analysis was performed on a random sample of 2518 subjects to construct non-laboratory- and laboratory-based risk assessment algorithms for detection of undiagnosed DM; both algorithms were validated on data of the remaining sample (n = 839). The Hosmer-Lemeshow test and area under the receiver operating characteristic (ROC) curve (AUC) were used to assess the calibration and discrimination of the DM risk algorithms.

RESULTS

Of 3357 subjects recruited, 271 (8.1%) had undiagnosed DM defined by fasting glucose ≥7.0 mmol/L or 2-h post-load plasma glucose ≥11.1 mmol/L after an oral glucose tolerance test. The non-laboratory-based risk algorithm, with scores ranging from 0 to 33, included age, body mass index, family history of DM, regular exercise, and uncontrolled blood pressure; the laboratory-based risk algorithm, with scores ranging from 0 to 37, added triglyceride level to the risk factors. Both algorithms demonstrated acceptable calibration (Hosmer-Lemeshow test: P = 0.229 and P = 0.483) and discrimination (AUC 0.709 and 0.711) for detection of undiagnosed DM.

CONCLUSION

A simple-to-use nomogram for detecting undiagnosed DM has been developed using validated non-laboratory-based and laboratory-based risk algorithms.

The cost-effectiveness of testing strategies for type 2 diabetes: a modelling study

BACKGROUND

An estimated 850,000 people have diabetes without knowing it and as many as 7 million more are at high risk of developing it. Within the NHS Health Checks programme, blood glucose testing can be undertaken using a fasting plasma glucose (FPG) or a glycated haemoglobin (HbA1c) test but the relative cost-effectiveness of these is unknown.

OBJECTIVES

To estimate and compare the cost-effectiveness of screening for type 2 diabetes using a HbA1c test versus a FPG test. In addition, to compare the use of a random capillary glucose (RCG) test versus a non-invasive risk score to prioritise individuals who should undertake a HbA1c or FPG test.

DESIGN

Cost-effectiveness analysis using the Sheffield Type 2 Diabetes Model to model lifetime incidence of complications, costs and health benefits of screening.

SETTING

England; population in the 40-74-years age range eligible for a NHS health check.

DATA SOURCES

The Leicester Ethnic Atherosclerosis and Diabetes Risk (LEADER) data set was used to analyse prevalence and screening outcomes for a multiethnic population. Alternative prevalence rates were obtained from the literature or through personal communication.

METHODS

(1) Modelling of screening pathways to determine the cost per case detected followed by long-term modelling of glucose progression and complications associated with hyperglycaemia; and (2) calculation of the costs and health-related quality of life arising from complications and calculation of overall cost per quality-adjusted life-year (QALY), net monetary benefit and the likelihood of cost-effectiveness.

RESULTS

Based on the LEADER data set from a multiethnic population, the results indicate that screening using a HbA1c test is more cost-effective than using a FPG. For National Institute for Health and Care Excellence (NICE)-recommended screening strategies, HbA1c leads to a cost saving of £12 and a QALY gain of 0.0220 per person when a risk score is used as a prescreen. With no prescreen, the cost saving is £30 with a QALY gain of 0.0224. Probabilistic sensitivity analysis indicates that the likelihood of HbA1c being more cost-effective than FPG is 98% and 95% with and without a risk score, respectively. One-way sensitivity analyses indicate that the results based on prevalence in the LEADER data set are insensitive to a variety of alternative assumptions. However, where a region of the country has a very different joint HbA1c and FPG distribution from the LEADER data set such that a FPG test yields a much higher prevalence of high-risk cases relative to HbA1c, FPG may be more cost-effective. The degree to which the FPG-based prevalence would have to be higher depends very much on the uncertain relative uptake rates of the two tests. Using a risk score such as the Leicester Practice Database Score (LPDS) appears to be more cost-effective than using a RCG test to identify individuals with the highest risk of diabetes who should undergo blood testing.

LIMITATIONS

We did not include rescreening because there was an absence of required relevant evidence.

CONCLUSIONS

Based on the multiethnic LEADER population, among individuals currently attending NHS Health Checks, it is more cost-effective to screen for diabetes using a HbA1c test than using a FPG test. However, in some localities, the prevalence of diabetes and high risk of diabetes may be higher for FPG relative to HbA1c than in the LEADER cohort. In such cases, whether or not it still holds that HbA1c is likely to be more cost-effective than FPG depends on the relative uptake rates for HbA1c and FPG. Use of the LPDS appears to be more cost-effective than a RCG test for prescreening.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Prevalence and Predictors of Pre-Diabetes and Diabetes among Adults 18 Years or Older in Florida: A Multinomial Logistic Modeling Approach

BACKGROUND

Individuals with pre-diabetes and diabetes have increased risks of developing macro-vascular complications including heart disease and stroke; which are the leading causes of death globally. The objective of this study was to estimate the prevalence of pre-diabetes and diabetes, and to investigate their predictors among adults ≥18 years in Florida.

METHODS

Data covering the time period January-December 2013, were obtained from Florida's Behavioral Risk Factor Surveillance System (BRFSS). Survey design of the study was declared using SVYSET statement of STATA 13.1. Descriptive analyses were performed to estimate the prevalence of pre-diabetes and diabetes. Predictors of pre-diabetes and diabetes were investigated using multinomial logistic regression model. Model goodness-of-fit was evaluated using both the multinomial goodness-of-fit test proposed by Fagerland, Hosmer, and Bofin, as well as, the Hosmer-Lemeshow's goodness of fit test.

RESULTS

There were approximately 2,983 (7.3%) and 5,189 (12.1%) adults in Florida diagnosed with pre-diabetes and diabetes, respectively. Over half of the study respondents were white, married and over the age of 45 years while 36.4% reported being physically inactive, overweight (36.4%) or obese (26.4%), hypertensive (34.6%), hypercholesteremic (40.3%), and 26% were arthritic. Based on the final multivariable multinomial model, only being overweight (Relative Risk Ratio [RRR] = 1.85, 95% Confidence Interval [95% CI] = 1.41, 2.42), obese (RRR = 3.41, 95% CI = 2.61, 4.45), hypertensive (RRR = 1.69, 95% CI = 1.33, 2.15), hypercholesterolemic (RRR = 1.94, 95% CI = 1.55, 2.43), and arthritic (RRR = 1.24, 95% CI = 1.00, 1.55) had significant associations with pre-diabetes. However, more predictors had significant associations with diabetes and the strengths of associations tended to be higher than for the association with pre-diabetes. For instance, the relative risk ratios for the association between diabetes and being overweight (RRR = 2.00, 95% CI = 1.55, 2.57), or obese (RRR = 4.04, 95% CI = 3.22, 5.07), hypertensive (RRR = 2.66, 95% CI = 2.08, 3.41), hypercholesterolemic (RRR = 1.98, 95% CI = 1.61, 2.45) and arthritic (RRR = 1.28, 95% CI = 1.04, 1.58) were all further away from the null than their associations with pre-diabetes. Moreover, a number of variables such as age, income level, sex, and level of physical activity had significant association with diabetes but not pre-diabetes. The risk of diabetes increased with increasing age, lower income, in males, and with physical inactivity. Insufficient physical activity had no significant association with the risk of diabetes or pre-diabetes.

CONCLUSIONS

There is evidence of differences in the strength of association of the predictors across levels of diabetes status (pre-diabetes and diabetes) among adults ≥18 years in Florida. It is important to monitor populations at high risk for pre-diabetes and diabetes, so as to help guide health programming decisions and resource allocations to control the condition.

Differences of prevalence of dyslipidemia and risk factors related to LDL-c in the patients with abnormal fasting glucose between Uygur and Han in Xinjiang

AIMS

To evaluate the incidence of dyslipidemia among Uygur and Han patients with impaired fasting glucose (IFG). To investigate the influence factors on LDL-c in this population.

METHODS

This cross-sectional study included a total of 4709 participants, consisting of Uygurs patients (n=2053) and Han patients (n=2656) from Xinjiang province, who were screened for diabetes mellitus. A stratified multistage sampling design was used to collect the participants. The influence factors on LDL-c were analyzed by Logistic regression analysis.

RESULTS

Among the IFG patients (n=1757), Uighur IFG group had a higher prevalence of dyslipidemia than that of Han IFG group, 99.8% vs. 63.7%, P<0.05. Similar trends were existed in the prevalence of hypercholesteremia, hypertriglyceridemia, high LDL-c and low HDL-c (all P<0.05). Among the Uighur groups, IFG group had higher dyslipidemia rate than that of euglycemia group (74%). However, there was no such difference in the Han groups. Logistic regression analysis revealed that risk factors associated with LDL-c were age, total cholesterol and 2 h postprandial blood glucose for the Uighur IFG patients. However, gender and total cholesterol were risk factors for Han IFG patients.

CONCLUSIONS

Uighur IFG patients had higher incidence of dyslipidemia than that of Han IFG patients. For Uyghur IFG patients, closing follow-up of total cholesterol and 2 h postprandial blood glucose were necessary. As to the Han IFG patients, we should pay more attention to male and total cholesterol in order to lower LDL-c levels. So, appropriately preventive and therapeutic measures should be chosen based on the characteristics of abnormal lipid profiles in different nationality.

Prevalence of undiagnosed diabetes and pre-diabetes among hypertensive patients attending Kiambu district Hospital, Kenya: a cross-sectional study

INTRODUCTION

Hypertension (HTN) and diabetes mellitus (DM) are two common non-communicable diseases (NCDs) that are closely linked: one cannot be properly managed without attention to the other. The aim of this study was to determine the prevalence of undiagnosed diabetic and pre-diabetic states that is abnormal glucose regulation (AGR) and factors associated with it among hypertensive patients in Kiambu Hospital, Kenya.

METHODS

We conducted a cross-sectional study from February 2014 to April 2014. Hypertensive patients aged ≥ 18 attending the out-patient medical clinic were included in the study. Pregnant and known diabetic patients were excluded. Data was collected on socio-demographics, behavior, and anthropometrics. Diabetes status was based on a Glycated Haemoglobin (HbA1C) classification of ≥ 6.5% for diabetes, 6.0-6.4% for pre-diabetes and ≤ 6.0% for normal. AGR was the dependable variable and included two diabetic categories; diabetes and pre-diabetes.

RESULTS

We enrolled 334 patients into the study: the mean age was 59 years (Standard deviation = 14.3). Of these patients 254 (76%) were women. Thirty two percent (107/334; 32%) were found to have AGR, with 14% (46) having un-diagnosed DM and 18%(61) with pre-diabetes. Factors associated with AGR were age ≥ 45 (OR = 3.23; 95% CI 1.37 ≥ 7.62), basal metabolic index (BMI) ≥ 25 Kg/m(2) (OR = 3.13; 95% CI 1.53 - 6.41), low formal education (primary/none)(OR= 2; 95%CI 1.08 - 3.56) and family history of DM (OR = 2.19; 95%CI 1.16 - 4.15).

CONCLUSION

There was a high prevalence of undiagnosed AGR among hypertensive patients. This highlights the need to regularly screen for AGR among hypertensive patients as recommended by WHO.

Why screening for type 2 diabetes is necessary even in poor resource settings

Screening for type 2 diabetes (T2DM) remains controversial, in spite of the explosive increase in the prevalence of the disorder and the morbidity and mortality associated with its complications. In this review, we attempt to show that T2DM is an ideal candidate disease for screening, and why screening is needed to improve clinical outcomes and prevent complications. We also suggest that screening can be made more cost-effective by adopting a targeted approach and utilizing low-cost tools. We conclude that screening for T2DM is warranted even in resource-constrained settings, and provide examples from rural India showing that such an approach is feasible with meticulous planning and judicious allocation of resources.

Prevalence of impaired glucose metabolism and potential predictors: a rapid appraisal among ≥ 45 years old residents of southern Tajikistan

BACKGROUND

An estimated 2% of all deaths in Tajikistan can be attributed to diabetes but reliable data are scarce for the country and across Central Asia. We assessed the prevalence of impaired glucose tolerance and diabetes and associated predictors among residents aged ≥ 45 years in two districts in southern Tajikistan.

METHODS

A population-representative survey following the WHO STEPwise approach to surveillance and including a two-stage cluster sampling was conducted. Enrolled participants were asked about risk factors for diabetes, and blood pressure, height and weight were measured. The blood glucose level was determined after overnight fasting, and the 2 h oral glucose tolerance test was performed if indicated.

RESULTS

Complete datasets were available for 584 out of 672 study participants. One third of the cohort was male and half were 45-54 years old. Overall, 21.2% of the participants were found to be diabetic, 5.1% had impaired glucose tolerance and 4.3% impaired fasting glucose. An elevated body mass index ≥ 25 was observed in 61.5% of the cohort and an elevated blood pressure in 45.6% (systolic, cut-off 140 mm Hg) and 52.3% (diastolic, cut-off 90 mm Hg) respectively. Half of the participants classified as diabetic were aware of their status.

CONCLUSIONS

Impaired glucose tolerance and overweight are common among elderly residents of southern Tajikistan. Primary health care services should be strengthened to improve early detection and ensure adequate treatment of diabetes and quality of care. Community-based awareness rising about available peripheral services is crucial.

Therapeutic Use of Metformin in Prediabetes and Diabetes Prevention

People with elevated, non-diabetic, levels of blood glucose are at risk of progressing to clinical type 2 diabetes and are commonly termed 'prediabetic'. The term prediabetes usually refers to high-normal fasting plasma glucose (impaired fasting glucose) and/or plasma glucose 2 h following a 75 g oral glucose tolerance test (impaired glucose tolerance). Current US guidelines consider high-normal HbA1c to also represent a prediabetic state. Individuals with prediabetic levels of dysglycaemia are already at elevated risk of damage to the microvasculature and macrovasculature, resembling the long-term complications of diabetes. Halting or reversing the progressive decline in insulin sensitivity and β-cell function holds the key to achieving prevention of type 2 diabetes in at-risk subjects. Lifestyle interventions aimed at inducing weight loss, pharmacologic treatments (metformin, thiazolidinediones, acarbose, basal insulin and drugs for weight loss) and bariatric surgery have all been shown to reduce the risk of progression to type 2 diabetes in prediabetic subjects. However, lifestyle interventions are difficult for patients to maintain and the weight loss achieved tends to be regained over time. Metformin enhances the action of insulin in liver and skeletal muscle, and its efficacy for delaying or preventing the onset of diabetes has been proven in large, well-designed, randomised trials, such as the Diabetes Prevention Program and other studies. Decades of clinical use have demonstrated that metformin is generally well-tolerated and safe. We have reviewed in detail the evidence base supporting the therapeutic use of metformin for diabetes prevention.

Increased cardiovascular disease, resource use, and costs before the clinical diagnosis of diabetes in veterans in the southeastern U.S

IMPORTANCE

Screening for diabetes might be more widespread if adverse associations with cardiovascular disease (CVD), resource use, and costs were known to occur earlier than conventional clinical diagnosis.

OBJECTIVE

The purpose of this study was to determine whether adverse effects associated with diabetes begin prior to clinical diagnosis.

DESIGN

Veterans with diabetes were matched 1:2 with controls by follow-up, age, race/ethnicity, gender, and VA facility. CVD was obtained from ICD-9 codes, and resource use and costs from VA datasets.

SETTING

VA facilities in SC, GA, and AL.

PARTICIPANTS

Patients with and without diagnosed diabetes.

MAIN OUTCOME MEASURES

Diagnosed CVD, resource use, and costs.

RESULTS

In this study, the 2,062 diabetic patients and 4,124 controls were 63 years old on average, 99 % male, and 29 % black; BMI was 30.8 in diabetic patients vs. 27.8 in controls (p<0.001). CVD prevalence was higher and there were more outpatient visits in Year -4 before diagnosis through Year +4 after diagnosis among diabetic vs. control patients (all p<0.01); in Year -2, CVD prevalence was 31 % vs. 24 %, and outpatient visits were 22 vs. 19 per year, respectively. Total VA costs/year/veteran were higher in diabetic than control patients from Year -4 ($4,083 vs. $2,754) through Year +5 ($8,347 vs. $5,700) (p<0.003) for each, reflecting underlying increases in outpatient, inpatient, and pharmacy costs (p<0.05 for each). Regression analysis showed that diabetes contributed an average of $1,748/year to costs, independent of CVD (p<0.001).

CONCLUSIONS AND RELEVANCE

VA costs per veteran are higher--over $1,000/year before and $2,000/year after diagnosis of diabetes--due to underlying increases in outpatient, inpatient, and pharmacy costs, greater number of outpatient visits, and increased CVD. Moreover, adverse associations with veterans' health and the VA healthcare system occur early in the natural history of the disease, several years before diabetes is diagnosed. Since adverse associations begin before diabetes is recognized, greater consideration should be given to systematic screening in order to permit earlier detection and initiation of preventive management. Keeping frequency of CVD and marginal costs in line with those of patients before diabetes is currently diagnosed has the potential to save up to $2 billion a year.

Diabetes in older people: new insights and remaining challenges

Diabetes in ageing communities imposes a substantial personal and public health burden by virtue of its high prevalence, its capacity to cause disabling vascular complications, the emergence of new non-vascular complications, and the effects of frailty. In this Review, we examine the current state of knowledge about diabetes in older people (aged ≥ 75 years) and discuss how recognition of the effect of frailty and disability is beginning to lead to new management approaches. A multidimensional and multidisciplinary assessment process is essential to obtain information on medical, psychosocial, and functional capabilities, and also on how impairments of these functions could limit activities. Major aims of diabetes care include maintenance of independence, functional status, and quality of life by reduction of symptom and medicine burden, and active identification of risks. Linking of therapeutic targets to individual functional status is mandatory and very tight glucose control is often not necessary. Hypoglycaemia remains an important avoidable iatrogenic event. Quality diabetes care in older people remains an important challenge for health professionals.

Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States

OBJECTIVE

Preconception care for women with diabetes can reduce the occurrence of adverse birth outcomes. We aimed to estimate the preconception care (PCC)-preventable health and cost burden of adverse birth outcomes associated with diagnosed and undiagnosed pregestational diabetes mellitus (PGDM) in the United States.

STUDY DESIGN

Among women of reproductive age (15-44 years), we estimated age- and race/ethnicity-specific prevalence of diagnosed and undiagnosed diabetes. We applied age and race/ethnicity-specific pregnancy rates, estimates of the risk reduction from PCC for 3 adverse birth outcomes (preterm birth, major birth defects, and perinatal mortality), and lifetime medical and lost productivity costs for children with those outcomes. Using a probabilistic model, we estimated the reduction in adverse birth outcomes and costs associated with universal PCC compared with no PCC among women with PGDM. We did not assess maternal outcomes and associated costs.

RESULTS

We estimated 2.2% of US births are to women with PGDM. Among women with diagnosed diabetes, universal PCC might avert 8397 (90% prediction interval [PI], 5252-11,449) preterm deliveries, 3725 (90% PI, 3259-4126) birth defects, and 1872 (90% PI, 1239-2415) perinatal deaths annually. Associated discounted lifetime costs averted for the affected cohort of children could be as high as $4.3 billion (90% PI, 3.4-5.1 billion) (2012 US dollars). PCC among women with undiagnosed diabetes could yield an additional $1.2 billion (90% PI, 951 million-1.4 billion) in averted cost.

CONCLUSION

Results suggest a substantial health and cost burden associated with PGDM that could be prevented by universal PCC, which might offset the cost of providing such care.

We can change the natural history of type 2 diabetes

As diabetes develops, we currently waste the first ∼10 years of the natural history. If we found prediabetes and early diabetes when they first presented and treated them more effectively, we could prevent or delay the progression of hyperglycemia and the development of complications. Evidence for this comes from trials where lifestyle change and/or glucose-lowering medications decreased progression from prediabetes to diabetes. After withdrawal of these interventions, there was no "catch-up"-cumulative development of diabetes in the previously treated groups remained less than in control subjects. Moreover, achieving normal glucose levels even transiently during the trials was associated with a substantial reduction in subsequent development of diabetes. These findings indicate that we can change the natural history through routine screening to find prediabetes and early diabetes, combined with management aimed to keep glucose levels as close to normal as possible, without hypoglycemia. We should also test the hypothesis with a randomized controlled trial.

Antihypertensive drug class interactions and risk for incident diabetes: a nested case-control study

BACKGROUND

We aimed to determine how single and combination antihypertensive therapy alters risk for diabetes mellitus (DM).Thiazide diuretics (TD), β blockers (BB), and renin-angiotensin system blockers (RASB) impact DM risk while calcium channel blockers (CCB) are neutral. DM risk associated with combinations is unclear.

METHODS AND RESULTS

We enrolled nondiabetic patients from Kaiser Permanente Northwest with a fasting plasma glucose (FPG) <126 mg/dL between 1997 and 2010. DM cases were defined by a FPG ≥ 126 mg/dL, random plasma glucose ≥ 200 mg/dL, HbA1c ≥ 7.0%, or new DM prescription (index date). We used incidence density sampling to match 10 controls per case on the date of follow-up glucose test (to reduce detection bias), in addition to age and date of cohort entry. Exposure to antihypertensive class was assessed during the 30 days prior to index date. Our cohort contained 134 967 patients and had 412 604 glucose tests eligible for matching. A total of 9097 DM cases were matched to 90 495 controls (median age 51 years). Exposure to TD (OR 1.54, 95% CI 1.41 to 1.68) or BB (OR 1.19, 95% CI 1.11 to 1.28) was associated with an increased DM risk, while CCB and RASB exposure was not. TD+BB combination resulted in the fully combined diabetogenic risk of both agents (OR 1.99, 95% CI 1.80 to 2.20; interaction OR 1.09, 95% CI 0.97 to 1.22). In contrast, combination of RASB with either TD or BB showed significant negative interactions, resulting in a smaller DM risk than TD or BB monotherapy.

CONCLUSIONS

Diabetogenic potential of combination therapy should be considered when prescribing antihypertensive therapy.