Temporal trends in BMI among adults with diabetes

Nicotinamide riboside kinase 1 protects against diet and age-induced pancreatic β-cell failure

OBJECTIVE

Disturbances in NAD⁺ metabolism have been described as a hallmark for multiple metabolic and age-related diseases, including type 2 diabetes. While alterations in pancreatic β-cell function are critical determinants of whole-body glucose homeostasis, the role of NAD⁺ metabolism in the endocrine pancreas remains poorly explored. Here, we aimed to evaluate the role of nicotinamide riboside (NR) metabolism in maintaining NAD⁺ levels and pancreatic β-cell function in pathophysiological conditions.

METHODS

Whole body and pancreatic β-cell-specific NRK1 knockout (KO) mice were metabolically phenotyped in situations of high-fat feeding and aging. We also analyzed pancreatic β-cell function, β-cell mass and gene expression.

RESULTS

We first demonstrate that NRK1, the essential enzyme for the utilization of NR, is abundantly expressed in pancreatic β-cells. While NR treatment did not alter glucose-stimulated insulin secretion in pancreatic islets from young healthy mice, NRK1 knockout mice displayed glucose intolerance and compromised β-cells response to a glucose challenge upon high-fat feeding or aging. Interestingly, β cell dysfunction stemmed from the functional failure of other organs, such as liver and kidney, and the associated changes in circulating peptides and hormones, as mice lacking NRK1 exclusively in β-cells did not show altered glucose homeostasis.

CONCLUSIONS

This work unveils a new physiological role for NR metabolism in the maintenance of glucose tolerance and pancreatic β-cell function in high-fat feeding or aging conditions.

Trends in HbA1c and Body Mass Index Among Individuals with Type 2 Diabetes: Evidence from a US Database 2012-2019

INTRODUCTION

Given the high rates of obesity and poor glycemic control among individuals with type 2 diabetes (T2D), this study examines current trends in HbA1c and body mass index (BMI) as well as the association between HbA1c and BMI among adults with T2D.

METHODS

Data from the IBM® MarketScan® Explorys® Claims-EMR Data were used to construct eight annual cohorts for the years 2012-2019. Each annual cohort included adults identified with T2D who had at least one recorded HbA1c laboratory result and BMI value in the year of interest. Given these cohorts, trends in HbA1c and BMI were described over time using generalized estimating equation (GEE) tests.

RESULTS

Results indicate that, over the study period from 2012-2019, average BMI increased significantly and there was a decrease in the percentage of adults with T2D who achieved glycemic control. In addition, for all years, higher BMI classification was associated with higher HbA1c values. When examining results for patients in different age groups, the findings were generally consistent with the overall population. In each age group, but most notably the age 18-44 group, the mean BMI increased over time and higher BMI was associated with higher HbA1c.

CONCLUSION

Given the increase in BMI and decreasing percentage of individuals achieving glycemic control among adults with T2D found over the study period, therapies which decrease BMI as well as HbA1c can potentially have a significant impact on the management of T2D. The growing proportion of the younger age group with higher mean BMI may remain a key subgroup of interest.

The Double Whammy of Obesity and Diabetes on Female Reproductive Health

The rising global prevalence of obesity and diabetes, especially in youth, confers substantial metabolic consequences and increased mortality in affected individuals. While obesity is strongly tied to the development of insulin resistance and type 2 diabetes, emerging evidence shows that obesity rates are also increasing exponentially in those with type 1 diabetes, contributing to insulin resistance and cardiometabolic sequelae. In addition, both obesity and diabetes can exert adverse effects on female reproductive health independently, with the presence of both conditions likely to exacerbate reproductive dysfunction in this cohort. If the current trends in obesity and diabetes incidence persist, it is likely that more women will be at risk of obesity- and diabetes-related reproductive disorders. This review aims to describe the epidemiology and mechanisms of obesity in women with diabetes, and summarize current literature regarding reproductive disorders in diabetes and weight management strategies in this cohort.

Nutraceutical characteristics of the brown seaweed carotenoid fucoxanthin

Fucoxanthin (Fx), a major carotenoid found in brown seaweed, is known to show a unique and wide variety of biological activities. Upon absorption, Fx is metabolized to fucoxanthinol and amarouciaxanthin, and these metabolites mainly accumulate in visceral white adipose tissue (WAT). As seen in other carotenoids, Fx can quench singlet oxygen and scavenge a wide range of free radicals. The antioxidant activity is related to the neuroprotective, photoprotective, and hepatoprotective effects of Fx. Fx is also reported to show anti-cancer activity through the regulation of several biomolecules and signaling pathways that are involved in either cell cycle arrest, apoptosis, or metastasis suppression. Among the biological activities of Fx, anti-obesity is the most well-studied and most promising effect. This effect is primarily based on the upregulation of thermogenesis by uncoupling protein 1 expression and the increase in the metabolic rate induced by mitochondrial activation. In addition, Fx shows anti-diabetic effects by improving insulin resistance and promoting glucose utilization in skeletal muscle.

Diet quality trends among adults with diabetes by socioeconomic status in the U.S.: 1999-2014

BACKGROUND

The diet quality of adults living in the United States has improved overtime. We aim to determine whether diet quality among adults with diabetes mellitus has changed over time, and to examine trends in socioeconomic disparities in diet quality.

METHODS

Repeated cross-sectional analysis of eight National Health and Nutrition Examination Survey (NHANES) cycles (1999-2000 through 2013-2014). We included 5882 adult participants (age 20 or older) with diabetes mellitus (type 1 or 2) who completed 24-h dietary recalls. Diet quality was measured by the Healthy Eating Index 2010 (HEI) score (range 0-100, higher scores indicate better diet quality). We tested whether there were differences in diet quality across education, income, and food security categories, and whether any differences changed over time, using weighted linear regression models accounting for the complex survey design and adjusted for age, gender, and race/ethnicity.

RESULTS

Twenty nine percent of US adults with diabetes had less than a high school diploma, 17% had income < 100% of federal poverty level, and 15% reported food insecurity. Average adjusted HEI score increased from 49.4 to 52.4 over the study period (p for trend = 0.003). We observed differences in HEI between high and low education (4.1, 95% CI 3.0-5.3), high and low income (3.7, 95%CI 2.4-5.0) and food secure relative to food insecure (2.1, 95% CI 0.8-3.3). These differences did not improve over time for education (p = 0.56), income (p = 0.65) or food security (p = 0.39) categories.

CONCLUSIONS

Diet quality for adults with diabetes in the U.S. has improved overall; however, substantial disparities exist and have not improved. A concerted effort to improve diet quality in vulnerable groups may be needed.

Secular trends in the association between obesity and hypertension among adults in the United States, 1999-2014

OBJECTIVE

To examine the secular trends in the association between obesity and hypertension among American adults between 1999 and 2014.

METHODS

Data from the 1999-2014 National Health and Nutrition Examination Survey (eight survey cycles) were used. Obesity was determined from measured body mass index, with hypertension assessed from measured blood pressure and self-reported medication use. Meta-regression was used to examine the linear, quadratic, and cubic trends of the relationship between the observed odds ratio effect sizes (obesity and hypertension) and the NHANES cycles (year) using a random-effects model.

RESULTS

Across the years of 1999 to 2014, there was a significant, positive linear trend (p = .006) in the association between overweight/obesity and hypertension.

CONCLUSION

Our findings suggest that the association between overweight/obesity and hypertension is becoming stronger over time. Continued surveillance of temporal changes associated with obesity and hypertension is necessary to monitor how such changes may underlie changes in the risk for chronic disease.

SIGNIFICANCE OF THE STUDY

This novel study evaluates whether the magnitude of association between obesity and hypertension has changed over the last 15-years.

Elevated blood apelin levels in type 2 diabetes mellitus: A systematic review and meta-analysis

AIMS

Apelin is a circulatory blood peptide acting as a ligand for the orphan G protein-coupled receptor known as APJ. Whether apelin blood levels can affect the pathogenesis of type 2 diabetes mellitus is an open question. In the present study, we aimed to assess the levels of circulatory apelin peptide in the type 2 diabetic subjects using systematic review and meta-analysis under random-effects model and standardized mean difference (SMD) as the effect size. For heterogeneity testing, Q and I²% statistic indices as well as meta-regression were applied.

METHODS

Using specialized biomedical online databases of Pubmed, Pubmed Central, Medline, Google scholar, Scopus and Embase databases without the beginning date restriction until July 2018, the systematic review retrieved nine studies for meta-analysis after fulfilling the inclusion and exclusion criteria.

RESULTS

Analysis of Q and I²% statistic indices as well as meta-regression showed a high heterogeneity in the 16 selected studies (737.578 and 96.475, respectively), thus, the random-effects model was chosen. The primary analysis for the main hypothesis on a total number of 1102 cases and 1078 healthy control subjects found that the weighted pooled SMD for the impact of apelin blood concentration in type 2 diabetes mellitus was as follows: SMD = 2.136 (95% confidence interval, 1.580-2.693). The P-value for the significance of the combined SMD examined by the z-test was 0.000 and thus, it was clearly significant.

CONCLUSIONS

This meta-analysis presents evidence that apelin circulatory levels are higher in type 2 diabetic subjects than normal controls.

Outcomes of One Anastomosis Gastric Bypass in 472 Diabetic Patients

BACKGROUND

The positive impact of Roux-en-Y gastric bypass (RYGB) on metabolic syndrome and glycemic control has been proven in obese patients. One anastomosis gastric bypass (OAGB) is a simple, effective and easy to learn procedure. OAGB provides encouraging results for the treatment of diabetes obese patients, but does it have the ability to be an alternative procedure to RYGB in the treatment of these patients? The aim of this study is to evaluate the outcomes of OAGB on diabetic obese patients at the bariatric centre of our university hospital. By extension, we evaluated the possibility of BMI and the preoperative antidiabetic medication usage to be predictive factors for postoperative diabetes resolution.

METHODS

This is a retrospective single-centre study of 472 diabetic patients who underwent OAGB from November 2009 to December 2015. All patients were followed-up for at least 1 year, and up to 3 years, where available. Weight, HbA1c, and anti-diabetic medications were recorded at baseline, 3, 6, 12, 24 and 36 months.

RESULTS

A total of 472 patients have been followed-up for 1 year and 361 for 3 years. The mean BMI decreased from 46.8 ± 7.2 to 29.5 ± 2.8 kg/m² and HbA1c from 9.6 ± 1.3 to 5.7 ± 1.5% at the 12-month follow-up. At the 3-year follow-up, the mean BMI was 32.1 ± 3.3 and HbA1c mean was 5.8 ± 0.9%. Diabetes remission was achieved by 84.1% of patients.

CONCLUSIONS

OAGB can be an excellent alternative to RYGB for the treatment of diabetes and obesity. Pre-operative medications may be used to predict postoperative diabetes remission, but not BMI.

Croton membranaceus Improves Some Biomarkers of Cardiovascular Disease and Diabetes in Genetic Animal Models

INTRODUCTION

Cardiovascular disease (CVD) accounts for 17.3 million deaths per year globally. In Ghana, CVD accounts for 22.2% of deaths. Croton membranaceus (CM) Mull. Arg. (Euphorbiaceae), a medicinal plant in Ghana is mainly used traditionally for the treatment of benign prostatic hyperplasia and measles. However, some hypoglycaemic and hypotensive effects have recently been reported but not scientifically examined.

AIM

The study aimed at establishing whether Croton membranaceus (CM) used for prostatitis had any effect on CVD markers.

MATERIALS AND METHODS

In experiment 1, lipid profile changes were determined. Twenty four male Spontaneously Hypertensive Rats (SHR) were divided into 4 groups. Low (LD), intermediate (ID) and high dose (HD) groups received 25, 50 and 100 mg/kg b.wt. CM aqueous root extracts (CMARE) for 60 days, respectively, the controls received distilled water. In experiment 2, blood glucose levels (BGL) were determined. 21 db/db mice were divided into 3 groups of 7 mice each alongside db/+ mice (7) (negative control). Groups 1 and 2 received 250 mg/kg b.wt CMARE and metformin, respectively. Group 3 (positive control) and db/+ mice (negative control) received distilled water. Mice were monitored for 15 hours. Data collected were analysed using SPSS version 20.

RESULTS

Hypotriglyceridaemic effect was observed (p=0.005). High Density Lipoprotein cholesterol (HDL) and Low Density Lipoprotein cholesterol (LDL) showed significant increases (p=0.013) and decreases (p=0.003), respectively. A significant CRP reduction was observed for ID and HD groups (p = 0.010, p = 0.011, respectively). BGL was reduced in Metformin and Croton groups (p=0.000; p= 0.006, respectively) after 3 hours.

CONCLUSION

In conclusion, CMARE has positive effects on some CVD biomarkers and a hypoglycaemic effect.

Association between Dioxin and Diabetes Mellitus in an Endemic Area of Exposure in Taiwan: A Population-Based Study

Dioxin has been recognized as an environmental endocrine disruptor, but epidemiology studies of its effects on type 2 diabetes mellitus (DM) found inconsistent results, especially in men. Therefore, we conducted a study in Taiwan to evaluate the association between exposure to dioxin and DM.We recruited participants in an area where the residents were exposed to dioxin released from a factory. Using 20 and 64 pg WHO98-TEQDF/g lipid as the cut-offs, we categorized participants into 3 groups according to the level of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) in the serum. We defined DM as a fasting plasma glucose level more than 126 mg/dl or an existing diagnosis.Of the 2898 participants, 425 patients of DM were identified, and we observed positive associations between dioxin and DM. After adjusting for age and body mass index (BMI), we found that a high serum dioxin level was an independent risk factor for DM (adjusted odds ratio [AOR] associated with 20-63 pg WHO98-TEQDF/g lipid = 2.1, 95% confidence interval [95% CI] 1.5-2.9; AOR for ≥64 pg WHO98-TEQDF/g lipid = 3.2, 95% CI 2.1-4.8). The findings are compatible with those in previous studies of PCDD/Fs. When we stratified the participants by sex, the serum dioxin level remained an independent risk factor for DM in both men and women.Exposure to dioxin is a risk factor for DM, independent of age and BMI in both men and women. Therefore, screening and intervention programs should be considered in endemic areas of exposure to dioxin.

Facing Morbid Obesity: How to Approach It

Obesity is a major public health problem, with a prevalence of 10% to 20% in Western Europe. Morbid obesity, characterized by body mass index >40 kg/m(2), showed an increased prevalence in the last 30 years. Obesity is associated with reduced economic and social opportunities, reduced quality of life, and is a determinant of several "intermediate risk factors," leading to an increased mortality and a loss in life expectancy. The rising prevalence of morbid obesity increased the demand for bariatric surgery, also called "metabolic surgery": after these interventions, there is a decrease in metabolic comorbidities, cardiovascular (CV) risk, and total mortality. In this review, we update the evaluation of morbid obese patients from the physical examination to the metabolic, CV and respiratory assessments in order to correctly stratify the CV risk and provide the best treatment. To obtain these achievements, multidisciplinary work has to be carried out with a team involving several experts with different skills.

Trends in cardiovascular disease risk factors in people with and without diabetes mellitus: a Middle Eastern cohort study

AIMS/HYPOTHESIS

To investigate secular trends in cardiovascular disease (CVD) risk factors during a decade of follow-up in a Middle Eastern cohort, and to compare observed trends between diabetic and non-diabetic populations.

METHODS

In a population of 6181 participants (2622 males and 3559 females), diabetes status and CVD risk factors were evaluated in 4 study phases from 1999-2011. 1045 subjects had type 2 diabetes mellitus at baseline and 5136 participants were diabetes-free. To examine the trends of CVD risk factors, generalized estimation equation models were constructed. The interaction between the diabetes status and each phase of the study was checked in a separate model.

RESULTS

During the follow-up period diabetic females significantly gained better control of their blood pressure, serum low density lipoprotein cholesterol and general and central obesity measures compared to non-diabetic counterparts, although 60% of them had high BP and 64% had high serum LDL-C levels till the end of the study. Diabetic males however, experienced significantly better control on their serum LDL-C and general and central obesity measures compared to their non-diabetic controls; but 24% of them were still smoker, 63% had high BP and 60% had high serum LDL-C levels at the end of the follow-up (all Ps interaction <0.05). Use of lipid-lowering and antihypertensive medications increased consistently in both diabetic and non-diabetic populations.

CONCLUSIONS/INTERPRETATION

Although CVD risk factors have been controlled to some extent among diabetic population in Iran, still high numbers of people with diabetes have uncontrolled CVD risk factors that prompt more attention.

Reduction of specific circulating lymphocyte populations with metabolic risk factors in patients at risk to develop type 2 diabetes

Low-grade inflammation, characterized by increased pro-inflammatory cytokine levels, is present in patients with obesity-linked insulin resistance, hyperglycemia and hyperlipidemia and considered to play a leading role to progression into type 2 diabetes (T2D). In adipose tissue in obese patients and in pancreatic islets in T2D patients cellular inflammation is present. However, the systemic leukocyte compartment and the circulating endothelial/precursor compartment in patients at risk to develop T2D has so far not been analyzed in detail. To address this, peripheral blood cells from a cohort of 20 subjects at risk to develop diabetes with normal to impaired glucose tolerance were analyzed by flow cytometry using a wide range of cellular markers and correlated to known metabolic risk factors for T2D i.e. fasting plasma glucose (FPG), 2 h plasma glucose (2 h PG), HbA1c, body mass index (BMI), homeostasis model assessment of β-cell function (HOMA-B), homeostasis model assessment of insulin sensitivity (HOMA-IS) and fasting insulin (FI). The four highest ranked cell markers for each risk factor were identified by random forest analysis. In the cohort, a significant negative correlation between the number of TLR4⁺ CD4 T cells and increased FPG was demonstrated. Similarly, with increased BMI the frequency of TLR4⁺ B cells was significantly decreased, as was the frequency of IL-21R⁺ CD4 T cells. Unlinked to metabolic risk factors, the frequency of regulatory T cells was reduced and TLR4⁺ CD4 T cells were increased with age. Taken together, in this small cohort of subjects at risk to develop T2D, a modulation of the circulating immune cell pool was demonstrated to correlate with risk factors like FPG and BMI. This may provide novel insights into the inflammatory mechanisms involved in the progression to diabetes in subjects at risk.

Impact of hypertension on the association of BMI with risk and age at onset of type 2 diabetes mellitus: age- and gender-mediated modifications

AIMS

Given that BMI correlates with risk of Type 2 diabetes mellitus (T2DM), and that hypertension is a common comorbid condition, we hypothesize that hypertension augments significantly the impact of obesity on T2DM onset.

METHODS

We obtained data on T2DM in Kuwaiti natives from Kuwait Health Network Registry. We considered 1339 comorbid individuals with onset of hypertension preceding that of T2DM, and 3496 non-hypertensive individuals but with T2DM. Multiple linear regressions, ANOVA tests, and Cox proportional hazards models were used to quantify the impact of hypertension on correlation of BMI with age at onset and risk of T2DM.

RESULTS

Impact of increasing levels of BMI on age at onset ot T2DM is seen augmented in patients diagnosed with hypertension. We find that the slope of the inverse linear relationship between BMI and onset age of T2DM is much steep in hypertensive patients (-0.69, males and -0.39, females) than in non-hypertensive patients (-0.36, males and -0.17, females). The decline in onset age for an unit increase of BMI is two-fold in males than in females. Upon considering BMI as a categorical variable, we find that while the mean onset age of T2DM in hypertensive patients decreases by as much as 5-12 years in every higher BMI categories, significant decrease in non-hypertensive patients exists only when severely obese. Hazard due to hypertension (against the baseline of non-hypertension and normal weight) increases at least two-fold in every obese category. While males have higher hazard due to hypertension in early adulthood, females have higher hazard in late adulthood.

CONCLUSION

Pre-existing condition of hypertension augments the association of BMI with Type 2 diabetes onset in both males and females. The presented results provide health professionals directives on the extent of weight-loss required to delay onset of Type 2 diabetes in hypertensive versus non-hypertensive patients.

Urine bile acids relate to glucose control in patients with type 2 diabetes mellitus and a body mass index below 30 kg/m2

Bile acids are important endocrine signalling molecules, modulating glucose homeostasis through activation of cell surface and nuclear receptors. Bile acid metabolism is altered in type 2 diabetes mellitus; however, whether this is of pathogenic consequence is not fully established. In this study urinary bile acid excretion in individuals with type 2 diabetes and matched healthy volunteers was assessed. Urinary bile acid excretion in type 2 diabetes patients was considered in the context of prevailing glycaemia and the patient body mass index. Urine bile acids were measured by liquid chromatography-tandem mass spectrometry, allowing individual quantification of 15 bile acid species. Urinary bile acid excretion in patients with type 2 diabetes who were normal weight (BMI 18.5-24.9 kg/m2) and overweight (BMI 25-29.9 kg/m2) were elevated compared to healthy normal weight volunteers, both p<0.0001. In obese (BMI ≥ 30 kg/m2) type 2 diabetes patients, urinary bile acid excretion was significantly lower than in the normal and overweight type 2 diabetes groups (both p<0.01). Total bile acid excretion positively correlated with HbA1c in normal (rs=0.85, p=<0.001) and overweight (rs=0.61, p=0.02) but not obese type 2 diabetes patients (rs=-0.08, p=0.73). The glycaemia-associated increases in urine bile acid excretion in normal weight and overweight type 2 diabetes seen in this study may represent compensatory increases in bile acid signalling to maintain glucose homeostasis. As such alterations appear blunted by obesity; further investigation of weight-dependent effects of bile acid signalling on type 2 diabetes pathogenesis is warranted.

Bariatric surgery relieves type 2 diabetes and modulates inflammatory factors and coronary endothelium eNOS/iNOS expression in db/db mice

Overexpression of endothelial nitric oxide synthetase (eNOS)/inducible nitric oxide synthase (iNOS) and inhibition of inflammatory factors can improve vascular function. We hypothesized that bariatric (gastric bypass) surgery could inhibit inflammatory factors and improve the eNOS/iNOS expression of coronary arterioles in the db/db mice. The animals were randomly allocated to the following groups: sham-operated lean mice, lean mice that underwent surgery, sham-operated db/db mice, and db/db mice that underwent surgery (5, 10, 20, and 30 days post-operation). The plasma levels of adiponectin, ghrelin, and IL-6, as well as the protein expression of eNOS/iNOS in coronary arterioles were measured with Western blot. Bariatric surgery decreased body mass and blood glucose levels in db/db mice. Ghrelin receptor and GHS-R1a expression in the hypothalamus were increased in db/db mice, but surgery attenuated GHS-R1a expression. Bariatric surgery elevated plasma concentration and protein expression of adiponectin and ghrelin, and attenuated plasma concentration and protein expression of IL-6. Coronary protein expression of eNOS and SOD2 was lower in the sham-operated db/db mice, and bariatric surgery increased eNOS and SOD2 expression. Gastric bypass surgery upregulates ghrelin and adiponectin expression, and decreases IL-6 expression, which might induce up-regulation of eNOS and SOD2, and down-regulation of iNOS. These interactions could counteract the endothelium dysfunction in type 2 diabetes mellitus.

Risk of type 2 diabetes and cumulative excess weight exposure in the Framingham Offspring Study

AIM

Mid-life obesity is associated with T2D risk. However, less is known about the cumulative effect of obesity during adulthood.

METHODS

Framingham Offspring Study participants who had an examination at 35±2 years and were initially free of T2D were included in this study (N=1026). A cumulative excess weight (CEW) score (year*kg/m²) was calculated until T2D diagnostic or the end of follow-up.

RESULTS

Eighty-four individuals (8.2%) developed T2D over 20±6 years. Mean CEW scores were 118.0±114.6 year*kg/m² in individuals who developed T2D and 30.2±91.4 year*kg/m² in those who did not develop T2D (P<0.01). T2D risk was doubled for each standard deviation increase in the CEW score (OR=1.99 [1.64-2.40]; P<0.001). However, CEW score was only significantly associated with T2D incidence for participants with a baseline BMI <25 kg/m² (OR =2.13 [1.36-3.36]; P<0.001).

CONCLUSIONS

Accumulating weight between the mid-thirties to the mid-fifties increases the risk of developing T2D. However, BMI in mid-thirties remains a stronger predictor of T2D risk.

Bariatric surgery: the challenges with candidate selection, individualizing treatment and clinical outcomes

Obesity is recognized as a global health crisis. Bariatric surgery offers a treatment that can reduce weight, induce remission of obesity-related diseases, and improve the quality of life. In this article, we outline the different options in bariatric surgery and summarize the recommendations for selecting and assessing potential candidates before proceeding to surgery. We present current data on post-surgical outcomes and evaluate the psychosocial and economic effects of bariatric surgery. Finally, we evaluate the complication rates and present recommendations for post-operative care.

Imbalance of angiogenesis in diabetic complications: the mechanisms

Type 2 diabetes mellitus is a complex disease and a chronic health-care problem. Nowadays, because of alteration of lifestyle such as lack of exercise, intake of high fat diet subsequently obesity and aging population, the prevalence of diabetes mellitus is increasing quickly in around the world. The international diabetes federation estimated in 2008, that 246 million adults in worldwide suffered from diabetes mellitus and the prevalence of disease is expected to reach to 380 million by 2025. Although, mainly in management of diabetes focused on hyperglycemia, however, it is documented that abnormalities of angiogenesis may contribute in the pathogenesis of diabetes complications. Angiogenesis is the generation of new blood vessels from pre-existing ones. Normal angiogenesis depends on the intricate balance between angiogenic factors (such as VEGF, FGF₂, TGF-β, angiopoietins) and angiostatic factors (angiostatin, endostatin, thrombospondins). Vascular abnormalities in different tissues including retina and kidney can play a role in pathogenesis of micro-vascular complications of diabetes; also vascular impairment contributes in macrovascular complications e.g., diabetic neuropathy and impaired formation of coronary collaterals. Therefore, identifying of different mechanisms of the diabetic complications can give us an opportunity to prevent and/or treat the following complications and improves quality of life for patients and society. In this review, we studied the mechanisms of angiogenesis in micro-vascular and macro-vascular complications of diabetes mellitus.

Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects

BACKGROUND

Weight loss protects against type 2 diabetes but is hard to maintain with behavioral modification alone. In an analysis of data from a nonrandomized, prospective, controlled study, we examined the effects of bariatric surgery on the prevention of type 2 diabetes.

METHODS

In this analysis, we included 1658 patients who underwent bariatric surgery and 1771 obese matched controls (with matching performed on a group, rather than individual, level). None of the participants had diabetes at baseline. Patients in the bariatric-surgery cohort underwent banding (19%), vertical banded gastroplasty (69%), or gastric bypass (12%); nonrandomized, matched, prospective controls received usual care. Participants were 37 to 60 years of age, and the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) was 34 or more in men and 38 or more in women. This analysis focused on the rate of incident type 2 diabetes, which was a prespecified secondary end point in the main study. At the time of this analysis (January 1, 2012), participants had been followed for up to 15 years. Despite matching, some baseline characteristics differed significantly between the groups; the baseline body weight was higher and risk factors were more pronounced in the bariatric-surgery group than in the control group. At 15 years, 36.2% of the original participants had dropped out of the study, and 30.9% had not yet reached the time for their 15-year follow-up examination.

RESULTS

During the follow-up period, type 2 diabetes developed in 392 participants in the control group and in 110 in the bariatric-surgery group, corresponding to incidence rates of 28.4 cases per 1000 person-years and 6.8 cases per 1000 person-years, respectively (adjusted hazard ratio with bariatric surgery, 0.17; 95% confidence interval, 0.13 to 0.21; P<0.001). The effect of bariatric surgery was influenced by the presence or absence of impaired fasting glucose (P=0.002 for the interaction) but not by BMI (P=0.54). Sensitivity analyses, including end-point imputations, did not change the overall conclusions. The postoperative mortality was 0.2%, and 2.8% of patients who underwent bariatric surgery required reoperation within 90 days owing to complications.

CONCLUSIONS

Bariatric surgery appears to be markedly more efficient than usual care in the prevention of type 2 diabetes in obese persons. (Funded by the Swedish Research Council and others; ClinicalTrials.gov number, NCT01479452.).

Evaluation of efficacy and safety of gabapentin, duloxetine, and pregabalin in patients with painful diabetic peripheral neuropathy

AIM

To compare the efficacy and safety of gabapentin (GBP), duloxetine (DLX), and pregabalin (PGB) in patients with painful diabetic peripheral neuropathy (DPNP).

METHODS

A prospective, randomized, open label, 12-week study was conducted. A total of 152 patients with history of pain attributed to DPNP with a minimum 40-mm score on visual analogue scale (VAS) were randomized to receive GBP, DLX, or PGB. The primary efficacy measure was pain severity as measured on 11 point VAS. Secondary efficacy measures included sleep interference score, Patient Global Impression of Change (PGIC), and Clinical Global Impression of Change (CGIC). Assessment of safety was done by recording the occurrence of adverse drug reactions. Data was analyzed using descriptive statistics, Chi square test, analysis of variance (ANOVA), and repeated measures ANOVA.

RESULTS

Of total 152 patients, 50 patients received GBP, DLX each while 52 received PGB. A significant reduction in pain score (VAS), sleep interference score, PGIC, and CGIC was seen in all the three treatment groups across time (P<0.05) with no statistically significant difference between the groups. There was a significant interaction between the time and treatment groups (P<0.001) for pain score (VAS), sleep interference score, and PGIC. The improvement in pain scores (VAS) and sleep interference score was higher with PGB compared to DLX and GBP. Adverse drug reactions were mild and occurred in 9.2% of all cases.

CONCLUSIONS

Monotherapy with GBP, DLX, or PGB Produced a clinically and subjectively meaningful pain relief in patients with DPNP with onset of pain relief being faster and superior with PGB.

Effects of gastric bypass surgery in patients with type 2 diabetes and only mild obesity

OBJECTIVE

Roux-en-Y gastric bypass (RYGB) ameliorates type 2 diabetes in severely obese patients through mechanisms beyond just weight loss, and it may benefit less obese diabetic patients. We determined the long-term impact of RYGB on patients with diabetes and only class I obesity.

RESEARCH DESIGN AND METHODS

Sixty-six consecutively selected diabetic patients with BMI 30-35 kg/m(2) underwent RYGB in a tertiary-care hospital and were prospectively studied for up to 6 years (median 5 years [range 1-6]), with 100% follow-up. Main outcome measures were safety and the percentage of patients experiencing diabetes remission (HbA(1c) <6.5% without diabetes medication).

RESULTS

Participants had severe, longstanding diabetes, with disease duration 12.5 ± 7.4 years and HbA(1c) 9.7 ± 1.5%, despite insulin and/or oral diabetes medication usage in everyone. For up to 6 years following RYGB, durable diabetes remission occurred in 88% of cases, with glycemic improvement in 11%. Mean HbA(1c) fell from 9.7 ± 1.5 to 5.9 ± 0.1% (P < 0.001), despite diabetes medication cessation in the majority. Weight loss failed to correlate with several measures of improved glucose homeostasis, consistent with weight-independent antidiabetes mechanisms of RYGB. C-peptide responses to glucose increased substantially, suggesting improved β-cell function. There was no mortality, major surgical morbidity, or excessive weight loss. Hypertension and dyslipidemia also improved, yielding 50-84% reductions in predicted 10-year cardiovascular disease risks of fatal and nonfatal coronary heart disease and stroke.

CONCLUSIONS

This is the largest, longest-term study examining RYGB for diabetic patients without severe obesity. RYGB safely and effectively ameliorated diabetes and associated comorbidities, reducing cardiovascular risk, in patients with a BMI of only 30-35 kg/m(2).

Obesity, Diabetes, the Cardiorenal Syndrome, and Risk for Cancer

Numerous epidemiological studies confirm that the prevalence of obesity and the cardiorenal metabolic syndrome (CRS) is extraordinarily high and that the rates have increased dramatically in the last three decades. In addition, epidemiological data demonstrate that obesity, the CRS, and diabetes are inextricably linked and are all associated with an increased incidence of a number of solid tissue cancers. The mechanisms for this association have been examined, including, but not limited to, higher levels of insulin and free levels of insulin-like growth factor and insulin resistance in obesity and the CRS. Mortality, morbidity, and the associated health care costs which are the link between obesity, the CRS, and diabetes are just beginning to be examined. In addition, we review the advantages of implementing lifestyle and surgical changes to modify obesity, lessening the development of the CRS, diabetes, and associated cancers. Epidemiological data regarding the general mechanisms of the pathogenesis of cancers associated with obesity, the CRS, and diabetes (specifically colon, pancreas, esophageal, liver, breast, prostate, thyroid, and renal carcinomas) are reviewed. The mechanisms by which obesity and other components of the CRS contribute to the pathogenesis of these cancers, such as hormone alterations and insulin- and insulin-like growth factor-dependent pathways of tumor pathogenesis, include the attending roles of inflammation and oxidative stress. Emphasis has been placed on obesity as a modifiable risk factor which, when addressed, provides a reduction in the rate of cancer deaths. In a second part to be published in the next issue of this journal, the relationship between diabetes and cancer will be reviewed in detail.

Correlation of renin angiotensin and aldosterone system activity with subcutaneous and visceral adiposity: the framingham heart study

BACKGROUND

Animal studies suggest that local adipocyte-mediated activity of the renin-angiotensin-aldosterone system (RAAS) contributes to circulating levels, and may promote the development of obesity-related hypertension in rodents.

METHODS

We examined relations of systemic RAAS activity, as assessed by circulating plasma renin activity (PRA), serum aldosterone level, and aldosterone:renin ratio (ARR), with specific regional adiposity measures in a large, community-based sample. Third Generation Framingham Heart Study participants underwent multidetector computed tomography assessment of SAT and VAT volumes during Exam 1 (2002 and 2005). PRA and serum aldosterone were measured after approximately 10 minutes of supine rest; results were log-transformed for analysis. Correlation coefficients between log-transformed RAAS measures and adiposity measurements were calculated, adjusted for age and sex. Partial correlations between log-transformed RAAS measures and adiposity measurements were also calculated, adjusted for standard CVD risk factors.

RESULTS

Overall, 992 women and 897 men were analyzed (mean age 40 years; 7% hypertension; 3% diabetes). No associations were observed with SAT (renin r = 0.04, p = 0.1; aldosterone r = -0.01, p = 0.6) or VAT (renin r = 0.03, p = 0.2; aldosterone r = -0.03, p = 0.2). Similar results were observed for ARR, in sex-stratified analyses, and for BMI and waist circumference. Non-significant partial correlations were also observed in models adjusted for standard cardiovascular risk factors.

CONCLUSIONS

Regional adiposity measures were not associated with circulating measures of RAAS activity in this large population-based study. Further studies are required to determine whether adipocyte-derived RAAS components contribute to systemic RAAS activity in humans.

Impact of laparoscopic adjustable gastric banding on type 2 diabetes

Bariatric surgery is becoming an accepted option for obese people with type 2 diabetes. Our aim was to assess the impact of laparoscopic adjustable gastric banding (LAGB) through a systematic review of the literature. Data was sourced from Scopus, MEDLINE and EMBASE published from 2000 through May 2011, and five unpublished studies that were performed by industry for regulatory approval were also included. Studies were selected on the basis that they provide some detail of diabetes status before and after LAGB. There were 35 studies meeting the inclusion criteria. There was considerable heterogeneity in study design, sample size, length of follow-up, attrition rates and classification of diabetes status. Weight loss was progressive over the first 2 years with a weighted average of 47% excess weight loss at 2 years. Remission or improvement in diabetes varied from 53% to 70% over different time periods. Results were broadly consistent, demonstrating clinically relevant improvements in diabetes outcomes with sustained weight loss in obese people with type 2 diabetes following LAGB surgery. However, there were significant shortcomings in the reviewed literature with few high-quality studies, inconsistent reporting of diabetes outcomes and high attrition rates. Long-term studies that address these limitations are needed.

Review of Metabolic Surgery for Type 2 Diabetes in Patients with a BMI < 35 kg/m(2)

Bariatric/metabolic surgery is considered an accepted treatment option for type 2 diabetes mellitus (T2DM) with body mass index (BMI)  ≧  35 kg/m(2). Mounting evidence also shows that metabolic surgery is effective for T2DM with BMI  <  35 kg/m(2). To evaluate current status of metabolic surgery, we reviewed the available clinical studies which described surgical treatment for T2DM with mean BMI  <  35 kg/m(2). 18 studies with 477 patients were identified. 30% of the patients was insulin users. The follow-up period ranged from 6 to 216 months. The weight loss effect was reasonable, not excessive. Mean BMI decreased from 30.4 to 24.8 kg/m(2). Remission of T2DM was achieved in 64.7% of the patients with fasting plasma glucose and glycated hemoglobin approaching slightly above normal range. Clinical T2DM status was an important factor when selecting the eligible candidates for metabolic surgery. Postoperative complication rate of 10.3% with mortality of 0% in the studies has been acceptable. Even though it would be premature at this point to state that metabolic surgery is an accepted treatment option for T2DM with BMI < 35 kg/m(2), it is clear that a high proportion of T2DM patients will derive substantial benefit from metabolic surgery.

Epidemiology and economic impact of obesity and type 2 diabetes

Obesity has become a major public health concern in the United States and the rest of the world. This disease carries significant health risks that encompass several organ systems. Type 2 diabetes mellitus is a major comorbidity of obesity that predisposes patients to significant end-organ damage. The prevalence of obesity and diabetes is increasing worldwide, and the economic impact of these diseases currently assumes a significant portion of health care expenditure. These factors mandate implementation of therapeutic medical and surgical strategies that target prevention and treatment of obesity and its related medical conditions.

Atherogenic dyslipidemia in patients with transient ischemic attack

BACKGROUND AND PURPOSE

There is mounting evidence that atherogenic dyslipidemia (ie, low high-density lipoprotein cholesterol combined with high triglyceride concentrations) is an independent predictor of high cardiovascular risk and possibly of stroke.

METHODS

All patients included in the SOS-TIA cohort underwent an initial standardized evaluation, including medical history, physical examination, routine blood biochemistry, and diagnostic testing, and were followed for 1 year. Lipid profile was evaluated under fasting conditions. Atherogenic dyslipidemia was defined as high-density lipoprotein cholesterol blood concentration ≤ 40 mg/dL and triglycerides ≥ 150 mg/dL.

RESULTS

Among 1471 consecutive patients with transient ischemic attack (TIA) or minor stroke, overall prevalence of atherogenic dyslipidemia was 5.8%, but varied from 4.6% to 11.1%, depending on final diagnosis (possible TIA or TIA with a cerebral ischemic lesion, respectively). Prevalence of atherogenic dyslipidemia was independently associated with male sex, diabetes, and body mass index, but not with ABCD2 score. Atherogenic dyslipidemia also strongly associated with symptomatic intracranial stenosis ≥ 50% (adjusted odds ratio, 2.77; 95% CI, 1.38-5.55), but not with symptomatic extracranial stenosis ≥ 50% (adjusted odds ratio, 1.20; 95% CI, 0.64-2.26). Despite appropriate secondary prevention treatment, 90-day stroke risk was greater in patients with versus without atherogenic dyslipidemia (4.8% versus 1.7%; P=0.04).

CONCLUSIONS

The atherogenic dyslipidemia phenotype in patients with TIA may be associated with intracranial artery stenosis and higher risk of early recurrent stroke. Additional data are needed to confirm these findings and to assess the best way to reduce important residual risk in such patients.

Incidence of diabetes in Asian-Indian subjects: a five year follow-up study from Bangladesh

AIMS

To determine the incidence of Type 2 diabetes and its risk factors. Further, to examine the effect of relative changes in obesity (BMI and waist circumference).

METHODS

A sample of 2011 non-diabetic adults aged 20 and above were randomly selected and followed from 1999 to 2004. Fasting blood glucose including biophysical and anthropometric measures was measured.

RESULTS

The overall 5 year cumulative incidence of diabetes was 16.4 per 1000 person-years and 65.1 per 1000 person-years in those with impaired fasting glucose adjusted for age and sex. Among obesity measures, only waist >85in. increased the risk for diabetes in males (RR=3.0). Relative changes stratified by loss in BMI and WC ≥5% or gain of BMI >15% from the baseline values for men were significantly associated with the incidental cases of diabetes. Increased hip circumference for men was significantly associated with a protective effect while an opposite association was observed for women.

CONCLUSION

Relative change in both loss and excessive gain of BMI were risks for increased diabetes. Targeted intervention in those with impaired fasting blood glucose will expectedly reduce the incidental cases. Further investigations are needed for non obese related diabetes in Asian Indian subjects.

Increasing BMI and waist circumference and prevalence of obesity among adults with Type 2 diabetes: the National Health and Nutrition Examination Surveys

OBJECTIVE

Obesity remains one of the most important modifiable risk factors for the prevention of Type 2 diabetes and its related comorbid conditions. The aim of this study was to examine trends in average body mass index (BMI), waist circumference, and obesity prevalence among adults with and without Type 2 diabetes.

METHODS

Information on BMI and waist circumference among 4162 adults with and 40,376 adults without Type 2 diabetes was obtained from the National Health and Examination Surveys completed during years 1976-2006. Mean BMI, waist circumference and prevalence of total obesity (BMI ≥30 kg/m²) and obesity stage III (BMI ≥40 kg/m²) were determined by survey periods after adjustment for the survey period weights and age standardization to the US 2000 Census. Means and proportions between first and last survey periods were compared using Z scores.

RESULTS

During this 20-year period, mean BMI increased from 29.2 kg/m² to 34.2 kg/m² among adults with Type 2 diabetes and from 25.2 kg/m² to 28.1 kg/m² among adults without diabetes (P<.0001 for both comparisons). Mean waist circumference increased substantially in all groups. Among adults with and without Type 2 diabetes, total obesity increased by 58% and 136%, respectively, while Class III obesity increased by 141% and 345%, respectively (P<.0001 for all comparisons).

CONCLUSIONS

Obesity prevalence is rising rapidly among adults with and without Type 2 diabetes. This has important implications for the likely growth of the population with Type 2 diabetes and diabetes related comorbid conditions.

Morbid obesity in pediatric diabetes mellitus: surgical options and outcomes

The current obesity epidemic has led to a dramatic increase in insulin resistance and type 2 diabetes mellitus among adolescents, along with other obesity-related comorbidities, such as hypertension, hyperlipidemia, obstructive sleep apnea, psychosocial impairment and nonalcoholic fatty liver disease. Medical treatment of severe obesity is effective in only a small percentage of adolescent patients. In light of the potentially life-threatening complications of obesity, bariatric surgery can be considered a treatment option for adolescent patients with morbid obesity. Indications for surgery rely on both BMI and comorbidity criteria, as well as the ability of the adolescents and their family to understand and comply with perioperative protocols. The long-term effects of bariatric surgery in adolescents are not known; therefore, participation in prospective outcome studies is important. The risk associated with bariatric surgery in adolescents seems to be similar to that observed in adult patients in the short term. Data suggest that bypass procedures successfully reverse or improve abnormal glucose metabolism in the majority of patients and may be more effective in adolescents than adults. This improvement in glucose metabolism occurs before marked weight loss in patients undergoing bypass procedures, suggesting a direct effect on the hormonal control of glucose metabolism.

Improving cardiovascular risk reduction for primary prevention--utility of lifetime risk assessment

The objective of this article is to review the evidence basis for short-term risk assessments of overall coronary heart disease (CHD) burden as compared with lifetime risk estimates of CHD, based on the current medical literature. We reviewed literature published in the last 6 years using the terms "cardiovascular prevention," "Framingham risk scoring," "lifetime risk," and "cardiovascular risk assessment," and subsequently evaluated 98 publications to determine the variation in these approaches to estimate cardiovascular risk factors and impact on clinical decision making. The current evidence base suggests that lifetime risk estimates offset the significant impact of age on traditional, short-term risk estimates of cardiovascular risk. We conclude that the use of lifetime risk estimates may be more clinically meaningful than traditional, short-term risk estimates to assess an individual's overall risk burden, and may prevent the potential delay of therapeutic interventions to reduce cardiovascular events. For primary care, this difference may be of relevance to patients and should be communicated to them.

Obesity stigma: a newly recognized barrier to comprehensive and effective type 2 diabetes management

PURPOSE

The purpose of this article is to increase awareness regarding the social problem of obesity stigma and its effects on persons with type 2 diabetes mellitus (T2DM). In addition, practical strategies to dispel stigma and improve diabetes care that nurse practitioners (NPs) can integrate into practice will be introduced.

DATA SOURCES

Thorough review of the literature was conducted including MEDLINE, PsycINFO and CINAHL, spanning the years 1994-2008.

CONCLUSIONS

Obesity and diabetes are both epidemics that demand immediate attention; however, obesity stigma can act as a barrier to ongoing management of both conditions. Obese patients with T2DM may feel responsible not only for their weight but also their diabetes. Therefore, NPs can employ specific counseling strategies that may be beneficial with T2DM obese patients to improve continuity of care while decreasing weight-related stigmatization.

IMPLICATIONS FOR PRACTICE

Negative attitudes toward obesity by healthcare professionals can act as a barrier to diabetes management. Primary care providers including NPs must begin through self-reflection to recognize their own attitudes regarding weight-stigma and how these attitudes may affect their patients. By implementing effective strategies to reduce weight bias, an environment conducive to diabetes and lifestyle modification management may prevent patients from forgoing care.

The effect of obesity on health outcomes

The prevalence of obesity has progressively increased globally over the last 30 years. The determinants of this pandemic are many, poorly defined and priorities debated. While public health measures to prevent obesity have largely failed we are presented with a growing burden of disease and disability. Cardiovascular disease, type-2 diabetes, obesity related cancers, osteoarthritis and psychological disturbance generate much of the morbidity and years of life lost associated with increasing levels of obesity. Obesity has a clearly measurable impact on physical and mental health, health related quality of life, and generates considerable direct and indirect costs. The evolving obesity pandemic is exacting a considerable toll on those affected, the treating health services, and on our communities. Weight loss appears to be the most effective therapy for obesity and obesity related comorbidity. As health care researchers and providers we are likely to play a peripheral role in the prevention of obesity, but a central role in effectively treating those afflicted by the obesity pandemic.

Circadian rhythms of GIP and GLP1 in glucose-tolerant and in type 2 diabetic patients after biliopancreatic diversion

AIMS/HYPOTHESIS

We tested the hypothesis that the reversibility of insulin resistance and diabetes observed after biliopancreatic diversion (BPD) is related to changes in circadian rhythms of gastrointestinal hormones.

METHODS

Ten morbidly obese participants, five with normal glucose tolerance (NGT) and five with type 2 diabetes, were studied before and within 2 weeks after BPD. Within-day variations in glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide 1 (GLP1) levels were assessed using a single cosinor model. Insulin sensitivity was assessed by euglycaemic-hyperinsulinaemic clamp.

RESULTS

Basal GLP1 relative amplitude (amplitude/mesor x 100) was 25.82-4.06% in NGT; it increased to 41.38-4.32% after BPD but was unchanged in diabetic patients. GLP1 and GIP mesor were shifted in time after surgery in diabetic patients but not in NGT participants. After BPD, the GLP1 AUC significantly increased from 775 +/- 94 to 846 +/- 161 pmol l(-1) min in NGT, whereas GIP AUC decreased significantly from 1,373 +/- 565 to 513 +/- 186 pmol l(-1) min in diabetic patients. Two-way ANOVA showed a strong influence of BPD on both GIP (p = 0.010) and GLP1 AUCs (p = 0.033), which was potentiated by the presence of diabetes, particularly for GIP (BPD x diabetes, p = 0.003). Insulin sensitivity was markedly improved (p < 0.01) in NGT (from 9.14 +/- 3.63 to 36.04 +/- 8.55 micromol [kg fat-free mass](-1) min(-1)) and diabetic patients (from 9.49 +/- 3.56 to 38.57 +/- 4.62 micromol [kg fat-free mass](-1) min(-1)).

CONCLUSIONS/INTERPRETATION

An incretin circadian rhythm was shown for the first time in morbid obesity. The effect of BPD on the 24 h pattern of incretin differed between NGT and diabetic patients. GLP1 secretion impairment was reversed in NGT and could not be overcome by surgery in diabetes. On the other hand, GIP secretion was blunted after the operation only in diabetic patients, suggesting a role in insulin resistance and diabetes.

Meta-analysis of duloxetine vs. pregabalin and gabapentin in the treatment of diabetic peripheral neuropathic pain

BACKGROUND

Few direct head-to-head comparisons have been conducted between drugs for the treatment of diabetic peripheral neuropathic pain (DPNP). Approved or recommended drugs in this indication include duloxetine (DLX), pregabalin (PGB), gabapentin (GBP) and amitriptyline (AMT). We conducted an indirect meta-analysis to compare the efficacy and tolerability of DLX with PGB and GBP in DPNP, using placebo as a common comparator.

METHODS

We searched PubMed, EMBASE, CENTRAL databases and regulatory websites for randomized, double-blind, placebo-controlled, parallel group or crossover clinical trials (RCTs) assessing DLX, PGB, GBP and AMT in DPNP. Study arms using approved dosages with assessments after 5-13 weeks were eligible. Efficacy criteria were: reduction in 24-hour pain severity (24 h PS) for all three drugs, and response rate (>or= 50% pain reduction) and Patient Global Impression of Improvement/Change (PGI-I/C) for DLX and PGB only. Tolerability criteria included: discontinuation, diarrhoea, dizziness, headache, nausea and somnolence. Direct comparisons versus placebo were conducted with pooled fixed - and random-effects analyses on endpoints reported in at least two studies of each drug. Indirect comparisons were performed between DLX and each of PGB and GBP using Bayesian simulation.

RESULTS

Three studies of DLX, six of PGB, two of GBP and none of AMT met the inclusion criteria. In random-effects and fixed-effects analyses of DLX, PGB and GBP, all were superior to placebo for all efficacy parameters, with some tolerability trade-offs. Indirect comparison of DLX with PGB found no differences in 24 h PS, but significant differences in PGI-I/C, favouring PGB, and in dizziness, favouring DLX were apparent. Comparing DLX and GBP, there were no statistically significant differences.

CONCLUSION

From the few available studies suitable for indirect comparison, DLX shows comparable efficacy and tolerability to GBP and PGB in DPNP. Duloxetine provides an important treatment option for this disabling condition.

Obesity prevalence in gaziantep, Turkey

BACKGROUND

Obesity is associated with reduced quality of life, development of serious chronic conditions such as heart disease and diabetes, increased medical care costs, and premature death. Environmental effects, especially feeding habits may cause hyperinsulinemia and obesity. A Healthy People 2010 objective is to reduce the proportion of adults who are obese to 15%.

MATERIALS AND METHODS

This cross-sectional study was conducted on 1647 persons in a sample representing Gaziantep, Turkey. Over the selected 329 houses, 310 houses were reached (94.2%) and data about 1315 related persons was collected. The body mass index (BMI) shows the relationship between the weight and the height of people, calculated by the ratio of mass by kg over the square value of height measure. In statistical analyses chi-square, student's t-test and logistic regression analysis were used.

RESULTS

The mean BMI increased with time for both sex, whereas decreased for 60+ age group. The fastest increase for both sex was seen while transition from 18 year to 19-29 age groups occurred. Another increase in women was in 30-39 age group; BMI=25.08+/-4.39 in 19-29 ages whilst BMI=29.02+/-5.79 in 30-39 ages. The increases in both sex in other age groups were not as much as in this group.

CONCLUSION

Obesity is not only a problem in the Gaziantep but is also a major health concern in Europe and other regions of the world. As an accepted method against obesity, life-style changes should be put into use from childhood supported in school and family life.

Characteristics and cardiovascular risk of new cases of type 2 diabetes in Otago, New Zealand, 1998-2004

We compared clinical and metabolic characteristics and estimated cardiovascular risk for 2073 new cases of type 2 diabetes enrolled on the Otago Diabetes Register, 1998-2004 by age at diagnosis (<40 years, 40-59 years, 60-79 years, >79 years). Data were extracted and means or proportions calculated. 5-year cardiovascular risk was estimated using New Zealand risk equation tables. The <40 year age group had the highest proportion of current smokers (27%). Weight, body mass index and diastolic blood pressure decreased significantly with increasing age from 104.2 kg, 35.9 kg/m(2) and 80.5 mmHg, respectively, for the <40 year age group to 71.6 kg, 26.9 kg/m(2) and 76.2 mmHg, respectively, for the > or =80 year age group (p<0.01). The reverse trend was observed for systolic blood pressure. HbA1c and triglycerides were significantly higher and HDL-cholesterol significantly lower in the <40 year age group compared with other groups (p<0.001). Estimated 5-year risk of cardiovascular disease was lower in the young age group when compared with older age groups despite, overall, having the worst array of modifiable clinical risk factors. A new approach to assessment and communication of cardiovascular risk and aggressive treatment of modifiable risk factors is likely to be necessary to prevent potentially serious diabetes complications at a young age.

Overweight, obesity and high waist circumference: regional differences in prevalence in primary medical care

INTRODUCTION

The prevalence of obesity and elevated waist circumference in Germany is high. However, there are insufficient data on the situation in primary care and on regional distribution to support medical preventive measures.

METHODS

The German Metabolic and Cardiovascular Risk Project (GEMCAS) is a national cross-sectional study including 1511 primary care practices and 35 869 patients. Height, weight, waist circumference, laboratory values, and type 2 diabetes were documented.

RESULTS

The crude prevalence of obesity was 23.9% (95% CI 23.4 to 24.3) (standardized 22.8% [95% CI 22.3 to 23.2]), with a minimum in Bremen (19.8% [95% CI 15.1 to 24.5]) and a maximum in Saxony-Anhalt (28.3% [95% CI 25.4 to 31.1]). The crude prevalence of high waist circumference (> 102/88 cm) was 39.5% (95% CI 39.0 to 40.0) (standardized 36.5% [95% CI 36.0 to 36.9]), with a minimum in Hamburg (30.5% [95% CI 26.2 to 34.8]) and a maximum in Saxony-Anhalt (42.1% [95% CI 39.2 to 45.1]). The prevalence of obesity as assessed by BMI was higher in men than in women, but greater in women as assessed by waist circumference. Nationwide, 50 out of every 100 patients with obesity had type 2 diabetes, and 32 of 100 patients with a high waist circumference had type 2 diabetes.

CONCLUSIONS

The prevalence of obesity is higher in northeastern Germany than in the southwest. Overall, abdominal obesity is considerably more frequent than obesity based on BMI. Surprisingly, a high prevalence of obesity in some federal states does not automatically mean a higher number of people with type 2 diabetes.