The prevention or delay of type 2 diabetes

Use of Focus Groups to Inform a New Community-Based Youth Diabetes Prevention Program

There have been few youth-led diabetes prevention programs. Our objective was to conduct focus groups to explore peer influences on adolescent lifestyle behaviors and strategies for implementing a youth peer education model for diabetes prevention. We conducted six focus groups with 52 youth (ages 13-22; 62% male, 38% female; 64% Hispanic, 36% non-Hispanic Black) from East Harlem, NYC. We used a Thematic Analysis approach to identify major themes, compared findings, and resolved differences through discussion and consensus. Three dominant themes arose: (1) Adolescents generally encounter more unhealthy peer influences on diet and more healthy peer influences on physical activity; (2) Adolescents endorse youth-led diabetes prevention strategies and describe ideal qualities for peer leaders and methods to support and evaluate leaders; (3) Adolescents prefer text messaging to monitor behaviors, track goals, and receive personalized guidance. Using study findings, our Community Action Board developed a peer-led diabetes prevention program for prediabetic adolescents.

Prebiotics as a Tool for the Prevention and Treatment of Obesity and Diabetes: Classification and Ability to Modulate the Gut Microbiota

Diabetes and obesity are metabolic diseases that have become alarming conditions in recent decades. Their rate of increase is becoming a growing concern worldwide. Recent studies have established that the composition and dysfunction of the gut microbiota are associated with the development of diabetes. For this reason, strategies such as the use of prebiotics to improve intestinal microbial structure and function have become popular. Consumption of prebiotics for modulating the gut microbiota results in the production of microbial metabolites such as short-chain fatty acids that play essential roles in reducing blood glucose levels, mitigating insulin resistance, reducing inflammation, and promoting the secretion of glucagon-like peptide 1 in the host, and this accounts for the observed remission of metabolic diseases. Prebiotics can be either naturally extracted from non-digestible carbohydrate materials or synthetically produced. In this review, we discussed current findings on how the gut microbiota and microbial metabolites may influence host metabolism to promote health. We provided evidence from various studies that show the ability of prebiotic consumption to alter gut microbial profile, improve gut microbial metabolism and functions, and improve host physiology to alleviate diabetes and obesity. We conclude among other things that the application of systems biology coupled with bioinformatics could be essential in ascertaining the exact mechanisms behind the prebiotic–gut microbe–host interactions required for diabetes and obesity improvement.

Administration of Jerusalem artichoke reduces the postprandial plasma glucose and glucose-dependent insulinotropic polypeptide (GIP) concentrations in humans

Background

The consumption of Jerusalem artichoke has multiple beneficial effects against diabetes and obesity.

Objective

The aim of this study was to determine the effect of a single administration of Jerusalem artichoke tubers on postprandial glycemia and the concentrations of incretin hormones in humans.

Method

Grated Jerusalem artichoke was administered prior to a meal (Trial 1; white rice for prediabetic participants, n = 10). Dose-dependent effect of Jerusalem artichoke (Trial 2; white rice for prediabetic participants, n = 4) and effect prior to the fat-rich meal were also investigated (Trial 3; healthy participants, n = 5) in this pilot study. Circulating glucose, insulin, triglyceride, glucagon, active glucagon-like peptide-1 (GLP-1), and active glucose-dependent insulinotropic polypeptide (GIP) concentrations were subsequently measured in all the trials.

Results

Jerusalem artichoke significantly reduced the glucose and GIP concentrations after the consumption of either meal in Trial 1 and Trial 3, whereas there were no differences in the insulin, glucagon, and active GLP-1 concentrations. Also, there was no significant difference in the triglyceride concentration after the ingestion of the fat-rich meal in Trial 3. The glucose and GIP-lowering effects were dose-dependent, and the consumption of at least 100 g of Jerusalem artichoke was required to have these effects in Trial 2.

Conclusion

This study demonstrates that a single administration of Jerusalem artichoke tubers reduces postprandial glucose and active GIP concentrations in prediabetic and healthy individuals.

Evidence generation, decision making, and consequent growth in health disparities

Evidence is valuable because it informs decisions to produce better outcomes. However, the same evidence that is complete for some individuals or groups may be incomplete for others, leading to inefficiencies in decision making and growth in disparities in outcomes. Specifically, the presence of treatment effect heterogeneity across some measure of baseline risk, and noisy information about such heterogeneity, can induce self-selection into randomized clinical trials (RCTs) by patients with distributions of baseline risk different from that of the target population. Consequently, average results from RCTs can disproportionately affect the treatment choices of patients with different baseline risks. Using economic models for these sequential processes of RCT enrollment, information generation, and the resulting treatment choice decisions, we show that the dynamic consequences of such information flow and behaviors may lead to growth in disparities in health outcomes across racial and ethnic categories. These disparities arise due to either the differential distribution of risk across those categories at the time RCT results are reported or the different rate of change of baseline risk over time across race and ethnicity, even though the distribution of risk within the RCT matched that of the target population when the RCT was conducted. We provide evidence on how these phenomena may have contributed to the growth in racial disparity in diabetes incidence.

Data on diabetes from the French cohort study in schizophrenia

To establish the impact of antipsychotic medication on the incidence of diabetes, we have analysed data from the prospective French Cohort study of mortality in schizophrenia. This generated a large database of 3470 patients with schizophrenia initially enrolled in 1993 for which data collection on comorbidity has been collected systematically every three years since. The primary objective of the study was to evaluate the mortality rate in the study cohort. From this database, the prevalence and incidence of diabetes can be studied. In 1993, nine patients in 10 were prescribed conventional antipsychotics and the remainder amisulpride and clozapine. Since the introduction of risperidone and olanzapine, atypical antipsychotics are now used in one-third of patients. Multiple antipsychotic medications are used in many patients, with the exception of those receiving clozapine. At inclusion, 2.2% of patients in the study cohort had a diagnosis of diabetes. Morbidity rates were higher in females than in males (3.4% and 1.6%, respectively) and it was only in females that the standard morbidity ratio with respect to the general population was significantly elevated (2.2; 95% confidence intervals: 1.6 and 2.9). The prevalence of diabetes in the study cohort rose over the course of the study. Multivariate regression analysis was performed in order to identify potential determinants of diabetes. For pre-existing diabetes, four factors were identified: age at first hospitalisation, age, obesity and duration of schizophrenia. The same factors with the exception of length of illness were identified for the incident cases. There was no evidence for an interaction between the class and type of antipsychotic medication and risk of treatment emergent diabetes. However, the use of multiple antipsychotic treatments makes the individualisation of specific risks associated with any other antipsychotic drug impossible.

Importance and Potential of Dentists in Identifying Patients at High Risk of Diabetes

OBJECTIVES

The study was conducted to assess the utilization of medical and dental services by dental patients at two dental school hospitals and to approximate the number of patients having no known previous diagnosis of type 2 diabetes but are at high risk of acquiring it.

METHODS

A cross-sectional study was conducted at two dental school hospitals in India. A 20-item questionnaire was administered as interviews among the dental patients aged 35 to 55 years. Data was collected on past dental and medical visits, medical history, family history relevant to diabetes, cardiovascular health, BMI and waist circumference (measured).

RESULTS

A total of 413 adult patients (males 61.26%, females 38.74%) participated in the surveys. The mean age was 43.06 years. Results revealed that nearly 50% did not have a medical or a dental visit in the last 1 year, 33% had Cardiovascular Diseases (CVD). Among those who did not have medical visit in last one year 45% had BMI >25 kg, 55% had waist circumference above the normal range and 38% were at high risk of diabetes.

CONCLUSION

The high number of patients without a medical visit in the past year or more, as well as the high levels of diabetes risk indicators, affirms the need for dentists to perform chair-side screenings for diabetes. These results suggest the need for additional training among dental students to improve early detection and identification of high-risk patients to minimize potential morbidity due to diabetes.

Issues in Defining the Burden of Prediabetes Globally

PURPOSE OF REVIEW

Using a global perspective, this review collates evidence on the heterogeneity of prediabetes definitions and diagnostic methods, their clinical and public health implications, and discusses possible options for improvement.

RECENT FINDINGS

Our review notes that the concept of prediabetes is increasingly recognized worldwide, but against a background of non-uniform definition and diagnostic criteria. This results in widely varying burden estimation. Current evidence shows a variety of prediabetes phenotypes. This reflects biological and diagnostic heterogeneity, resulting from the use of different tests (glucose or HbA_1C) and thresholds to define prediabetes. The biological and diagnostic variabilities have implications for the characterization of the burden of prediabetes, natural history, prognosis, screening, implementation of lifestyle or drug interventions to mitigate related health risks, and monitoring of the effects of such interventions.

Hypertensive disorders during pregnancy and 3 years after delivery in women with gestational hyperglycemia

AIMS

Women with gestational hyperglycemia commonly experience hypertensive disorders during pregnancy. More information is needed about how hypertension develops in these patients over time. We investigated the prevalence of hypertension during and 3 years after pregnancy in Caucasian women with gestational hyperglycemia. We also investigated metabolic syndrome presence, glucose tolerance status, insulin sensitivity and insulin secretion levels in the follow-up period.

METHODS

In a prospective longitudinal study with a 3-year follow-up, we assessed hypertension status and clinical-related characteristics of 103 consecutive women with gestational hyperglycemia sub-grouped according to their hypertensive status during and after pregnancy.

RESULTS

Overall, 29 (28.1%) women had hypertension during pregnancy (24 gestational hypertension; 4 chronic hypertension; 1 preeclampsia). At follow-up 16 (15.5%) women were diagnosed as having hypertension (11 with hypertension in pregnancy; 5 with a normotensive pregnancy). Women with hypertension after pregnancy had higher BMI, metabolic syndrome rate and worse insulin resistance indexes than normotensive women. Weight increase at follow-up (OR 1.17, 95% CI 1.00-1.35) and hypertension in pregnancy (OR 6.72, 95% CI 1.17-38.64) were associated with hypertension after pregnancy.

CONCLUSIONS

Women with gestational hyperglycemia should undergo regular monitoring during and after pregnancy to detect metabolic and clinical impairments and to prevent cardiovascular harm.

Benefits of Nut Consumption on Insulin Resistance and Cardiovascular Risk Factors: Multiple Potential Mechanisms of Actions

Epidemiological and clinical studies have indicated that nut consumption could be a healthy dietary strategy to prevent and treat type 2 diabetes (T2DM) and related cardiovascular disease (CVD). The objective of this review is to examine the potential mechanisms of action of nuts addressing effects on glycemic control, weight management, energy balance, appetite, gut microbiota modification, lipid metabolism, oxidative stress, inflammation, endothelial function and blood pressure with a focus on data from both animal and human studies. The favourable effects of nuts could be explained by the unique nutrient composition and bioactive compounds in nuts. Unsaturated fatty acids (monounsaturated fatty acids and polyunsaturated fatty acids) present in nuts may play a role in glucose control and appetite suppression. Fiber and polyphenols in nuts may also have an anti-diabetic effect by altering gut microbiota. Nuts lower serum cholesterol by reduced cholesterol absorption, inhibition of HMG-CoA reductase and increased bile acid production by stimulation of 7-α hydroxylase. Arginine and magnesium improve inflammation, oxidative stress, endothelial function and blood pressure. In conclusion, nuts contain compounds that favourably influence glucose homeostasis, weight control and vascular health. Further investigations are required to identify the most important mechanisms by which nuts decrease the risk of T2DM and CVD.

Probiotics, prebiotics, synbiotics and insulin sensitivity

Animal studies indicate that the composition of gut microbiota may be involved in the progression of insulin resistance to type 2 diabetes. Probiotics and/or prebiotics could be a promising approach to improve insulin sensitivity by favourably modifying the composition of the gut microbial community, reducing intestinal endotoxin concentrations and decreasing energy harvest. The aim of the present review was to investigate the effects of probiotics, prebiotics and synbiotics (a combination of probiotics and prebiotics) on insulin resistance in human clinical trials and to discuss the potential mechanisms whereby probiotics and prebiotics improve glucose metabolism. The anti-diabetic effects of probiotics include reducing pro-inflammatory cytokines via a NF-κB pathway, reduced intestinal permeability, and lowered oxidative stress. SCFA play a key role in glucose homeostasis through multiple potential mechanisms of action. Activation of G-protein-coupled receptors on L-cells by SCFA promotes the release of glucagon-like peptide-1 and peptide YY resulting in increased insulin and decreased glucagon secretion, and suppressed appetite. SCFA can decrease intestinal permeability and decrease circulating endotoxins, lowering inflammation and oxidative stress. SCFA may also have anti-lipolytic activities in adipocytes and improve insulin sensitivity via GLUT4 through the up-regulation of 5'-AMP-activated protein kinase signalling in muscle and liver tissues. Resistant starch and synbiotics appear to have favourable anti-diabetic effects. However, there are few human interventions. Further well-designed human clinical studies are required to develop recommendations for the prevention of type 2 diabetes with pro- and prebiotics.

Diabetes in Asia and the Pacific: Implications for the Global Epidemic

The last three decades have witnessed an epidemic rise in the number of people with diabetes, especially type 2 diabetes, and particularly in developing countries, where more than 80% of the people with diabetes live. The rise of type 2 diabetes in South Asia is estimated to be more than 150% between 2000 and 2035. Although aging, urbanization, and associated lifestyle changes are the major determinants for the rapid increase, an adverse intrauterine environment and the resulting epigenetic changes could also contribute in many developing countries. The International Diabetes Federation estimated that there were 382 million people with diabetes in 2013, a number surpassing its earlier predictions. More than 60% of the people with diabetes live in Asia, with almost one-half in China and India combined. The Western Pacific, the world's most populous region, has more than 138.2 million people with diabetes, and the number may rise to 201.8 million by 2035. The scenario poses huge social and economic problems to most nations in the region and could impede national and, indeed, global development. More action is required to understand the drivers of the epidemic to provide a rationale for prevention strategies to address the rising global public health "tsunami." Unless drastic steps are taken through national prevention programs to curb the escalating trends in all of the countries, the social, economic, and health care challenges are likely to be insurmountable.

A review of potential metabolic etiologies of the observed association between red meat consumption and development of type 2 diabetes mellitus

Epidemiological studies suggest that red and processed meat consumption is related to an increased risk of type 2 diabetes. However, it is not clearly understood which components of red and processed meat contribute to this increased risk. This review examines potential mechanisms addressing the role of saturated fatty acid, sodium, advanced glycation end products (AGEs), nitrates/nitrites, heme iron, trimethylamine N-oxide (TMAO), branched amino acids (BCAAs) and endocrine disruptor chemicals (EDCs) in the development of type 2 diabetes based on data from published clinical trials and animal models. TMAO which is derived from dietary carnitine and choline by the action of bacterial enzymes followed by oxidation in the liver may be a strong candidate molecule mediating the risk of type 2 diabetes. BCAAs may induce insulin resistance via the mammalian target of rapamycin complex 1 (mTORC1) and ribosomal protein S6 kinase β 1 (S6k1)-associated pathways. The increased risk associated with processed meat compared with red meat suggests that there are interactions between the saturated fat, salt, and nitrates in processed meat and iron, AGEs and TMAO. Intervention studies are required to clarify potential mechanisms and explore interactions among components, in order to make firm recommendations on red and processed meat consumption.

Treating the metabolic syndrome

The metabolic syndrome (MS), a cluster of metabolic abnormalities with insulin resistance as its central component, is increasing in prevalence and is associated with an increased risk of cardiovascular disease and Type 2 diabetes mellitus (T2DM). Current evidence supports an aggressive intervention approach that comprises lifestyle modification in conjunction with drug treatment of the MS components. Healthier eating and regular exercise greatly reduce waistline and body mass index, lower blood pressure and improve lipid profile. Lifestyle modification has been proven to prevent T2DM development. Nevertheless, appropriate treatment of MS components often requires pharmacologic intervention with insulin-sensitizing agents, such as metformin and thiazolidinediones, while statins and fibrates, or angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are the first-line lipid-modifying or antihypertensive drugs. Only severely obese patients require specific drug treatments. Very often, drug combinations will be necessary to manage multiple risk factors. As we progress in the understanding of the pathophysiology of the MS, new targets for therapies will probably be identified and new treatments will prove to be even more efficacious than those currently available for the management of this life-threatening condition.

The therapeutic value of yoga in neurological disorders

Background:

The ancient mind and body healing methods of yoga recently sparked fervor in the scientific community as an alternative and complementary means of therapy. Since the World Health Organization officially began promoting yoga in developing countries in 1978, yoga has been cited for its therapeutic potential and has been widely recognized in Western culture. However, as an increasing number of people practice yoga for remedial purposes, researchers raise two important questions: 1) Is yoga a valid complementary management and rehabilitation treatment modality? 2) What conditions show promise of treatment with this intervention?.

Objective:

This review article uses comprehensive scientific, evidence-based studies to analyze the efficacy of various basic and applied aspects of yoga in disease prevention and health promotion. It specifically intends to expose the effects of yoga in neurological disorders, particularly epilepsy, stroke, multiple sclerosis, Alzheimer's disease, peripheral nervous system disease, and fibromyalgia.

Materials and Methods:

Information was gathered from various resources including PubMed, Ovid, MD-Consult, USC, and U.C.L.A. libraries. Studies were selected and reviewed on the basis of sample size, control, randomization, double-blinding, and statistical analysis of results.

Results:

The pratice of yoga and meditation demonstrates statistically encouraging physiological and psychological improvements in the aforementioned neurological disorders. However, there were certain flaws and inadequacies in the study designs employed to evaluate the same. A critical analysis of these studies is presented.

Conclusions:

With the aim to focus attention on this widespread yet largely unexamined treatment modality, this paper seeks to provide direction and support for further research necessary to validate yoga as an integrative, alternative, and complementary therapy.

Association between dietary meat consumption and incident type 2 diabetes: the EPIC-InterAct study

AIMS/HYPOTHESIS

A diet rich in meat has been reported to contribute to the risk of type 2 diabetes. The present study aims to investigate the association between meat consumption and incident type 2 diabetes in the EPIC-InterAct study, a large prospective case-cohort study nested within the European Prospective Investigation into Cancer and Nutrition (EPIC) study.

METHODS

During 11.7 years of follow-up, 12,403 incident cases of type 2 diabetes were identified among 340,234 adults from eight European countries. A centre-stratified random subsample of 16,835 individuals was selected in order to perform a case-cohort design. Prentice-weighted Cox regression analyses were used to estimate HR and 95% CI for incident diabetes according to meat consumption.

RESULTS

Overall, multivariate analyses showed significant positive associations with incident type 2 diabetes for increasing consumption of total meat (50 g increments: HR 1.08; 95% CI 1.05, 1.12), red meat (HR 1.08; 95% CI 1.03, 1.13) and processed meat (HR 1.12; 95% CI 1.05, 1.19), and a borderline positive association with meat iron intake. Effect modifications by sex and class of BMI were observed. In men, the results of the overall analyses were confirmed. In women, the association with total and red meat persisted, although attenuated, while an association with poultry consumption also emerged (HR 1.20; 95% CI 1.07, 1.34). These associations were not evident among obese participants.

CONCLUSIONS/INTERPRETATION

This prospective study confirms a positive association between high consumption of total and red meat and incident type 2 diabetes in a large cohort of European adults.

A review of yoga programs for four leading risk factors of chronic diseases

Yoga, a form of physical activity, is rapidly gaining in popularity and has many health benefits. Yet healthcare providers have been slow to recognize yoga for its ability to improve health conditions, and few interventions have been developed that take full advantage of its benefits. The purpose of this article is to review published studies using yoga programs and to determine the effect of yoga interventions on common risk factors of chronic diseases (overweight, hypertension, high glucose level and high cholesterol). A systematic search yielded 32 articles published between 1980 and April 2007. The studies found that yoga interventions are generally effective in reducing body weight, blood pressure, glucose level and high cholesterol, but only a few studies examined long-term adherence. Additionally, not enough studies included diverse populations at high risk for diabetes and its related common health problems.

The role of diet in prevention and management of type 2 diabetes: implications for public health

The aim of this review is to examine the current scientific knowledge on the relationship between diet and Type 2 diabetes and consider further implications for public health. The review focuses on the main nutritional elements which have been identified as significant in the prevention and management of Type 2 diabetes. Research findings on the role of carbohydrate, fiber, alcohol, and individual fatty acids are discussed, while the role of specific micro-nutrients and the influence of obesity are comprehensively presented. The association between dietary habits and Type 2 diabetes etiology and management is also reviewed, in order to examine the positive effects of adherence to a healthy dietary pattern, including the plausible role of the Mediterranean diet.

Effectively translating diabetes prevention: a successful model in a historically underserved community

Lifestyle interventions can prevent diabetes through weight loss, but they are rarely translated for use in underserved communities. The aim of this study was to describe how a community-academic partnership formed and developed a program to address local health disparities by developing a low-cost, culturally and economically appropriate, peer-led community-based diabetes prevention program. Using a participatory approach, the partnership chose to focus on diabetes prevention, and co-developed all intervention, recruitment, research, and evaluation strategies. The partnership's philosophy to maintain high clinical and scientific standards paired with their ability to represent and engage the community facilitated the development of a randomized controlled trial that achieved statistically significant and sustained weight loss, and the recruitment of a largely Spanish-speaking, low income, uninsured population. The success of this intervention lies in the partnership's commitment to the community, co-ownership of research, and a careful balance between academic rigor and community engagement and relevance.

Predisease: when does it make sense?

Screening often leads to finding conditions that are not at the stage or level that would classify them as disease but, at the same time, are not at a stage or level at which people can be declared entirely disease free. These "in-between" states have sometimes been designated as "predisease." Examples include precancerous lesions, increased intraocular pressure ("preglaucoma"), prediabetes, and prehypertension. When the goal of preventing adverse health outcomes is kept in mind, this review poses the idea that "predisease" as a category on which to act makes sense only if the following 3 conditions are met. First, the people designated as having predisease must be far more likely to develop disease than those not so designated. Second, there must be a feasible intervention that, when targeted to people with predisease, effectively reduces the likelihood of developing disease. Third, the benefits of intervening on predisease must outweigh the harms in the population. A systematic review of screening guidelines (published in 2003-2010) for 4 sample conditions (cervical cancer, glaucoma, diabetes, and hypertension) is included to assess whether they address these issues, followed by a discussion of the framework questions as they pertain to each condition.

Chinese herbal medicines for people with impaired glucose tolerance or impaired fasting blood glucose

BACKGROUND

Around 308 million people worldwide are estimated to have impaired glucose tolerance (IGT); 25% to 75% of these will develop diabetes within a decade of initial diagnosis. At diagnosis, half will have tissue-related damage and all have an increased risk for coronary heart disease.

OBJECTIVES

The objective of this review was to assess the effects and safety of Chinese herbal medicines for the treatment of people with impaired glucose tolerance or impaired fasting glucose (IFG).

SEARCH STRATEGY

We searched the following databases: The Cochrane Library, PubMed, EMBASE, AMED, a range of Chinese language databases, SIGLE and databases of ongoing trials.

SELECTION CRITERIA

Randomised clinical trials comparing Chinese herbal medicines with placebo, no treatment, pharmacological or non-pharmacological interventions in people with IGT or IFG were considered.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. Trials were assessed for risk of bias against key criteria: random sequence generation, allocation concealment, blinding of participants, outcome assessors and intervention providers, incomplete outcome data, selective outcome reporting and other sources of bias.

MAIN RESULTS

This review examined 16 trials lasting four weeks to two years involving 1391 participants receiving 15 different Chinese herbal medicines in eight different comparisons. No trial reported on mortality, morbidity or costs. No serious adverse events like severe hypoglycaemia were observed. Meta-analysis of eight trials showed that those receiving Chinese herbal medicines combined with lifestyle modification were more than twice as likely to have their fasting plasma glucose levels return to normal levels (i.e. fasting plasma glucose <7.8 mmol/L and 2hr blood glucose <11.1 mmol/L) compared to lifestyle modification alone (RR 2.07; 95% confidence intervall (CI) 1.52 to 2.82). Those receiving Chinese herbs were less likely to progress to diabetes over the duration of the trial (RR 0.33; 95% CI 0.19 to 0.58). However, all trials had a considerable risk of bias and none of the specific herbal medicines comparison data was available from more than one study. Moreover, results could have been confounded by rates of natural reversion to normal glucose levels.

AUTHORS' CONCLUSIONS

The positive evidence in favour of Chinese herbal medicines for the treatment of IGT or IFG is constrained by the following factors: lack of trials that tested the same herbal medicine, lack of details on co-interventions, unclear methods of randomisation, poor reporting and other risks of bias.

Revisiting the association between cardiovascular risk factors and diabetes: data from a large population-based study

PURPOSE

The purpose of this study was to examine the association between cardiovascular risk factors and the presence of diabetes in a large population-level dataset.

METHODS

A secondary analysis was conducted using data from the 2007 Behavioral Risk Factor Surveillance System, a population-based survey (n = 403,137) conducted in the United States.

RESULTS

The majority of the respondents were middle-aged and overweight. Approximately half of the sample reported little or no physical activity. Estimates from a logistic regression model for a weighted sample of white, black, and Hispanic adults revealed that having hypertension or elevated cholesterol was a strong predictor of diabetes even when controlling for age, gender, race, education, income, body mass index, smoking status, and physical activity.

CONCLUSIONS

The results confirmed the importance of diabetes educators counseling patients with hypertension or hypercholesterolemia about their increased risk for developing diabetes.

Decreased insulin secretion and insulin sensitivity are associated with liver function in subjects with fasting glucose between 100 and 109 mg/dL in Taiwanese population

OBJECTIVE

In 2003, the American Diabetes Association recommended that the lower limit for the diagnosis of impaired fasting glucose (IFG) should be reduced from 110 to 100 mg/dL in the analysis of the associated risk factors of IFG. It has been proposed that liver dysfunction may contribute to the development of type 2 diabetes. A primary aim was to investigate the relationship between liver enzyme and insulin resistance (IR) in IFG group. The secondary aim was to investigate IR and beta-cell function assessed by homeostasis model assessment (HOMA-IR and HOMA-%B, respectively) in subjects with fasting plasma glucose (FPG) between 100 and 109 mg/dL.

METHODS

We enrolled 284 subjects whose medical history and physical examination required tests to screen for metabolic abnormalities. In addition, we also excluded all factors affecting glucose or insulin metabolism. According to the FPG level, they were divided into the following groups: group A, FPG < 100 mg/dL; group B, FPG = 100 to 109 mg/dL; group C, FPG = 110 to 125 mg/dL.

RESULTS

Group B as compared with group A had significant increase of HOMA-IR and decrease of HOMA-%B. Among the whole population, the fasting insulin level, the fasting glucose, HbA1c, HOMA-IR, alanine aminotransferase, gamma-glutamyltranspeptidase, aspartate aminotransferase, and the diastolic blood pressure all increased significantly as the glycemic status progressed, whereas HOMA-%B levels decreased significantly as the glycemic status progressed. The lipid profile, alkaline phosphatase, and systolic blood pressure did not differ significantly among 3 different glycemic classifications.

CONCLUSIONS

Study results indicate that, first, there was a significant decrease of insulin sensitivity and insulin secretion in subjects with fasting glucose from 100 to 109 mg/dL compared with subjects with normal fasting glucose. Second, alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyltranspeptidase were associated with IR as the glycemic status progressed in the IFG group.

Glycated hemoglobin as a marker of cardiovascular risk

PURPOSE OF REVIEW

Diabetes mellitus is an established risk factor for cardiovascular disease. This review examines glycated hemoglobin, an indicator of long-term average blood glucose concentrations, in risk prediction for cardiovascular disease.

RECENT FINDINGS

Glycated hemoglobin concentrations predict cardiovascular disease risk in people with diabetes, and trial data suggest that good blood glucose control is associated with reduction in cardiovascular disease. Elevated glycated hemoglobin levels below the thresholds accepted for diabetes are also associated with increasing cardiovascular disease risk independent of classical risk factors in a continuous relationship across the whole normal distribution. A 1% increase in absolute concentrations of glycated hemoglobin is associated with about 10-20% increase in cardiovascular disease risk. The continuous relationship is most evident for coronary heart disease in men; the shape of the risk curve is less clear for women and for other cardiovascular endpoints such as stroke or peripheral vascular disease.

SUMMARY

Glycated hemoglobin concentration predicts cardiovascular risk both in people with diabetes and in the general population, and may help identify individuals at higher risk of cardiovascular disease for targeted interventions, including blood pressure or cholesterol reduction. Understanding the nature of this relationship may inform new preventive and therapeutic interventions.

Are health care professionals advising patients with diabetes or at risk for developing diabetes to exercise more?

OBJECTIVE

With increased focus on the obesity and diabetes epidemics, and the clear benefit of exercise in disease prevention and management, this study determined the lifetime prevalence of health professional advice to exercise among individuals with or at risk for diabetes.

RESEARCH DESIGN AND METHODS

The Medical Expenditure Panel Survey is a nationally representative survey of the U.S. population. In the 2002 survey, 26,878 adults responded when asked about ever receiving health professional advice to exercise more. Information on sociodemographic characteristics and health conditions were self-reported. Type 2 diabetes risk factors were age > or =45 years, non-Caucasian ethnicity, physical inactivity, BMI > or =25 kg/m(2), hypertension, and cardiovascular disease.

RESULTS

A total of 73% of adults with diabetes were told by a health professional to exercise more versus 31% of adults without diabetes. The proportion receiving advice increased as the number of diabetes risk factors increased until reaching similar rates as people with diabetes. After adjustment for sociodemographic and clinical factors, the strongest correlates of receiving advice were BMI and cardiovascular risk factors. Among respondents with diabetes, the likelihood of receiving advice did not vary by age, sex, education, or income level but was less likely in Hispanics.

CONCLUSIONS

Health professionals advised most patients with or at highest risk for diabetes to exercise, suggesting recognition of its importance for disease management. As risk factors declined, fewer patients were advised to exercise, suggesting missed opportunities for disease prevention. However, exercise has not increased proportional to exercise advice. The challenge remains converting patient awareness into behavior change.

Obesity, inactivity, and the prevalence of diabetes and diabetes-related cardiovascular comorbidities in the U.S., 2000-2002

OBJECTIVE

Obesity and physical inactivity are established risk factors for type 2 diabetes and cardiovascular comorbidities. Whether adiposity or fitness level is more important to health is controversial. The objective of this research is to determine the relative associations of physical activity and BMI with the prevalence of diabetes and diabetes-related cardiovascular comorbidities in the U.S.

RESEARCH DESIGN AND METHODS

The Medical Expenditure Panel Survey (MEPS) is a nationally representative survey of the U.S. population. From 2000 to 2002, detailed information on sociodemographic characteristics and health conditions were collected for 68,500 adults. Normal weight was defined as BMI 18.5 to <25 kg/m(2), overweight 25 to < or =30 kg/m(2), obese (class I and II) 30 to <40 kg/m(2), and obese (class III) > or =40 kg/m(2). Physical activity was defined as moderate/vigorous activity > or =30 min > or =3 days per week.

RESULTS

The likelihood of having diabetes and diabetes-related cardiovascular comorbidities increased with BMI regardless of physical activity and increased with physical inactivity regardless of BMI. Compared with normal-weight active adults, the multivariate-adjusted odds ratio (OR) for diabetes was 1.52 (95% CI 1.25-1.86) for normal-weight inactive adults and 1.65 (1.40-1.96) for overweight inactive adults; the OR for diabetes and comorbid hypertension was 1.71 (1.32-2.19) for normal-weight inactive adults and 1.84 (1.47-2.32) for overweight inactive adults.

CONCLUSIONS

Both physical inactivity and obesity seem to be strongly and independently associated with diabetes and diabetes-related comorbidities. These results support continued research investigating the independent causal nature of these factors.

Efficient cutoff points for three screening tests for detecting undiagnosed diabetes and pre-diabetes: an economic analysis

OBJECTIVE

Opportunistic screening for undiagnosed type 2 diabetes and pre-diabetes (either impaired glucose tolerance or impaired fasting glucose) is recommended by the American Diabetes Association. The aim of this study was to determine efficient cutoff points for three screening tests for detecting undiagnosed diabetes alone or both undiagnosed diabetes and pre-diabetes.

RESEARCH DESIGN AND METHODS

We estimated the number of individuals with undiagnosed diabetes alone or with both undiagnosed diabetes and pre-diabetes that could be detected by using different cutoff points for each screening test as the product of the prevalence of each condition, the sensitivity of the tests at each cutoff point for identifying each condition, and the number of individuals who would be eligible for screening in the U.S. We estimated the total cost of opportunistic screening by multiplying the cost for screening one person by the number of individuals screened.

RESULTS

The most efficient cutoff points for both detecting pre-diabetes and undiagnosed diabetes (100 mg/dl for the fasting plasma glucose test, 5.0% for the HbA(1c) test, and 100 mg/dl for the random capillary blood glucose test) were less than those for detecting undiagnosed diabetes alone (110 mg/dl for the fasting plasma glucose test, 5.7% for the HbA(1c) test, and 120 mg/dl for the random capillary blood glucose test).

CONCLUSIONS

A lower cutoff value should be used when screening for pre-diabetes and undiagnosed diabetes together than when screening for undiagnosed diabetes alone.

Economic evaluation of therapeutic interventions to prevent Type 2 diabetes in Canada

AIMS

To compare the health and economic outcomes of using acarbose, an intensive lifestyle modification programme, metformin or no intervention to prevent progression to diabetes in Canadian individuals with impaired glucose tolerance (IGT).

METHODS

A model was developed to simulate the course of individuals with IGT under each treatment strategy. Patients remain in the IGT state or transition from IGT to diabetes, to normal glucose tolerance (NGT) or to death. Effectiveness and resource use data were derived from published intervention trials. A comprehensive health-care payer perspective incorporating all major direct costs, reported in 2000 Canadian dollars, was adopted.

RESULTS

Over a decade, 70 of the 1000 untreated patients are expected to die and 542 develop diabetes. Intensive lifestyle modification is estimated to prevent 117 cases of diabetes, while metformin would prevent 52 and acarbose 74 cases. The proportion of those who return to NGT also increases with any treatment. While lifestyle modification is more effective, it can increase overall costs depending on how it is implemented, whereas acarbose and metformin reduce costs by nearly $1000 per patient. Lifestyle modification was cost effective, varying from CAD $10 000/LYG vs. acarbose. Acarbose costs somewhat more than metformin, but is more effective: CAD $1798/LYG.

CONCLUSION

The results of this model suggest that the treatment of IGT in Canada is a cost-effective way to prevent diabetes and may generate savings. While pharmacological treatments tended to be less costly, intensive lifestyle modification, if maintained, led to the greatest health benefits at reasonable incremental costs.

Glycemic index, glycemic load, and dietary fiber intake and incidence of type 2 diabetes in younger and middle-aged women

BACKGROUND

Increasing evidence suggests an important role of carbohydrate quality in the development of type 2 diabetes.

OBJECTIVE

Our objective was to prospectively examine the association between glycemic index, glycemic load, and dietary fiber and the risk of type 2 diabetes in a large cohort of young women.

DESIGN

In 1991, 91249 women completed a semiquantitative food-frequency questionnaire that assessed dietary intake. The women were followed for 8 y for the development of incident type 2 diabetes, and dietary information was updated in 1995.

RESULTS

We identified 741 incident cases of confirmed type 2 diabetes during 8 y (716 300 person-years) of follow-up. After adjustment for age, body mass index, family history of diabetes, and other potential confounders, glycemic index was significantly associated with an increased risk of diabetes (multivariate relative risks for quintiles 1-5, respectively: 1, 1.15, 1.07, 1.27, and 1.59; 95% CI: 1.21, 2.10; P for trend = 0.001). Conversely, cereal fiber intake was associated with a decreased risk of diabetes (multivariate relative risks for quintiles 1-5, respectively: 1, 0.85, 0.87, 0.82, and 0.64; 95% CI: 0.48, 0.86; P for trend = 0.004). Glycemic load was not significantly associated with risk in the overall cohort (multivariate relative risks for quintiles 1-5, respectively: 1, 1.31, 1.20, 1.14, and 1.33; 95% CI: 0.92, 1.91; P for trend = 0.21).

CONCLUSIONS

A diet high in rapidly absorbed carbohydrates and low in cereal fiber is associated with an increased risk of type 2 diabetes.

Thiazolidinedione therapy in the prevention/delay of type 2 diabetes in patients with impaired glucose tolerance and insulin resistance

AIM

The second-generation thiazolidinediones (TZDs), rosiglitazone and pioglitazone, significantly decrease fasting plasma glucose and glycosylated haemoglobin (HbA(1c)) levels in patients with diabetes. Recent studies suggest that early treatment with TZDs may prevent the progression from insulin resistance (IR) to type 2 diabetes mellitus (T2DM). This prospective analysis examined the effect of early TZD treatment in the prevention or delay of T2DM in a multiethnic population with impaired glucose tolerance (IGT) and IR.

METHODS

The analysis included 172 patients (aged 29-86 years) with IGT and IR (normal or borderline HbA(1c), C-peptide levels > 2 mg/ml, fasting blood sugar 100-125 mg/dl, and 2-h postprandial blood glucose levels 140-200 mg/dl). Patients in the active treatment group (n = 101) had received troglitazone for an average of 10 months before being randomly switched to rosiglitazone (4 mg/day) or pioglitazone (30 mg/day). Patients were switched when troglitazone was withdrawn from the US market because of liver toxicity concerns. Patients with IGT and IR who received no antidiabetic medication served as a control group (n = 71). HbA(1c) and C-peptide levels were measured at baseline (2 years) and study end point (3 years). Kaplan-Meier testing, using time to outcome as the main outcome variable, determined risk reduction in the TZD group relative to the control group.

RESULTS

Mean HbA(1c) and C-peptide levels decreased for patients receiving either TZD at the 2-year assessment, and reductions were maintained at study end point. After 2 years, none of the patients receiving TZD therapy progressed to T2DM; three patients progressed to T2DM by study end point. In the control group, 11 patients became diabetic after 2 years and 19 patients became diabetic by the end of the study. The incidence (risk reduction) of diabetes after 3 years was 88.9% lower in the TZD group compared with the control group (p < 0.001).

CONCLUSIONS

The TZDs, rosiglitazone and pioglitazone, were effective in reducing HbA(1c) and C-peptide levels in patients with IGT/IR. Progression of IR/IGT to T2DM appears to be significantly delayed or prevented with early TZD treatment.

Predictors of angina pectoris versus myocardial infarction from the Women's Health Initiative Observational Study

Although risk factors for acute coronary syndromes have been extensively studied, characteristics distinguishing women who will develop unstable angina rather than acute myocardial infarction (MI) are less well understood. This analysis evaluates baseline demographic, physical, and medical characteristics as predictors of angina versus MI in the Women's Health Initiative Observational Study. During a prospective 4.5-year follow-up of 92,152 postmenopausal women, 1,527 hospitalizations for angina and 797 for MI were confirmed by centrally trained physician adjudicators. In a multivariate analysis of women with incident angina or MI, high cholesterol (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.47 to 0.80; p = 0.0004) and prior coronary disease (OR 0.70, 95% CI 0.55 to 0.89; p = 0.004) independently predicted angina (referent), whereas current cigarette smoking (OR 1.60, 95% CI 1.13 to 2.26; p = 0.007) and diabetes mellitus (1.44, 95% CI 1.10 to 1.87; p = 0.007) predicted MI. Older age and hypertension were independently, but less strongly, predictive of MI. Aspirin or statin use, physical activity, body mass index, and educational levels were not independently associated with one or the other type of acute coronary syndrome. Thus, specific risk factors strongly and independently predicted whether women with an acute coronary syndrome would present with angina or with MI.

[Lifestyle and metabolic control in patients with type 2 diabetes mellitus. Construct validation of IMEVID questionnaire]

OBJECTIVE

To evaluate construct validity of an instrument to measure lifestyle in patients with type 2 diabetes mellitus (IMEVID questionnaire)

DESIGN

Comparative cross-sectional study.

SETTING

Six family medicine units (primary care).

PATIENTS

412 adults with type 2 diabetes.

MEASUREMENTS

The IMEVID was applied by self-administration and the following metabolic control parameters values were measured: body mass index (BMI), waist/hip index (WHI), hemoglobin A1C (HbA1C), total cholesterol (TC), triglycerides (TG), systolic blood pressure (SBP), diastolic blood pressure (DBP), and the average of fasting plasma glucose in the last three months (FG). The test hypothetic construct was that higher total scores in the IMEVID (better lifestyle) would be associated with lower values in the metabolic control parameters. Three groups of subjects were formed based on the total score: group one (quartile 75). Differences on these parameters between groups were researched.

RESULTS

389 subjects completed the study, 69,2% were women. Seven IMEVID domains had weak correlations at least with two of eight parameters (r between 0.22 and 0.16; P<.05). The total score had correlation with six of eight parameter (r between 0.18 and 0.10; P< or =.05). The group three subjects had lower levels of BMI, WHI, HbA1C, FG, TC and TGL than group one subjects (P<.05).

CONCLUSIONS

IMEVID has construct validity to measure the lifestyle in subjects with DM2. Its total score discriminates outstanding clinical characteristics in these patients.

Fortschritte in der Prävention des Typ-2-Diabetes

Type 2 diabetes mellitus is a major health problem associated with excess morbidity and mortality. Defects in the action and/or secretion of insulin are the two major abnormalities leading to development of glucose intolerance. Any intervention in the impaired glucose tolerance phase that reduces resistance to insulin or protects the beta-cells, or both, should prevent or delay progression to diabetes. The natural history of type 2 diabetes includes a preceding period of impaired glucose tolerance (IGT)/impaired fasting glucose (IFG) which provides an opportunity for targeted intervention within large communities. As the prevalence of this metabolic disorder is rapidly increasing and current treatment fails to stabilise the disease in most patients, prevention should be considered as a key objective in the near future. Lifestyle intervention studies have consistently shown that quite modest changes can reduce the progression from IGT to diabetes by 50-60%. The Diabetes Prevention Program (DPP) randomised trial has shown that a combined program of weight loss, improvement of diet and increase of physical exercise lowers the risk for development of type 2 diabetes by 58% compared with placebo. It may, however, not be possible to translate these successful findings to larger cohorts or maintain the lifestyle changes longer term. This has lead to consideration of pharmacotherapy. Benefits have been found for metformin, acarbose and troglitazone. Treatment with metformin was less effective than lifestyle modifications, resulting in an average reduction of risk for development of type 2 diabetes by 31% compared with placebo. Similarly, acarbose in the STOP-NIDDM trial reduced the risk of developing type 2 diabetes in patients with IGT by 25%. Remarkably, cardiovascular event rates, in particular myocardial infarction, were significantly reduced when acarbose was used instead of placebo in subjects with glucose intolerance. The ACE inhibitors captopril (CAPPP) or ramipril (HOPE) and the Angiotensin-II receptor antagonist losartan (LIFE) have been shown to reduce the appearance of diabetes by one third when given to patients with hypertension. Since many hypertensive patients are insulin-resistant and have an increased risk in developing type 2 diabetes, the protective effect of these classes of antihypertensive drugs might be explained by their antiinsulin-resistance effects.

Processed meat intake and incidence of Type 2 diabetes in younger and middle-aged women

AIM/HYPOTHESIS

The aim of this study was to investigate the association between processed and other meat intake and incidence of Type 2 diabetes in a large cohort of women.

METHODS

Incident cases of Type 2 diabetes were identified during 8 years of follow-up in a prospective cohort study of 91246 U.S. women aged 26 to 46 years and being free of diabetes and other major chronic diseases at baseline in 1991.

RESULTS

We identified 741 incident cases of confirmed Type 2 diabetes during 716276 person-years of follow-up. The relative risk adjusted for potential non-dietary confounders was 1.91 (95% CI: 1.42-2.57) in women consuming processed meat five times or more a week compared with those consuming processed meat less than once a week ( p<0.001 for trend). Further adjustment for intakes of magnesium, cereal fibre, glycaemic index, and caffeine or for a Western dietary pattern did not appreciably change the results and associations remained strong after further adjustment for fatty acid and cholesterol intake. Frequent consumption of bacon, hot dogs, and sausage was each associated with an increased risk of diabetes. While total red meat (beef or lamb as main dish, pork as main dish, hamburger, beef, pork or lamb as sandwich or mixed dish) intake was associated with an increased risk of diabetes, this association was attenuated after adjustment for magnesium, cereal fiber, glycaemic index, and caffeine (relative risk: 1.44; 95% CI: 0.92-2.24).

CONCLUSION/INTERPRETATION

Our data suggest that diets high in processed meats could increase the risk for developing Type 2 diabetes.

Position of the American Dietetic Association: Integration of medical nutrition therapy and pharmacotherapy

It is the position of the American Dietetic Association that the application of medical nutrition therapy (MNT) and lifestyle counseling as a part of the Nutrition Care Process is an integral component of the medical treatment for management of specific disease states and conditions and should be the initial step in the management of these situations. If optimal control cannot be achieved with MNT alone and concurrent pharmacotherapy is required, then The Association promotes a team approach to care for clients receiving concurrent MNT and pharmacotherapy and encourages active collaboration among dietetics professionals and other members of the health care team. There are a number of medical conditions, many of them chronic, that will respond to MNT and, therefore, MNT should be the first intervention for these conditions. In addition to being a vital element of the optimal management and control of these conditions, MNT is also a cost-effective method of management. However, because of the long-term nature of these conditions, concurrent pharmacotherapy may become necessary to achieve or maintain optimal control. In cases where this is necessary, MNT should continue to be an integral component of the therapy because it may complement or enhance the therapeutic effectiveness of pharmacotherapy, thereby reducing or eliminating the need for multiple medications. The utilization of a coordinated multidisciplinary team approach is critical to the success of the concurrent use of MNT and pharmacotherapy because of the long-term duration of the treatments, the necessity of monitoring compliance and effectiveness, and the likelihood of multiple medication-nutrient interactions.

[French diabetologists' standpoint on the prevention of type 2 diabetes. A survey carried out during the ALFEDIAM Convention Bordeaux 2003]

An opinion poll was carried out during the ALFEDIAM Congress Bordeaux 2003. One hundred and thirty-seven participants (mean age 43.6 +/- 8.3 years/sex Ratio approximately 1) among whom 22.6% run private practices, 51.8% work in hospitals and 21.3% are both private and hospital practitioners, have been questioned about their conception of the prevention of type 2 diabetes. Prediabetes is an acknowledged entity for 61% of the people surveyed. Two thirds use as a diagnostical criterion, moderate fasting hyperglycemia and/or a impaired glucose tolerance. Oral glucose tolerance test (OGTT) is still commonly practised among 51.9% but that is done sparingly only to confirm the diagnosis of diabetes in presence either of several risk factors or of a moderate fasting hyperglycemia. According to 70% of the answers, the detection of diabetes must be repeated every year among at risk subjects aged over 45. The metabolic syndrome is defined according to diverse criteria. The right definition of ATP III is given only in 5% of the cases. As regards the treatment, the combined requirements of physical activity and dietary rules are approved by 97% of the answers. The majority of the persons questioned in the survey consider that a slight loss of weight (less than 5% of the initial weight) is sufficient in a high risk risk individual.On the other hand, opinions are divided as regards the use of drugs at the pre-diabetes stage. Metformin is the only one that is accepted by more than 50% with a rate of 58.4% of positive answers, acarbose and orlistat rating respectively 37.2% and 35%. However a great majority (83.6%) are in favour of the reimbursement of antidiabetic drugs in this indication, for high risk individuals, provided a study has clearly demonstrated the efficiency of the molecule concerned.