bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effects of Race and Region on Cardiovascular Morbidity Among Elderly Americans With Diabetes
Authors: Bertoni Alain G. , Kirk Julienne K. , Case L. Douglas , Kay Christine , Goff David C. , Narayan K.M. Venkat , Bell Ronny A.
Published: March 2007

OBJECTIVE—There is conflicting evidence about whether nonwhite Americans with diabetes have an increased risk of cardiovascular disease (CVD). Because geographic region is known to influence the risk of CVD in the U.S., we sought to determine the effects of race and region on cardiovascular morbidity among elderly Americans with diabetes.

RESEARCH DESIGN AND METHODS—We performed a national, retrospective, cohort study using the Medicare claims of 126,153 white and 17,962 black patients with diabetes, aged ≥65 years in 1994, who were followed through 1999 for incident acute myocardial infarction, ischemic heart disease, stroke, and heart failure. The effect of race, sex, and region on the incidence of these diseases was assessed using Cox proportional hazards regression, adjusting for baseline demographics and comorbidities.

RESULTS—The incidence of any CVD ranged from 23.9/100 person-years among southern black men to 29.2/100 person-years among non-southern black women. The risk of CVD was lower among southern black men (hazard ratio 0.87 [95% CI 0.82–0.92]) and women (0.95 [0.91–0.99]) than their southern white counterparts. In the three other U.S. regions combined (northeast, midwest, and west), black men had a similar risk for CVD (1.01 [0.95–1.07]), and black women had a greater risk (1.10 [1.05–1.16]) than non-southern white men and women, respectively.

CONCLUSIONS—Among elderly Americans with diabetes, the incidence of CVD is unlikely to differ a great deal between whites and blacks. Residence in the South seems to confer a modest benefit for elderly black people with diabetes.
The Impact of Diabetes on Employment and Work Productivity
Authors: Tunceli Kaan , Bradley Cathy J. , Nerenz David , Williams L. Keoki , Pladevall Manel , Elston Lafata Jennifer
Published: March 2007

OBJECTIVE—The purpose of this study was to longitudinally examine the effect of diabetes on labor market outcomes.

RESEARCH DESIGN AND METHODS—Using secondary data from the first two waves (1992 and 1994) of the Health and Retirement Study, we identified 7,055 employed respondents (51–61 years of age), 490 of whom reported having diabetes in wave 1. We estimated the effect of diabetes in wave 1 on the probability of working in wave 2 using probit regression. For those working in wave 2, we modeled the relationships between diabetic status in wave 1 and the change in hours worked and work-loss days using ordinary least-squares regressions and modeled the presence of health-related work limitations using probit regression. All models control for health status and job characteristics and are estimated separately by sex.

RESULTS—Among individuals with diabetes, the absolute probability of working was 4.4 percentage points less for women and 7.1 percentage points less for men relative to that of their counterparts without diabetes. Change in weekly hours worked was not statistically significantly associated with diabetes. Women with diabetes had 2 more work-loss days per year compared with women without diabetes. Compared with individuals without diabetes, men and women with diabetes were 5.4 and 6 percentage points (absolute increase), respectively, more likely to have work limitations.

CONCLUSIONS—This article provides evidence that diabetes affects patients, employers, and society not only by reducing employment but also by contributing to work loss and health-related work limitations for those who remain employed.
The Association of Comorbid Depression With Mortality in Patients With Type 2 Diabetes
Authors: Katon Wayne J. , Rutter Carolyn , Simon Greg , Lin Elizabeth H.B. , Ludman Evette , Ciechanowski Paul , Kinder Leslie , Young Bessie , Von Korff Michael
Published: March 2007

OBJECTIVE—We assessed whether patients with comorbid minor and major depression and type 2 diabetes had a higher mortality rate over a 3-year period compared with patients with diabetes alone.

RESEARCH DESIGN AND METHODS—In a large health maintenance organization (HMO), 4,154 patients with type 2 diabetes were surveyed and followed for up to 3 years. Patients initially filled out a written questionnaire, and HMO-automated diagnostic, laboratory, and pharmacy data and Washington State mortality data were collected to assess diabetes complications and deaths. Cox proportional hazards regression models were used to calculate adjusted hazard ratios of death for each group compared with the reference group.

RESULTS—There were 275 (8.3%) deaths in 3,303 patients without depression compared with 48 (13.6%) deaths in 354 patients with minor depression and 59 (11.9%) deaths among 497 patients with major depression. A proportional hazards model with adjustment for age, sex, race/ethnicity, and educational attainment found that compared with the nondepressed group, minor depression was associated with a 1.67-fold increase in mortality (P = 0.003), and major depression was associated with a 2.30-fold increase (P < 0.0001). In a second model that controlled for multiple potential mediators, both minor and major depression remained significant predictors of mortality.

CONCLUSIONS—Among patients with diabetes, both minor and major depression are strongly associated with increased mortality. Further research will be necessary to disentangle causal relationships among depression, behavioral risk factors (adherence to medical regimens), diabetes complications, and mortality.
Development, Progression, and Regression of Microalbuminuria in Japanese Patients With Type 2 Diabetes Under Tight Glycemic and Blood Pressure Control
Authors: Yamada Takashi , Komatsu Mitsuhisa , Komiya Ichiro , Miyahara Yasuhiro , Shima Yukino , Matsuzaki Mitsuko , Ishikawa Yuka , Mita Reiko , Fujiwara Mika , Furusato Nobuko , Nishi Kazue , Aizawa Toru
Published: March 2007

OBJECTIVE— The goal of this study was to know the fate of albuminuria in Japanese patients with type 2 diabetes under tight blood pressure and glycemic control.

RESEARCH DESIGN AND METHODS— Patients having normoalbuminuria (urinary albumin excretion <30 mg/g creatinine, n = 179) or microalbuminuria (albumin excretion 30–299 mg/g creatinine, n = 94) at baseline have been followed up for 8 years: ratio of men to women was 160/113, the mean age was 58 years, pretreatment HbA1c (A1C) was 8.8%, and blood pressure was 136/76 mmHg. A1C <6.5% and blood pressure <130/80 mmHg were targeted, and the A1C of 6.5 ± 0.7% (mean ± SD) and blood pressure of 127 ± 11/72 ± 6 mmHg have been maintained during the 8 years. Development of microalbuminuria or macroalbuminuria (albumin excretion ≥300 mg/g creatinine) in initially normoalbuminuric patients and progression to macroalbuminuria or regression to normoalbuminuria in initially microalbuminuric patients were assessed at year 8.

RESULTS— Development occurred in 27 (15%) of the normoalbuminuric patients and progression and regression in 16 (17%) and 20 (21%), respectively, of the microalbuminuric patients. Significant independent relationships existed between development and higher achieved mean systolic blood pressure (SBP) and regression and lower achieved mean SBP. In the patients with achieved mean SBP <120 mmHg, development was 3%, progression was 11%, and regression was 44% during 8 years. Prediction for nephropathy by blood pressure and glycemia alone was limited. Nevertheless, albumin excretion at year 8 was positively correlated with achieved mean SBP and baseline albuminuria.

CONCLUSIONS— Development and progression were low and regression was high with SBP of 120 mmHg, provided A1C was maintained at 6.5%.
Prevalence of the Metabolic Syndrome Defined by the International Diabetes Federation Among Adults in the U.S.
Authors: Ford Earl S.
Published: March 2007

OBJECTIVE—The International Diabetes Federation (IDF) has proposed a new definition of the metabolic syndrome that emphasizes central adiposity as determined by ethnic group–specific thresholds of waist circumference. The objective of this study was to estimate the prevalence of this syndrome using the IDF definition among U.S. adults and to compare it with the prevalence estimated using the definition of the National Cholesterol Education Program (NCEP).

RESEARCH DESIGN AND METHODS—A total of 3,601 men and women aged ≥20 years from the National Health and Nutrition Examination Survey 1999–2002 were included in the analyses.

RESULTS—Based on the NCEP definition, the unadjusted prevalence of the metabolic syndrome was 34.5 ± 0.9% (percent ± SE) among all participants, 33.7 ± 1.6% among men, and 35.4 ± 1.2% among women. Based on the IDF definition, the unadjusted prevalence of the metabolic syndrome was 39.0 ± 1.1% among all participants, 39.9 ± 1.7% among men, and 38.1 ± 1.2% among women. The IDF definition led to higher estimates of prevalence in all of the demographic groups, especially among Mexican-American men. The two definitions similarly classified ∼93% of the participants as having or not having the metabolic syndrome.

CONCLUSIONS—In the U.S., the use of the IDF definition of the metabolic syndrome leads to a higher prevalence estimate of the metabolic syndrome than the estimate based on the NCEP definition.
Increased Mortality Risks of Pre-Diabetes (Impaired Fasting Glucose) in Taiwan
Authors: Wen Chi Pang , Cheng Ting Yuan David , Tsai Shan Pou , Hsu Hui Ling , Wang Shu Li
Published: March 2007

OBJECTIVE—The objective of this article was to assess mortality risks at different levels of fasting blood glucose (FBG) in Taiwan, with particular attention to those pre-diabetic subjects with impaired fasting glucose (IFG).

RESEARCH DESIGN AND METHODS—Governmental employees and schoolteachers were followed up for an average of 11 years. With the use of Cox regression analyses, mortality risks were calculated for 36,386 subjects, aged 40–69.

RESULTS—FBG ≥110 mg/dl was associated with increased mortality risks for all causes, cardiovascular diseases (CVD), and diabetes. IFG, when defined as 110–125 mg/dl, was associated with a significant increase for CVD and/or diabetes mortality. These mortality risks remained elevated when known CVD risk factors were adjusted for. The IFG group shared risk factor characteristics more with the FBG ≥126 mg/dl group than with the FBG <110 mg/dl group. When IFG was defined as 100–125 mg/dl, the number of subjects quadrupled, but mortality risks diminished substantially because of the inclusion of 100–109 mg/dl group. The lowest FBG group, 50–75 mg/dl, had a significant 2-fold risk from all causes.

CONCLUSIONS—There was an overall J-shaped relationship between all-cause mortality and FBG. IFG, when defined as 110–125 mg/dl, is an independent risk factor and should be aggressively treated as a disease because its subsequent mortality risks for CVD and diabetes were significantly increased. The newly defined IFG at 100–125 mg/dl did not have the predictive power for later increases in CVD or diabetes mortality.
Beneficial Effects of a Dietary Approaches to Stop Hypertension Eating Plan on Features of the Metabolic Syndrome
Authors: Azadbakht Leila , Mirmiran Parvin , Esmaillzadeh Ahmad , Azizi Tohid , Azizi Fereidoun
Published: March 2007

OBJECTIVE—To determine the effects of a Dietary Approaches to Stop Hypertension (DASH) eating plan on metabolic risks in patients with the metabolic syndrome.

RESEARCH DESIGN AND METHODS—This was a randomized controlled outpatient trial conducted on 116 patients with the metabolic syndrome. Three diets were prescribed for 6 months: a control diet, a weight-reducing diet emphasizing healthy food choices, and the DASH diet with reduced calories and increased consumption of fruit, vegetables, low-fat dairy, and whole grains and lower in saturated fat, total fat, and cholesterol and restricted to 2,400 mg Na. The main outcome measures were the components of the metabolic syndrome.

RESULTS—Relative to the control diet, the DASH diet resulted in higher HDL cholesterol (7 and 10 mg/dl), lower triglycerides (−18 and −14 mg/dl), systolic blood pressure (SBP) (−12 and −11 mmHg), diastolic blood pressure (−6 and −7 mmHg), weight (−16 and −14 kg), fasting blood glucose (FBG) (−15 and −8 mg/dl), and weight (−16 and −15 kg), among men and women, respectively (all P < 0.001). The net reduction in triglycerides (−17 and −18 mg/dl), SBP (−11 and −11 mmHg), diastolic blood pressure (−5 and −6 mmHg), and FBG (−4 and −6 mg/dl), weight (−16 and −15 kg), and increase in HDL (5 and 10 mg/dl) among men and women, respectively, was higher in the DASH group (all P < 0.05). The weight-reducing diet resulted in significant change in triglycerides (−13 and −10 mg/dl), SBP (−6 and −6 mmHg), and weight (−13 and −12 kg) among men and women, respectively (all P < 0.05).

CONCLUSIONS—The DASH diet can likely reduce most of the metabolic risks in both men and women; the related mechanisms need further study.
Race Differences in Long-Term Diabetes Management in an HMO
Authors: Adams Alyce S. , Zhang Fang , Mah Connie , Grant Richard W. , Kleinman Ken , Meigs James B. , Ross-Degnan Dennis
Published: March 2007

OBJECTIVE—We examined race differences in diabetes outcomes over 4–8 years in a single HMO.

RESEARCH DESIGN AND METHODS—We identified black and white adult diabetic patients who were continuously enrolled (1992–2001) and in whom diabetes was 1) diagnosed before 1994 (n = 1,686) or 2) newly diagnosed in 1994–1997 (n = 1,280). We used hierarchical models to estimate the effect of race on average annual HbA1c (A1C) controlling for baseline A1C, BMI, and age, as well as annual measures of type of diabetes medications, diabetes-related hospitalization, time and the number of A1C tests, physician visits, and nondiabetes medications. Stratifying by sex accounted for significant interactions between sex and race.

RESULTS—At baseline, black and white patients had similar rates of A1C testing and physician visits, but blacks had higher unadjusted A1C values. In multivariate models, among patients with previously diagnosed diabetes, average A1C was nonsignificantly 0.11 higher (95% CI −0.12 to 0.34) in black than in white men but was 0.30 higher (0.14–0.46; P = 0.0007) in black than in white women. Among patients with newly diagnosed diabetes, the adjusted black-white gap was 0.49 among men (0.17–0.80; P = 0.007) and was 0.05 among women (−0.20 to –0.31), which was positive but not significant.

CONCLUSIONS—Factors other than the quality of care may explain persistent race differences in A1C in this setting. Future interventions should target normalization of A1C by identifying potential psychosocial barriers to therapy intensification among patients and clinicians and development of culturally appropriate interventions to aid patients in successful self-management.
Elevated Hip Fracture Risk in Type 1 Diabetic Patients
Authors: Miao Junmei , Brismar Kerstin , Nyrén Olof , Ugarph-Morawski Anna , Ye Weimin
Published: March 2007

OBJECTIVE—Patients with type 1 diabetes often have low bone mineral density, but epidemiological data on fracture risk are sparse and imprecise, particularly for men.

RESEARCH DESIGN AND METHODS—In the Swedish Inpatient Register, we identified a population-based cohort of 24,605 patients (12,551 men and 12,054 women) who were hospitalized for diabetes before age 31 years during 1975 through 1998. Follow-up for hip fracture was accomplished through cross-linkage in the Inpatient Register until the end of 1998. Censoring information was obtained from the registers of Death and Migration. Using the Kaplan-Meier method, we calculated the cumulative probability of getting a hip fracture. Standardized hospitalization ratios and their 95% CIs estimated relative risks with the age-, sex-, and calendar period–matched Swedish general population as reference.

RESULTS—In total, 70 and 51 first hip fractures were ascertained in men and women, respectively, corresponding to a cumulative probability (both sexes) of 65.8/1,000 until age 65 years. Markedly elevated risks were observed in both men and women (standardized hospitalization ratios = 7.6 [95% CI 5.9–9.6] and 9.8 [7.3–12.9], respectively), increasing with follow-up time. Ophthalmic, nephropathic, neurological, and cardiovascular complications were indicators of particularly high risks.

CONCLUSIONS—Both male and female type 1 diabetic patients are at increased risk for hip fracture. Although optimal preventive measures still need to be defined, the co-occurrence with other diabetes complications suggests that tighter metabolic control might reduce the risk.
A Computer Simulation Model of Diabetes Progression, Quality of Life, and Cost
Authors: Zhou Honghong , Isaman Deanna J.M. , Messinger Shari , Brown Morton B. , Klein Ronald , Brandle Michael , Herman William H.
Published: March 2007

OBJECTIVE—To develop and validate a comprehensive computer simulation model to assess the impact of screening, prevention, and treatment strategies on type 2 diabetes and its complications, comorbidities, quality of life, and cost.

RESEARCH DESIGN AND METHODS—The incidence of type 2 diabetes and its complications and comorbidities were derived from population-based epidemiologic studies and randomized, controlled clinical trials. Health utility scores were derived for patients with type 2 diabetes using the Quality of Well Being–Self-Administered. Direct medical costs were derived for managed care patients with type 2 diabetes using paid insurance claims. Monte Carlo techniques were used to implement a semi-Markov model. Performance of the model was assessed using baseline and 4- and 10-year follow-up data from the older-onset diabetic population studied in the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR).

RESULTS—Applying the model to the baseline WESDR population with type 2 diabetes, we predicted mortality to be 51% at 10 years. The prevalences of stroke and myocardial infarction were predicted to be 18 and 19% at 10 years. The prevalences of nonproliferative diabetic retinopathy, proliferative retinopathy, and macular edema were predicted to be 45, 16, and 18%, respectively; the prevalences of microalbuminuria, proteinuria, and end-stage renal disease were predicted to be 19, 39, and 3%, respectively; and the prevalences of clinical neuropathy and amputation were predicted to be 52 and 5%, respectively, at 10 years. Over 10 years, average undiscounted total direct medical costs were estimated to be $53,000 per person. Among survivors, the average utility score was estimated to be 0.56 at 10 years.

CONCLUSIONS—Our computer simulation model accurately predicted survival and the cardiovascular, microvascular, and neuropathic complications observed in the WESDR cohort with type 2 diabetes over 10 years. The model can be used to predict the progression of diabetes and its complications, comorbidities, quality of life, and cost and to assess the relative effectiveness, cost-effectiveness, and cost-utility of alternative strategies for the prevention and treatment of type 2 diabetes.
Modulation of Food Intake by Glucose in Patients With Type 2 Diabetes
Authors: Schultes Bernd , Peters Achim , Hallschmid Manfred , Benedict Christian , Merl Volker , Oltmanns Kerstin M. , Born Jan , Fehm Horst L. , Kern Werner
Published: March 2007

OBJECTIVE—A gain in body weight is a common adverse effect of glucose-lowering therapies in patients with type 2 diabetes, the mechanisms of which are not completely understood. Blood glucose is considered to play a crucial role in the regulation of food intake. On this background, we hypothesized that a short-term reduction of blood glucose concentration to normal values acutely increases food intake in type 2 diabetic patients.

RESEARCH DESIGN AND METHODS—To test this hypothesis, 12 patients with type 2 diabetes were examined twice, once during a euglycemic (5.0 mmol/l) clamp experiment and another time during a hyperglycemic (10.5 mmol/l) clamp. The experiments were performed in a single-blind fashion with the order of conditions balanced across patients. On both clamp conditions, insulin was infused at a constant rate of 2.5 mU/kg per min for 125 min. Simultaneously, a glucose solution was infused at a variable rate to achieve target glycemic levels. During the final 30 min of the clamps, the patients were allowed to eat as much as they liked from a standard breakfast buffet.

RESULTS—Compared with the hyperglycemic condition, the patients ingested on average 25 ± 10% more energy during euglycemia (645 ± 75 vs. 483 ± 37 kcal; P = 0.029). The increased energy intake during euglycemia was equally distributed across macronutrient components, i.e., during euglycemia the patients ate more carbohydrates (+27.1 ± 11.4%; P = 0.037), fat (+22.5 ± 10.0%; P = 0.046), and proteins (+25.2 ± 11.2%; P = 0.046) than during hyperglycemia. Circulating levels of insulin, amylin, leptin, ghrelin, and glucagon-like peptide-1 did not differ between the euglycemic and hyperglycemia clamp, excluding a major contribution of these hormones to the difference in food intake. Summing up the glucose administered intravenously and the food ingested yielded a remarkably similar total energy influx in both conditions (794 ± 64 vs. 790 ± 53 kcal; P = 0.961).

CONCLUSIONS—Together our data suggest that total energy supply to the organism is tightly regulated on a short-term basis independent of the route of influx. Alternatively, it can be hypothesized that euglycemia stimulated or that hyperglycemia suppressed food intake at the subsequent buffet meal in our type 2 diabetic patients. Regardless of these different interpretations, our data indicate an important regulatory role of glucose for food intake in type 2 diabetic patients that is of considerable clinical relevance.
“Pressure Gradient” as an Indicator of Plantar Skin Injury
Authors: Mueller Michael J. , Zou Dequan , Lott Donovan J.
Published: March 2007

OBJECTIVE—Peak plantar pressures (PPPs) have been studied extensively as a contributing factor to skin breakdown, especially in the forefoot where most plantar neuropathic ulcers occur. The purposes of this article were to 1) describe an additional pressure variable, the peak pressure gradient (PPG), 2) determine whether the PPG is higher in the forefoot than in the rearfoot (even when compared with PPP), and 3) determine the correlation between the PPG and PPP at the forefoot and rearfoot in subjects with diabetes, peripheral neuropathy, and a history of plantar ulcer.

RESEARCH DESIGN AND METHODS—Twenty subjects (12 male and 8 female) with diabetes, peripheral neuropathy, and a mean ± SD age of 57 ± 9 years participated. Plantar pressures were collected during walking in footwear. The PPP and the PPG (defined as the spatial change in plantar pressure across adjacent sites of the foot surface around the PPP) were determined for the forefoot and rearfoot, and the forefoot-to-rearfoot ratios for each variable were calculated.

RESULTS—The mean PPG was 143% higher in the forefoot than in the rearfoot, whereas the mean PPP was only 36% higher in the forefoot than in the rearfoot (P < 0.0001). The PPG forefoot-to-rearfoot ratio (2.84 ± 1.36) was nearly two times greater than the PPP forefoot-to-rearfoot ratio (1.48 ± 0.58) (P < 0.0001). The correlation between PPP and PPG was r = 0.59 at the forefoot and r = 0.75 at the rearfoot.

CONCLUSIONS—The PPG was substantially higher in the forefoot than in the rearfoot even when compared with the PPP. The PPG appears to be providing additional information about the stresses experienced by the soft tissues of the foot, especially in the forefoot. The PPG may be a useful indicator of skin trauma because spatial changes in high plantar pressures may identify high stress concentrations within the soft tissue.
Alcohol Consumption and Risk of Type 2 Diabetes Among Older Women
Authors: Beulens Joline W.J. , Stolk Ronald P. , van der Schouw Yvonne T. , Grobbee Diederick E. , Hendriks Henk F.J. , Bots Michiel L.
Published: March 2007

OBJECTIVE—This study aimed to investigate the relation between alcohol consumption and type 2 diabetes among older women.

RESEARCH DESIGN AND METHODS—Between 1993 and 1997, 16,330 women aged 49–70 years and free from diabetes were enrolled in one of the Dutch Prospect-EPIC (European Prospective Study Into Cancer and Nutrition) cohorts and followed for 6.2 years (range 0.1–10.1). At enrollment, women filled in questionnaires and blood samples were collected.

RESULTS—During follow-up, 760 cases of type 2 diabetes were documented. A linear inverse association (P = 0.007) between alcohol consumption and type 2 diabetes risk was observed, adjusting for potential confounders. Compared with abstainers, the hazard ratio for type 2 diabetes was 0.86 (95% CI 0.66–1.12) for women consuming 5–30 g alcohol per week, 0.66 (0.48–0.91) for 30–70 g per week, 0.91 (0.67–1.24) for 70–140 g per week, 0.64 (0.44–0.93) for 140–210 g per week, and 0.69 (0.47–1.02) for >210 g alcohol per week. Beverage type did not influence this association. Lifetime alcohol consumption was associated with type 2 diabetes in a U-shaped fashion.

CONCLUSIONS—Our findings support the evidence of a decreased risk of type 2 diabetes with moderate alcohol consumption and expand this to a population of older women.
Reducing Amputation Rates in Patients With Diabetes at a Military Medical Center
Authors: Driver Vickie R. , Madsen Jeff , Goodman Russell A.
Published: March 2007

OBJECTIVE— To describe and evaluate the Limb Preservation Service (LPS), a multidisciplinary, state-of-the-art, foot care clinic for patients with diabetes at Madigan Army Medical Center (MAMC). Evaluation criteria include the overall incidence of lower-extremity amputation (LEA) and the distribution of the anatomic level of amputation between 1999 and 2003.

RESEARCH DESIGN AND METHODS— This is a retrospective study of the incidence and types of LEAs performed in patients with diabetes at MAMC. Patients with diagnosed diabetes and LEA procedures were identified by ICD-9-Clinical Modification (CM) codes. Hospital and clinic characteristics that are integral to the success of the program are described.

RESULTS— The number of patients at MAMC with diagnosed diabetes increased 48% from 1999 to 2003; however, the number of LEAs decreased 82% from 33 in 1999 to 9 in 2003. Amputations of the foot, ankle, and toe comprise 71% of amputations among patients with diabetes.

CONCLUSIONS— The results of this study provide evidence of the value of a focused multidisciplinary foot care program for patients with diabetes. Associations between the creation of the LPS and LEA rates are discussed.
Comparison of Effect of Pioglitazone With Metformin or Sulfonylurea (Monotherapy and Combination Therapy) on Postload Glycemia and Composite Insulin Sensitivity Index During an Oral Glucose Tolerance Test in Patients With Type 2 Diabetes
Authors: Ceriello Antonio , Johns Don , Widel Mario , Eckland David J. , Gilmore Kathryn J. , Tan Meng H.
Published: March 2007

OBJECTIVE— Pioglitazone, metformin, and gliclazide lower HbA1c and fasting plasma glucose in patients with type 2 diabetes. We compared the effects of these three drugs, used as monotherapy and in combination, on postload glycemia and composite insulin sensitivity index (CISI) in these patients.

RESEARCH DESIGN AND METHODS— Postload glycemia and CISI were analyzed for 940 patients who had oral glucose tolerance tests (OGTTs) in four multicenter, randomized, double-blind, double-dummy, parallel group clinical trials (pioglitazone versus metformin, pioglitazone versus gliclazide, pioglitazone plus sulfonylurea versus metformin plus sulfonylurea, and pioglitazone plus metformin versus gliclazide plus metformin). Plasma glucose and insulin were determined during the 3-h OGTT performed at baseline and after 1 year of therapy. Incremental area under the curve for glucose was the surrogate for postload glycemia. CISI was calculated using the formula {10,000/√ of [(fasting glucose × fasting insulin) × (mean glucose × mean insulin)]} during the OGTT.

RESULTS— In monotherapy, pioglitazone reduced postload glycemia and enhanced CISI more than metformin and gliclazide. In combination therapy, pioglitazone plus sulfonylurea reduced postload glycemia and increased CISI more than metformin plus sulfonylurea. Pioglitazone plus metformin also decreased postload glycemia and increased CISI more than gliclazide plus metformin.

CONCLUSIONS— Pioglitazone improves postload glycemia and CISI more than metformin or gliclazide when used as monotherapy or in combination therapy in patients with type 2 diabetes.
Addition of Primary Care–Based Retinal Imaging Technology to an Existing Eye Care Professional Referral Program Increased the Rate of Surveillance and Treatment of Diabetic Retinopathy
Authors: Wilson Charlton , Horton Mark , Cavallerano Jerry , Aiello Lloyd M.
Published: March 2007

OBJECTIVE—Digital retinal imaging is a relatively new technology that can be used to assess patients for diabetic retinopathy. We evaluated the impact of adding a primary care–based retinal imaging technology to an existing eye care professional referral process on the rate of surveillance and treatment of diabetic retinopathy in a large, well-defined patient population over a 5-year period.

RESEARCH DESIGN AND METHODS—We performed systematic performance evaluations using a computerized patient information system and a comprehensive procedure log to describe annually the patient population, the number of patients with diabetes, and the proportion of patients with diabetes who received appropriate eye care services, including surveillance and laser treatment for diabetic retinopathy before and after implementation of a digital retinal imaging system at the Phoenix Indian Medical Center Primary Care Medical Clinic.

RESULTS—The rate of annual retinal examinations increased from 50% (95% CI 44–56%) to 75% (70–80%; P < 0.000001), representing a 50% increase in the retinal examination rate. The rate of laser therapy increased from 19.6 per 1,000 patients with diabetes in 1999 to 29.5 per 1,000 in 2003 for a 51% increase in the laser treatment rate.

CONCLUSIONS—Implementing retinal imaging technology in a primary care setting resulted in a significant increase in the rate of diabetic retinopathy surveillance and a proportional increase in the rate of laser treatment for diabetic retinopathy for a large patient population. Application of this technology in primary care settings holds the potential to extend sight-preserving care by increasing access to appropriate retinal care.
Impaired Glucose Tolerance and Bone Mineral Content in Overweight Latino Children With a Family History of Type 2 Diabetes
Authors: Afghani Afrooz , Cruz Martha L. , Goran Michael I.
Published: March 2007

OBJECTIVE—Research on the skeletal status of pre-diabetic (type 2 diabetic) children is warranted. We examined the hypothesis that bone mineral content (BMC) and bone mineral density (BMD) will be lower in children with impaired glucose tolerance (IGT) versus normal glucose tolerance (NGT).

RESEARCH DESIGN AND METHODS—Total body BMC and BMD of 184 overweight Latino children (106 boys, 78 girls, 11.9 ± 1.7 years) with a family history of type 2 diabetes were measured using dual-energy X-ray absorptiometry. Glucose tolerance was assessed by 2-h glucose after an oral glucose tolerance test. Area under the insulin curve (AUC) assessed the cumulative insulin response to oral glucose. Acute insulin response to glucose (AIR) was determined by an intravenous glucose tolerance test.

RESULTS—Partial correlations revealed an inverse relationship between BMC and AIR (r = −0.29, P = 0.00), AUC (r = −0.28, P = 0.00), fasting insulin (r = −0.16, P = 0.04), and 2-h insulin (r = −0.16, P = 0.04). There was no significant difference in BMC or BMD between children with IGT (n = 46) or NGT (n = 138). Stepwise multiple linear regression revealed that 89% of the variance in BMC is attributed to lean mass (87%), age (1%), and AIR (1%). BMD was explained by lean mass (69%), Tanner stage (3%), and AUC (2%).

CONCLUSIONS—The findings of this study suggest that in overweight children, lean mass is the primary predictor of BMC and BMD, whereas age, Tanner stage, and the acute and cumulative insulin responses to oral glucose make subtle independent contributions to the total variances. In addition, poor glycemic control does not seem to be detrimental to bone mass of pre-diabetic children.
Predicting the Development of Diabetes in Older Adults
Authors: Kanaya Alka M. , Fyr Christina L. Wassel , de Rekeneire Nathalie , Shorr Ronald I. , Schwartz Ann V. , Goodpaster Bret H. , Newman Anne B. , Harris Tamara , Barrett-Connor Elizabeth
Published: March 2007

OBJECTIVE— To create a simple prediction rule that could perform as well as the 2-h postchallenge plasma glucose (PCPG) test to predict those at risk for diabetes. We created a prediction rule in one sample and prospectively validated it for incident diabetes in a separate cohort.

RESEARCH DESIGN AND METHODS— A cross-sectional analysis with data from the Rancho Bernardo Study (age 67 ± 11 years) to derive a rule predicting abnormal PCPG ≥140 mg/dl, using demographic, clinical, and laboratory data of nondiabetic participants with fasting plasma glucose (FPG) <126 mg/dl. Data from the Health, Aging and Body Composition study (age 74 ± 3 years) were used to prospectively validate this rule for incident diabetes and compare it with the predictive ability of the PCPG test.

RESULTS— Of 1,549 RBS participants, 514 (33%) had PCPG ≥140 mg/dl. Female sex, age, triglycerides, and FPG were most significantly associated with abnormal PCPG. Based on standardized β-coefficients, we allotted 1 point for female sex, triglycerides ≥150 mg/dl, or FPG 95–104 mg/dl. Age ≥70 years or FPG 105–115 mg/dl were given 2 points, and FPG 116–125 mg/dl received 3 points. In the validation cohort, this simple prediction rule was as good as the 2-h PCPG test for predicting incident diabetes (C-statistic: 0.71 for both).

CONCLUSIONS— Advanced age, female sex, FPG, and triglycerides were able to predict adults at risk for diabetes equally well as the 2-h PCPG test. Using this rule, clinicians may better identify older persons who should receive intensive lifestyle intervention to prevent type 2 diabetes.
Household Income Is Associated With the Risk of Metabolic Syndrome in a Sex-Specific Manner
Authors: Dallongeville Jean , Cottel Dominique , Ferrières Jean , Arveiler Dominique , Bingham Annie , Ruidavets Jean Bernard , Haas Bernadette , Ducimetière Pierre , Amouyel Philippe
Published: March 2007

OBJECTIVE—To assess the relationship between household income and metabolic syndrome in men and women.

RESEARCH DESIGN AND METHODS—A total of 1,695 men and 1,664 women, aged 35–64 years, from three distinct geographical areas of France were investigated. Waist girth, plasma triglycerides, HDL cholesterol, glucose, and systolic blood pressure were used to define metabolic syndrome according to the National Cholesterol Education Program (NCEP)/Adult Treatment Panel III (ATPIII) guidelines. Household income, educational level, occupational category, working status, consumption of psychotropic drugs, accommodation status, household composition, physical activity at work and during leisure time, alcohol consumption, and smoking habits were recorded with a standardized questionnaire.

RESULTS—There were 390 (23.0%) men and 381 (16.9%) women who satisfied NCEP/ATPIII criteria for metabolic syndrome. Household income (P < 0.0001) and consumption of psychotropic drugs (P = 0.0005) were associated with metabolic syndrome in women but not in men. In contrast, educational level, occupational category, working status, and accommodation status were associated with metabolic syndrome in both men and women. After adjustment on lifestyle variables, household income (interaction P < 0.004) remained inversely associated with metabolic syndrome in women but not in men.

CONCLUSIONS—These data suggest that limited household income, which reflects a complex unfavorable social and economic environment, may increase the risk of metabolic syndrome in a sex-specific manner.
Follow-up of Nutritional and Metabolic Problems After Bariatric Surgery
Authors: Fujioka Ken
Published: March 2007

Over the next several years, the number of patients who will have had bariatric surgery for morbid obesity will reach close to a million. Several well-described nutritional problems such as B12 and iron deficiency will be noted in these patients. Many of these patients will be lost to the original surgeon and will now be in the care of the “other physicians.” These and other mineral and vitamin problems will need to be screened and treated. If these problems are left undiagnosed, severe and irreparable problems can result. Early problems, such as vomiting and dumping syndrome, will be easily recognized and treated, but other long-term problems, such as changes in bone metabolism, will need to be monitored. Again, if some of these long-term problems are not addressed in a timely fashion, then eventual treatment becomes much more difficult. This commentary will cover the common as well newer problems that are now developing in the patient who has had bariatric surgery. Patients who have undergone bariatric surgery require medical follow-up for reasons that are often determined by the type of surgical procedure performed. The majority of this review will deal with patients who have had the standard Roux-en-Y gastric bypass, which is a primarily restrictive procedure with a mild component of noncaloric malabsorption. At the end of this report, a short section will be devoted to the problems associated with the malabsorptive procedures.
Dosage Effects of Diabetes Self-Management Education for Mexican Americans
Authors: Brown Sharon A. , Blozis Shelley A. , Kouzekanani Kamiar , Garcia Alexandra A. , Winchell Maria , Hanis Craig L.
Published: March 2007

OBJECTIVE—The objective of this study was to compare two diabetes self-management interventions designed for Mexican Americans: “extended” (24 h of education, 28 h of support groups) and “compressed” (16 h of education, 6 h of support groups). Both interventions were culturally competent regarding language, diet, social emphasis, family participation, and incorporating cultural beliefs.

RESEARCH DESIGN AND METHODS—We recruited 216 persons between 35 and 70 years of age diagnosed with type 2 diabetes ≥1 year. Intervention groups of eight participants and eight support persons were randomly assigned to the compressed or extended conditions. The interventions differed in total number of contact hours over the yearlong intervention period, with the major difference being the number of support group sessions held. The same information provided in the educational sessions of the extended intervention was compressed into fewer sessions, thus providing more information during each group meeting.

RESULTS—The interventions were not statistically different in reducing HbA1c; however, both were effective. A “dosage effect” of attendance was detected with the largest HbA1c reductions achieved by those who attended more of the extended intervention. For individuals who attended ≥50% of the intervention, baseline to 12-month HbA1c change was −0.6 percentage points for the compressed group and −1.7 percentage points for the extended group.

CONCLUSIONS—Both culturally competent diabetes self-management education interventions were effective in promoting improved metabolic control and diabetes knowledge. A dosage effect was evident; attending more sessions resulted in greater improvements in metabolic control.
Continuous Subcutaneous Insulin Infusion (CSII) of Insulin Aspart Versus Multiple Daily Injection of Insulin Aspart/Insulin Glargine in Type 1 Diabetic Patients Previously Treated With CSII
Authors: Hirsch Irl B. , Bode Bruce W. , Garg Satish , Lane Wendy S. , Sussman Allen , Hu Peter , Santiago Olga M. , Kolaczynski Jerzy W. ,   for the Insulin Aspart CSII/MDI Comparison Study Group
Published: March 2007

OBJECTIVE—Multiple daily injection (MDI) therapy of bolus insulin aspart and basal insulin glargine was compared with continuous subcutaneous insulin infusion (CSII) with aspart in type 1 diabetic patients previously treated with CSII.

RESEARCH DESIGN AND METHODS—One hundred patients were enrolled in a randomized, multicenter, open-label, crossover study. After a 1-week run-in period with aspart by CSII, 50 subjects were randomly assigned to MDI therapy (aspart immediately before each meal and glargine at bedtime) and 50 subjects continued CSII. After 5 weeks of the first treatment, subjects crossed over to the alternate treatment for 5 weeks. During the last week of each treatment period, subjects wore a continuous glucose monitoring system for 48–72 h.

RESULTS—Mean serum fructosamine levels were significantly lower after CSII therapy than after MDI therapy (343 ± 47 vs. 355 ± 50 μmol/l, respectively; P = 0.0001). Continuous glucose monitoring profiles over a 24-h time period showed that glucose exposure was 24 and 40% lower for CSII than MDI as measured by area under the curve (AUC) glucose ≥80 mg/dl (1,270 ± 742 vs. 1,664 ± 1,039 mg · h · dl−1; P < 0.001) and AUC glucose ≥140 mg/dl (464 ± 452 vs. 777 ± 746 mg · h · dl−1, CSII vs. MDI, respectively; P < 0.001). Similar percentages of subjects reported hypoglycemic episodes (CSII: 92%, MDI: 94%) and nocturnal (12:00 a.m. to 8:00 a.m.) hypoglycemic episodes (CSII: 73%, MDI: 72%). Major hypoglycemia was infrequent (CSII: two episodes, MDI: five episodes).

CONCLUSIONS—In a trial of short duration, CSII therapy with insulin aspart resulted in lower glycemic exposure without increased risk of hypoglycemia, as compared with MDI with insulin aspart and glargine.
A Randomized Trial of Two Irremovable Off-Loading Devices in the Management of Plantar Neuropathic Diabetic Foot Ulcers
Authors: Katz Ira A. , Harlan Anthony , Miranda-Palma Bresta , Prieto-Sanchez Luz , Armstrong David G. , Bowker John H. , Mizel Mark S. , Boulton Andrew J.M.
Published: March 2007

OBJECTIVE—The purpose of this study was to compare the effectiveness of a removable cast walker (RCW) rendered irremovable (iTCC) with the total contact cast (TCC) in the treatment of diabetic neuropathic plantar foot ulcers.

RESEARCH DESIGN AND METHODS—In a prospective, randomized, controlled trial, 41 consecutive diabetic patients with chronic, nonischemic, neuropathic plantar foot ulcers were randomly assigned to one of two groups: a RCW rendered irremovable by wrapping it with a single layer of fiberglass casting material (i.e., an iTCC) or a standard TCC. Primary outcome measures were the proportion of patients with ulcers that healed at ≤12 weeks, healing rates, complication rates, cast placement/removal times, and costs.

RESULTS—The proportions of patients with ulcers that healed within 12 weeks in the iTCC and TCC groups were 80 and 74%, respectively (94 and 93%, respectively, when patients who were lost to follow-up were excluded). Survival analysis (healing rates) was statistically equivalent in the two groups, as were complication rates, but with a trend toward benefit in the iTCC group. The iTCC took significantly less time to place and remove than the TCC with 39% and 36% reductions, respectively. There was also an overall lower cost associated with the use of the iTCC compared with the TCC.

CONCLUSIONS—The iTCC may be equally efficacious, faster to place, easier to use, and less expensive than the TCC in the treatment of diabetic plantar neuropathic foot ulcers.
Blood Glucose and Heart Failure in Nondiabetic Patients
Authors: Nielson Christopher , Lange Theodore
Published: March 2007

OBJECTIVE—Nondiabetic patients were studied to determine whether increasing blood glucose is associated with subsequent incidence of heart failure.

RESEARCH DESIGN AND METHODS—Baseline morning blood glucose determinations were evaluated with respect to subsequent heart failure using records from 20,810 nondiabetic patients. The onset of heart failure >1 year after initial glucose determinations was evaluated for patients who had 2–12 years of care. Patients were excluded if they had ever had the diagnosis of diabetes, had a diagnosis of heart failure <1 year after initial blood glucose determinations, had a blood glucose determination >125 mg/dl, or used corticosteroids, loop diuretics, insulin, or oral hypoglycemics.

RESULTS—Of the 20,810 patients studied, 916 patients developed heart failure over a total analysis time of 71,890 years at risk. Higher baseline morning glucose levels were associated with increased heart failure from 3.5% (glucose <90 mg/dl) to 3.8% (90–99 mg/dl) to 4.8% (100–109 mg/dl) to 6% (110–125 mg/dl) over a mean 4- to 5-year evaluation period. The incidence rate increased from 7.5 cases per 1,000 person-years (glucose <90 mg/dl) to 8.4 (90–99 mg/dl, NS) to 11.1 (100–109 mg/dl, P < 0.001) to 13.7 (110–125 mg/dl, P < 0.0001), an 83% increase in heart failure if baseline glucose was >109 mg/dl compared with <90 mg/dl. A Cox proportionate hazards model including age, sex, BMI, creatinine, hypertension, lipids, smoking, medications, and coronary disease showed a progressive increase in hazard ratio from 1.25 (glucose 90–99 mg/dl, P < 0.05) to 1.46 (100–109 mg/dl, P < 0.001) to 1.55 (110–125 mg/dl, P < 0.001) compared with glucose <90 mg/dl. Kaplan-Meier analysis showed increased glucose- associated risk with time.

CONCLUSIONS—Patients with higher baseline blood glucose levels in the absence of diabetes and after adjustment for covariants have a significantly increased risk of heart failure.