bluuebunny/crossref_metadata_2025 huggingface dataset:
Quality of Care for Uninsured Patients With Diabetes in a Rural Area
Authors: Porterfield Deborah S. , Kinsinger Linda
Published: March 2007

OBJECTIVE—We compared quality of care for uninsured patients with diabetes in private physician offices and community/migrant health centers (C/MHCs).

RESEARCH DESIGN AND METHODS—We conducted a cross-sectional medical record review in a convenience sample of eight physician offices and three C/MHC sites in rural North Carolina. Billing systems generated lists of self-pay patients with diabetes. Abstraction of the medical records (n = 142) yielded data on process and intermediate outcome measures of diabetes care, which were derived from the Diabetes Quality Improvement Project.

RESULTS—Medical records of patients in C/MHCs demonstrated higher rates on four of six process measures of quality of care, including measurement of HbA1c (98 vs. 75%; P < 0.001), cholesterol (82 vs. 51%; P < 0.001), and urine protein (90 vs. 25%; P < 0.001). Nonsignificant trends in documented eye examinations and the intermediate outcome of blood pressure control were found in medical records of C/MHC patients. No differences were seen in the intermediate outcomes of glucose or lipid control. Notable differences in provider type, time since training, and use of flow sheets were found.

CONCLUSIONS—In our sample, uninsured patients with diabetes in C/MHCs had higher quality of care as suggested by higher rates of processes of care. Outcomes were similar in the two settings and well below targets. Further work is required to replicate these findings and to understand which features of C/MHCs may facilitate quality care for the uninsured and are replicable in other settings.
The Prevalence and Pattern of Complementary and Alternative Medicine Use in Individuals With Diabetes
Authors: Egede Leonard E. , Ye Xiaobou , Zheng Deyi , Silverstein Marc D.
Published: March 2007

OBJECTIVE—This study compared the prevalence and pattern of use of complementary and alternative medicine (CAM) in individuals with and without diabetes and identified factors associated with CAM use.

RESEARCH DESIGN AND METHODS—The 1996 Medical Expenditure Panel Survey, a nationally representative sample of the U.S. noninstitutionalized civilian population, was analyzed. Estimates of CAM use in individuals with common chronic conditions were determined, and estimates of CAM use in patients with diabetes were compared with that in individuals with chronic medical conditions. Patterns of use and costs of CAM use in patients with diabetes were compared with those in nondiabetic individuals. Multiple logistic regression was used to determine independent predictors of CAM use in individuals with diabetes, controlling for age, sex, race/ethnicity, household income, educational level, and comorbidity.

RESULTS—Individuals with diabetes were 1.6 times more likely to use CAM than individuals without diabetes (8 vs. 5%, P < 0.0001). In the general population, estimates of CAM use were not significantly different across selected chronic medical conditions, but diabetes was an independent predictor of CAM use. Among individuals with diabetes, older age (≥65 years) and higher educational attainment (high school education or higher) were independently associated with CAM use.

CONCLUSIONS—Diabetes is an independent predictor of CAM use in the general population and in individuals with diabetes. CAM use is more common in individuals aged ≥65 years and those with more than high school education.
Sulfonylurea Inadequacy
Authors: Wright Alex , Burden A.C. Felix , Paisey Richard B. , Cull Carole A. , Holman Rury R. ,   for the U.K. Prospective Diabetes Study Group
Published: March 2007

OBJECTIVE—To evaluate the efficacy of the addition of insulin when maximal sulfonylurea therapy is inadequate in individuals with type 2 diabetes.

RESEARCH DESIGN AND METHODS—Glycemic control, hypoglycemia, and body weight were monitored over 6 years in 826 patients with newly diagnosed type 2 diabetes in 8 of 23 U.K. Prospective Diabetes Study (UKPDS) centers that used a modified protocol. Patients were randomly allocated to a conventional glucose control policy, primarily with diet (n = 242) or an intensive policy with insulin alone (n = 245), as in the main study. However, for patients randomized to an intensive policy with sulfonylurea (n = 339), insulin was added automatically if the fasting plasma glucose remained >108 mg/dl (6.0 mmol/l) despite maximal sulfonylurea doses.

RESULTS—Over 6 years, ∼53% of patients allocated to treatment with sulfonylurea required additional insulin therapy. Median HbA1c in the sulfonylurea ± insulin group was significantly lower (6.6%, interquartile range [IQR] 6.0–7.6) than in the group taking insulin alone (7.1%, IQR 6.2–8.0; P = 0.0066), and significantly more patients in the sulfonylurea ± insulin group had an HbA1c <7% (47 vs. 35%, respectively; P = 0.011). Weight gain was similar in the intensive therapy groups, but major hypoglycemia occurred less frequently over all in the sulfonylurea (± insulin) group compared with the insulin alone group (1.6 vs. 3.2% per annum, respectively; P = 0.017).

CONCLUSIONS—Early addition of insulin when maximal sulfonylurea therapy is inadequate can significantly improve glycemic control without promoting increased hypoglycemia or weight gain.
Dietary Fat and Meat Intake in Relation to Risk of Type 2 Diabetes in Men
Authors: van Dam Rob M. , Willett Walter C. , Rimm Eric B. , Stampfer Meir J. , Hu Frank B.
Published: March 2007

OBJECTIVE—To examine dietary fat and meat intake in relation to risk of type 2 diabetes.

RESEARCH DESIGN AND METHODS—We prospectively followed 42,504 male participants of the Health Professionals Follow-Up Study who were aged 40–75 years and free of diagnosed diabetes, cardiovascular disease, and cancer in 1986. Diet was assessed by a validated food frequency questionnaire and updated in 1990 and 1994. During 12 years of follow-up, we ascertained 1,321 incident cases of type 2 diabetes.

RESULTS—Intakes of total fat (multivariate RR for extreme quintiles 1.27, CI 1.04–1.55, P for trend=0.02) and saturated fat (1.34, 1.09–1.66, P for trend=0.01) were associated with a higher risk of type 2 diabetes. However, these associations disappeared after additional adjustment for BMI (total fat RR 0.97, CI 0.79–1.18; saturated fat 0.97, 0.79–1.20). Intakes of oleic acid, trans-fat, long-chain n-3 fat, and α-linolenic acid were not associated with diabetes risk after multivariate adjustment. Linoleic acid was associated with a lower risk of type 2 diabetes in men <65 years of age (RR 0.74, CI 0.60–0.92, P for trend=0.01) and in men with a BMI <25 kg/m2 (0.53, 0.33–0.85, P for trend=0.006) but not in older and obese men. Frequent consumption of processed meat was associated with a higher risk for type 2 diabetes (RR 1.46, CI 1.14–1.86 for ≥5/week vs. <1/month, P for trend <0.0001).

CONCLUSIONS—Total and saturated fat intake were associated with a higher risk of type 2 diabetes, but these associations were not independent of BMI. Frequent consumption of processed meats may increase risk of type 2 diabetes.
Intensive Lifestyle Changes Are Necessary to Improve Insulin Sensitivity
Authors: McAuley Kirsten A. , Williams Sheila M. , Mann Jim I. , Goulding Ailsa , Chisholm Alex , Wilson Noela , Story Gretchen , McLay Rebecca T. , Harper Michelle J. , Jones Ianthe E.
Published: March 2007

OBJECTIVE—The extent to which lifestyle must be altered to improve insulin sensitivity has not been established. This study compares the effect on insulin sensitivity of current dietary and exercise recommendations with a more intensive intervention in normoglycemic insulin-resistant individuals.

RESEARCH DESIGN AND METHODS—Seventy-nine normoglycemic insulin-resistant (determined by the euglycemic insulin clamp) men and women were randomized to either a control group or one of two combined dietary and exercise programs. One group (modest level) was based on current recommendations and the other on a more intensive dietary and exercise program. Insulin sensitivity was measured using a euglycemic insulin clamp, body composition was measured using dual-energy X-ray absorptiometry, and anthropometry and aerobic fitness were assessed before and after a 4-month intervention period. Four-day dietary intakes were recorded, and fasting glucose, insulin, and lipids were measured.

RESULTS—Only the intensive group showed a significant improvement in insulin sensitivity (23% increase, P=0.006 vs. 9% in the modest group, P=0.23). This was associated with a significant improvement in aerobic fitness (11% increase in the intensive group, P=0.02 vs. 1% in the modest group, P=0.94) and a greater fiber intake, but no difference in reported total or saturated dietary fat.

CONCLUSIONS—Current clinical dietary and exercise recommendations, even when vigorously implemented, did not significantly improve insulin sensitivity; however, a more intensive program did. Improved aerobic fitness appeared to be the major difference between the two intervention groups, although weight loss and diet composition may have also played an important role in determining insulin sensitivity.
Health-Related Quality of Life and Treatment Satisfaction in Dutch Patients With Type 2 Diabetes
Authors: Redekop W. Ken , Koopmanschap Marc A. , Stolk Ronald P. , Rutten Guy E.H.M. , Wolffenbuttel Bruce H.R. , Niessen Louis W.
Published: March 2007

OBJECTIVE— To estimate the health-related quality of life (HRQOL) and treatment satisfaction for patients with type 2 diabetes in the Netherlands and to examine which patient characteristics are associated with quality of life and treatment satisfaction.

RESEARCH DESIGN AND METHODS—For a sample of 1,348 type 2 diabetes patients, recruited by 29 general practitioners, we collected data regarding HRQOL. This study was performed as part of a larger European study (Cost of Diabetes in Europe - Type 2 [CODE-2]). We used a generic instrument (Euroqol 5D) to measure HRQOL. Treatment satisfaction was assessed using the Diabetes Treatment Satisfaction Questionnaire.

RESULTS—Patients without complications had an HRQOL (0.74) only slightly lower than similarly aged persons in the general population. Insulin therapy, obesity, and complications were associated with a lower HRQOL, independent of age and sex. Although higher fasting blood glucose and HbA1c levels were negatively associated with HRQOL, these factors were not significant after adjustment for other factors using multivariate analysis. Overall treatment satisfaction was very high. Younger patients, patients using insulin, and patients with higher HbA1c levels were less satisfied with the treatment than other patients.

CONCLUSIONS—Obesity and the presence of complications are important determinants of HRQOL in patients with type 2 diabetes.
Diabetes-Related Morbidity and Mortality in a National Sample of U.S. Elders
Authors: Bertoni Alain G. , Krop Julie S. , Anderson Gerard F. , Brancati Frederick L.
Published: March 2007

OBJECTIVE—Although the number of elders with diabetes has increased dramatically, there are few data on rates of mortality and serious complications in older populations with diabetes. To determine such rates, we conducted a population-based, nonconcurrent cohort study using claims data from the 1994–1996 Medicare 5% Standard Analytical File.

RESEARCH DESIGN AND METHODS—Codes from the ICD-9 were used to identify diabetes and the following complications: amputation, lower extremity infection, gangrene, blindness, acute myocardial infarction, ischemic heart disease, stroke, and metabolic disorders. Using these codes, we assembled a cohort of 148,562 Medicare Part A and B beneficiaries who were ≥65 years of age, who were alive on 1 January 1995, who were not in managed care in 1994, and who had a diabetes-related claim in 1994. Age-specific rates of death and complications were then calculated.

RESULTS—During 24 months of follow-up, 22,044 (14.8%) elders with diabetes died. Death rates in men and women increased significantly with age. Compared with their counterparts in the general U.S. population, elders with diabetes suffered excess mortality at every age group, corresponding to an overall standardized mortality ratio of 1.41 (95% CI 1.39,1.43). The incidence of ischemic heart disease and stroke was 181.5 and 126.2 per 1,000 person-years, respectively, which was higher than the incidence of all other diabetes-related complications.

CONCLUSIONS—In every age group, elders with diabetes have significantly higher all-cause mortality rates than the general population. Medicare data may be useful in monitoring trends in diabetes-related morbidity and total mortality in U.S. elders with diabetes.
Lifetime Costs of Complications Resulting From Type 2 Diabetes in the U.S.
Authors: Caro J. Jaime , Ward Alexandra J. , O’Brien Judith A.
Published: March 2007

OBJECTIVE—To model the lifetime costs associated with complications of type 2 diabetes.

RESEARCH DESIGN AND METHODS—A cohort of 10,000 patients with diabetes was simulated using a model based on existing epidemiological studies. Complication rates were estimated for various stages of macrovascular disease, nephropathy, retinopathy, neuropathy, and hypoglycemia. At the beginning of the simulation, patients were assumed to have been treated for 5 years and have a mean HbA1c of 8.4. From the U.K. Prospective Diabetes Study, it was estimated that on current therapies, the HbA1c would drift upward on average 0.15% per year. Direct medical costs of managing each complication were estimated (in 2000 U.S. dollars) from all-payor databases, surveys, and literature.

RESULTS—Macrovascular disease was estimated to be the largest cost component, accounting for 85% of cumulative costs of complications over the first 5 years. The costs of complications were estimated to be $47,240 per patient over 30 years, on average. The management of macrovascular disease is estimated to be the largest cost component, accounting for 52% of the costs; nephropathy accounts for 21%, neuropathy accounts for 17%, and retinopathy accounts for 10% of the costs of complications.

CONCLUSIONS—The complications of diabetes account for substantial costs, with management of macrovascular disease being the largest and earliest. If improving glycemic control prevents complications, it will reduce these costs.
The Effect of Estrogen Use on Levels of Glucose and Insulin and the Risk of Type 2 Diabetes in American Indian Postmenopausal Women
Authors: Zhang Ying , Howard Barbara V. , Cowan Linda D. , Yeh Jeunliang , Schaefer Carl F. , Wild Robert A. , Wang Wenyu , Lee Elisa T.
Published: March 2007

OBJECTIVE—To examine the associations between estrogen use and levels of insulin and glucose as well as the effect of estrogen use on the risk of type 2 diabetes.

RESEARCH DESIGN AND METHODS—This report is based on 857 women who were both nondiabetic and postmenopausal at the baseline examination (1989–1992) and who completed a second examination (1993–1995) an average of 4 years later. The participants were divided into three groups: never, past, and current users based on their baseline estrogen use status. ANCOVA was used to compare the insulin and glucose levels among estrogen use groups. Logistic regression was used to evaluate the association between estrogen use and the incidence of type 2 diabetes.

RESULTS—Postmenopausal estrogen use was associated with lower fasting glucose (0.2 mmol/l lower) but higher 2-h glucose levels (0.4 mmol/l higher) compared with never users. It was not significantly associated with the risk of type 2 diabetes compared with past and never users, based on American Diabetes Association or World Health Organization definitions of diabetes or on only a 2-h glucose level ≥11.1 mmol/l. However, the risk of type 2 diabetes increased with increasing duration of estrogen use among current users, with an odds ratio of 1.10 per year of use (95% CI: 1.01–1.19).

CONCLUSIONS—The data suggest that estrogen use in American Indian postmenopausal women may relate to deterioration of glucose tolerance. Longer duration of estrogen use among current users may relate to an increased risk of type 2 diabetes.
Successful Prospective Prediction of Type 1 Diabetes in Schoolchildren Through Multiple Defined Autoantibodies
Authors: LaGasse James M. , Brantley Michael S. , Leech Nicola J. , Rowe Rachel E. , Monks Stephanie , Palmer Jerry P. , Nepom Gerald T. , McCulloch David K. , Hagopian William A.
Published: March 2007

OBJECTIVE—Almost 90% of type 1 diabetes appears in individuals without a close family history. We sought to evaluate the best current predictive strategy, multiple defined autoantibodies, in a long-term prospective study in the general population.

RESEARCH DESIGN AND METHODS—Autoantibodies to pancreatic islets (islet cell antibodies [ICAs]) and defined autoantibodies (d-aab) to human GAD, IA2/ICA512, and insulin were tested in 4,505 Washington schoolchildren. Eight years later, 3,000 (67%) subjects were recontacted, including 97% of subjects with any test >99th percentile.

RESULTS—Six subjects developed diabetes (median interval 2.8 years), all from among the 12 individuals with multiple d-aab, representing 50% positive predictive value (95% CI 25–75%) and 100% sensitivity (58–100%). Among the others, diabetes occurred in 0 of 6 with one d-aab plus ICA, 0 of 26 with ICA only, 0 of 7 with one d-aab equaling the 99th percentile and another d-aab equaling the 97.5th percentile, 0 of 86 with one d-aab, and 0 of 2,863 with no d-aab or ICA. Adjusted for verification bias, multiple d-aab were 99.9% specific (99.86–99.93%). At this age, new d-aab seldom appeared. Once present, d-aab usually persisted regardless of disease progression, although less so for insulin autoantibodies. Insulin secretion by sequential glucose tolerance testing remained normal in four multiple d-aab subjects not developing diabetes. Of children developing diabetes, five of six (83%) would be included if HLA-DQ genotyping preceded antibody testing, but HLA-DQ did not explain outcomes among high-risk subjects, even when considered along with other genetic markers.

CONCLUSIONS—Multiple d-aab were established by age 14 years and prospectively identified all schoolchildren who developed type 1 diabetes within 8 years.
Energy Metabolism in Diabetic and Nondiabetic Heart Transplant Recipients
Authors: Benedini Stefano , Fiocchi Roberto , Battezzati Alberto , Scifo Paola , Sereni Lucia Piceni , Gamba Amando , Mammana Carmelo , Del Maschio Alessandro , Perseghin Gianluca , Luzi Livio
Published: March 2007

OBJECTIVE—This study examined the metabolic effects of heart transplantation in patients in end-stage cardiac failure.

RESEARCH DESIGN AND METHODS—A total of 18 patients after heart transplantation for end-stage heart disease (age 47± 3 years; transplant age 5.5± 1.5 years; BMI 25.8± 0.8 kg/m2; cyclosporin A 4.2 ±0.6 mg/[kg·day]; azathioprine 0.87± 0.31 mg/[kg·day]), 12 patients with type 2 diabetes (D-Tx), and 6 patients without type 2 diabetes (Tx) were studied by means of 1) an oral glucose tolerance test (OGTT) to assess the β-cell secretory response, 2) a euglycemic-hyperinsulinemic (1 mU/[kg·min]) clamp combined with indirect calorimetry and a primed continuous infusion of [6,6-2H2]glucose and [1-13C]leucine to measure postabsorptive and insulin-stimulated carbohydrate and protein metabolism, and 3) 1H-NMR spectroscopy of the calf muscles to measure intramyocellular triglyceride (IMCL) content. The patients were selected from 480 transplant patients in whom there was a 6% prevalence of type 2 diabetes. Five healthy subjects matched for anthropometric parameters served as control subjects (CON).

RESULTS—Tx had postabsorptive and insulin-stimulated glucose, leucine, and free fatty acid metabolism, as well as IMCL content, similar to that of CON. D-Tx were characterized by a reduced secretory response during the OGTT and peripheral insulin resistance with respect to glucose metabolism, which was paralleled by increased plasma free fatty acid concentrations and IMCL content. A defective insulin-dependent suppression of the endogenous leucine flux (index of proteolysis) was also evident during the clamp in D-Tx.

CONCLUSIONS—Heart transplantation, notwithstanding the immunosuppressive therapy, was characterized by a normal postabsorptive and insulin-stimulated glucose, leucine, and free fatty acid metabolism in Tx. In contrast, insulin resistance with respect to glucose, free fatty acids, and protein metabolism was present in D-Tx regardless of whether diabetes was preexisting or consequent to heart transplantation.
Abnormal Carbohydrate Metabolism During Pregnancy
Authors: Paradisi Giancarlo , Biaggi Arabella , Ferrazzani Sergio , De Carolis Sara , Caruso Alessandro
Published: March 2007

OBJECTIVE—To evaluate whether abnormal endothelial function, a common finding in premenopausal women with type 2 diabetes, is present in early states of diabetes during pregnancy, such as impaired glucose tolerance (IGT) and gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS—Brachial artery flow-mediated dilatation (FMD) (endothelium-dependent) and nitrate-induced dilatation (NID) (endothelium-independent) were measured in 23 pregnant subjects with carbohydrate abnormalities (10 IGT, 13 GDM) and in 15 pregnant control subjects during the third trimester of gestation. High-resolution vascular ultrasonography was used to perform these investigations. A fasting lipid panel was obtained, and glucose and insulin values in response to a 100-g oral glucose load were also measured.

RESULTS—FMD was significantly reduced in both groups of women with abnormal carbohydrate metabolism compared with control subjects (7.6 ±1.1% in the IGT group and 4.1 ±0.9% in the GDM group vs. 10.9 ±1.1% in control subjects, P < 0.04 and P < 0.0001, respectively). Significant difference in FMD was also observed between IGT and GDM groups (P < 0.04). NID was comparable in the three groups. Among all subjects, FMD showed a strong independent negative correlation with glycemic area (r=−0.60, P < 0.0001).

CONCLUSIONS—Endothelial dysfunction, an early marker of macrovascular disease, is present in pregnancies complicated by IGT and GDM. This alteration, which seems to be directly related to glycemic levels, could explain, at least in part, the increased risk for concurrent hypertensive disorders during pregnancy in these women.
Effect of Diabetes on Renal Medullary Oxygenation During Water Diuresis
Authors: Epstein Franklin H. , Veves Aristidis , Prasad Pottumarthi V.
Published: March 2007

OBJECTIVES—To study the effect of water diuresis on renal medullary and cortical oxygenation in patients with diabetes using blood oxygenation level–dependent magnetic resonance imaging (BOLD MRI).

RESEARCH DESIGN AND METHODS—Nine mild diabetic subjects (48 ±2.7 years of age, six women) and nine nondiabetic subjects of similar age and sex, all without known vascular or renal disease, were studied noninvasively by MRI before and during water diuresis.

RESULTS—Water diuresis induced an increase in medullary oxygenation in control subjects, producing a decrease in R2* (apparent spin-spin relaxation time) of 1.89 ±0.27 (P < 0.01), but no significant change in the group of diabetic subjects.

CONCLUSIONS—These findings in middle-aged diabetic subjects, which resembled those previously described in elderly subjects >65 years of age, suggest early impairment of adaptive vasodilatation within the renal medulla in diabetes.
Hypertriglyceridemic HyperapoB in Type 2 Diabetes
Authors: Sniderman Allan D. , Lamarche Benoit , Tilley Jessica , Seccombe David , Frohlich Jiri
Published: March 2007

OBJECTIVES—Much less attention has been paid to LDL in type 2 diabetes than to VLDL or HDL. In particular, there are few data on apoB levels in these patients. Moreover, most reports have focused on mean lipoprotein levels and consequently there is little information on the frequencies of the various dyslipidemic phenotypes.

RESEARCH DESIGN AND METHODS—Plasma and lipoprotein lipids, apoB and apoA1 were measured by standardized methods. LDL particle size was determined by PAGE. The total cohort was divided into phenotypes by two different methods. The first was based on triglycerides (≥ or <1.5 mmol/l) and LDL cholesterol (≥ or <4 mmol/l), whereas the second was based on triglycerides (≥ or <1.5 mmol/l) and apoB (≥ or <120 mg/dl).

RESULTS—For the overall cohort, plasma triglycerides were elevated (2.13 ±1.6 mmol/l), total and LDL cholesterol were normal (5.34 ±1.1 and 3.28 ±0.88 mmol/l, respectively), and peak LDL size was reduced (252.9 ±5.8 Å). HDL cholesterol was between the 25th and 50th percentiles of the general population (1.12 ±0.36 mmol/l). The average level of apoB was 114 ±29 mg/dl, a value that is between the 50th and 75th percentiles of the general population and is higher than that for LDL cholesterol, which was between the 25th and the 50th percentiles of the population. The results of the phenotyping analysis were as follows. Using the conventional approach, only 23% has abnormal LDL, i.e., an elevated LDL cholesterol level. Using the new approach, almost 40% has an elevated apoB and therefore an elevated LDL particle number. Only 12.8% has combined hyperlipidemia based on the conventional approach, whereas almost one-third had the equivalent, hypertriglyceridemic hyperapoB-based on the new algorithm. The severity of the dyslipoproteinemia in this group was noteworthy. Although the average LDL cholesterol was 3.91 mmol/l, a value just below the 75th percentile of the general population, the average apoB was 145 mg/dl, a value that approximates the 95th percentile of the population.

CONCLUSIONS—The dyslipidemic profile of patients with type 2 diabetes is not uniform. A substantial group have normal lipids and normal LDL particle number and size whereas others have markedly abnormal profiles. Diagnosis based on triglycerides and apoB rather than triglycerides and LDL cholesterol revealed that more than one in five had hypertriglyceridemic hyperapoB, which is characterized by hypertriglyceridemia, marked elevation of LDL particle number, small dense LDL, and low HDL, a constellation of abnormalities that is associated with markedly accelerated atherogenesis and therefore justifies intensive medical therapy.
A Randomized Study and Open-Label Extension Evaluating the Long-Term Efficacy of Pramlintide as an Adjunct to Insulin Therapy in Type 1 Diabetes
Authors: Whitehouse Fred , Kruger Davida F. , Fineman Mark , Shen Larry , Ruggles James A. , Maggs David G. , Weyer Christian , Kolterman Orville G.
Published: March 2007

OBJECTIVE—To assess the effect of mealtime amylin replacement with pramlintide on long-term glycemic and weight control in patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS—In a 52-week, double-blind, placebo-controlled, multicenter study, 480 patients with type 1 diabetes were randomized to receive preprandial injections of placebo or 30 μg pramlintide q.i.d., in addition to existing insulin regimens. At week 20, pramlintide-treated patients were re-randomized to 30 or 60 μg pramlintide q.i.d. if decreases from baseline in HbA1c were <1% at week 13. Of the 342 patients who completed the 52-week study, 236 individuals (∼70%) elected to participate in a 1-year open-label extension in which all patients received 30 or 60 μg pramlintide q.i.d..

RESULTS—Treatment with pramlintide led to a mean reduction in HbA1c of 0.67% from baseline to week 13 that was significantly (P < 0.0001) greater than the placebo reduction (0.16%), and a significant placebo-corrected treatment difference was sustained through week 52 (P = 0.0071). The greater HbA1c reduction was associated with an average weight loss, rather than weight gain, and was not accompanied by an increased overall event rate of severe hypoglycemia. In the open-label extension, mean HbA1c levels decreased rapidly in patients receiving pramlintide for the first time and remained at reduced levels in patients who continued pramlintide treatment. The most common adverse events reported by the pramlintide group were mild nausea and anorexia, which both occurred during the initial weeks of treatment and dissipated over time.

CONCLUSIONS—Mealtime pramlintide treatment as an adjunct to insulin improved long-term glycemic control without inducing weight gain or increasing the overall risk of severe hypoglycemia in patients with type 1 diabetes.
A Controlled Evaluation of Staging Dietary Patterns to Reduce the Risk of Diabetes in African-American Women
Authors: Auslander Wendy , Haire-Joshu Debra , Houston Cheryl , Rhee Chaie-Won , Williams James Herbert
Published: March 2007

OBJECTIVE—This study evaluated the 3-month follow-up data of the Eat Well, Live Well Nutrition Program, a culturally specific, peer-led dietary change program designed to reduce the risk of type 2 diabetes in low-income African-American women. This peer-led program was delivered in the community and was tailored to the participants’ stage of change for individual dietary patterns. We report the results of the 3-month intervention and the extent to which dietary changes and other key outcomes were maintained at a 3-month follow-up assessment.

RESEARCH DESIGN AND METHODS—Using an experimental control group design, 294 overweight African-American women (ages 25–55 years), recruited in collaboration with a neighborhood organization, completed pre- and posttest and 3-month follow-up interviews of dietary behaviors, knowledge, attitudes, fat intake, and weight.

RESULTS—Significant reductions were found in fat intake among women in the treatment condition when compared with women in the control group; these reductions were maintained at 3-month follow-up assessment. Likewise, significant changes in dietary patterns were reported after the study and were maintained, except for one dietary pattern (replacement).

CONCLUSIONS—This model of health promotion, which individually tailors dietary patterns through staging and use of peer educators, has the potential for decreasing fat intake and increasing and maintaining specific low-fat dietary patterns among overweight African-American women at risk for diabetes.
Risk Factors for Development of Incipient and Overt Diabetic Nephropathy in Type 1 Diabetic Patients
Authors: Rossing Peter , Hougaard Philip , Parving Hans-Henrik
Published: March 2007

OBJECTIVE—To evaluate prospectively putative risk factors for development of microalbuminuria and macroalbuminuria in type 1 diabetes.

RESEARCH DESIGN AND METHODS—Prospective observational study of a cohort of type 1 diabetic patients followed in the outpatient clinic at Steno Diabetes Center for ≤10 years (median 9 years). We followed 537 patients aged ≥18 years with type 1 diabetes, with duration of diabetes ≥5 years, with normoalbuminuria (urinary albumin excretion rate ≤30 mg/24 h), and who were not taking antihypertensive medication. Risk factors for development of microalbuminuria and macroalbuminuria were evaluated.

RESULTS—The mean progression of urinary albumin excretion rate was 7.6% (SE 0.8) per year. During follow-up, 134 patients (25%) progressed to persistent microalbuminuria or macroalbuminuria (>30 mg/24 h in two of three consecutive urine samples). Cox multiple regression analysis using baseline values of putative predictors of progression showed the following significant predictors of progression from normoalbuminuria to microalbuminuria or macroalbuminuria: baseline log urinary albumin excretion rate 2.63 (relative risk; 95% CI 1.65–4.19), HbA1c 1.13% (1.04–1.23), presence of any retinopathy 1.90 (1.26–2.88), and smoking 1.61 (1.11–2.33). Sex, duration of diabetes, arterial blood pressure, serum creatinine, height, and social class were not risk factors.

CONCLUSIONS—Our study suggests that several potentially modifiable risk factors predict the development of microalbuminuria and macroalbuminuria in type 1 diabetic patients.
Predisposition to Atopic Symptoms to Inhaled Antigens May Protect From Childhood Type 1 Diabetes
Authors: Mattila Petri S. , Tarkkanen Jussi , Saxen Harri , Pitkäniemi Janne , Karvonen Marjatta , Tuomilehto Jaakko ,   the Childhood Diabetes in Finland (DiMe) Study Group
Published: March 2007

OBJECTIVE—To assess the inverse association between type 1 diabetes and asthma to establish whether environmental and/or genetic factors predisposing to asthma or to atopic symptoms to inhaled antigens protect from diabetes.

RESEACH DESIGN AND METHODS—Questionnaires were returned by 306 probands with childhood type 1 diabetes, their 506 nonaffected siblings, and 406 age- and sex-matched unaffected population control subjects. The main outcome measures were self-reported physician-diagnosed asthma and atopic symptoms to animal dust and pollen.

RESULTS—Risk of diabetes was inversely associated with asthma (odds ratio 0.49 [95% CI 0.24–1.00]), allergy to animal dust (0.67 [0.45–0.99]), and to a lesser degree to pollen (0.74 [0.51–1.07]) when the probands were compared with the population control subjects. Among the children of the families of an affected proband, the risk of diabetes appeared to be inversely associated with asthma (0.54 [0.27–1.09]) but not with allergy to animal dust (0.99 [0.66–1.47]) nor allergy to pollen (0.88 [0.62–1.27]).

CONCLUSIONS—The frequency of asthma and atopic symptoms to some inhaled antigens is decreased in individuals with childhood type 1 diabetes. Factors predisposing to atopic symptoms to inhaled antigens may protect from childhood type 1 diabetes.
Renal Outcome in Type 2 Diabetic Patients With or Without Coexisting Nondiabetic Nephropathies
Authors: Wong Teresa Yuk Hwa , Choi Paul Cheung Lung , Szeto Chun Cheuk , To Ka Fai , Tang Nelson Leung Sang , Chan Anthony Wing Hung , Li Philip Kam Tao , Lai Fernand Mac-Moune
Published: March 2007

OBJECTIVE—To determine the risk factors for adverse renal outcome in type 2 diabetic patients who underwent renal biopsy and were followed-up longitudinally.

RESEARCH DESIGN AND METHODS—We examined 68 consecutive patients with type 2 diabetes during the period of 1985–1999 who underwent renal biopsy for proteinuria ≥1 g/day, renal involvement (proteinuria or renal impairment) at the absence of retinopathy, renal involvement with duration of diabetes <5 years, or unexplained hematuria of glomerular origin. Their clinical features and underlying renal lesion were correlated with the renal outcome after longitudinal follow-up. Three groups of patients were defined based on their renal pathology: group I consisted of 24 patients (35%) with diabetic glomerulosclerosis (DGS) alone, group II consisted of 13 patients (19%) with nondiabetic nephropathy (NDN) superimposed on DGS, and group III consisted of 31 patients (46%) with NDN alone without evidence of DGS.

RESULTS—After a mean follow-up of 123 months from the diagnosis of type 2 diabetes (74 months from the time of renal biopsy), univariate analysis showed that risk factors for reaching end-stage renal disease (requiring maintenance dialysis, or a serum creatinine [SCr] ≥700 μmol/l) included proteinuria ≥2 g/day (P = 0.0087), SCr >120 μmol/l (P = 0.0005), presence of retinopathy (P < 0.00001) at the time of biopsy, and biopsy showing DGS (groups I and II) (P = 0.035). On multivariate analysis, retinopathy was the only independent variable correlated with end-stage renal failure. This study also showed that the association of hematuria or proteinuria with the absence of retinopathy constitutes the strongest indication for a nondiabetic lesion (positive predictive values of 94%).

CONCLUSIONS—Patients with type 2 diabetes undergoing renal biopsy constitute a heterogeneous group by their clinical presentations and underlying pathology, but longitudinal studies on the renal outcome of these patients remain limited. Our study showed that renal biopsy is indicated in selective diabetic patients because of potentially treatable nephropathy and of a better prognosis than DGS.
The Association Between Diabetes Metabolic Control and Drug Adherence in an Indigent Population
Authors: Schectman Joel M. , Nadkarni Mohan M. , Voss John D.
Published: March 2007

OBJECTIVE—Studies of the association between diabetes metabolic control and adherence to drug therapy have yielded conflicting results. Because low socioeconomic and minority populations have poorer diabetes outcomes and greater barriers to adherence, we examined the relationship between adherence and diabetes metabolic control in a large indigent population.

RESEARCH DESIGN AND METHODS—The study population consisted of patients receiving medical care from a university-based internal medicine clinic serving a low-income population in rural central Virginia. The sample comprised 810 patients with type 2 diabetes who received oral diabetes medications from the clinic pharmacy and had at least one HbA1c determination during the study period. Multiple linear regression was used to examine the association of HbA1c level as well as change in HbA1c level with medication adherence, demographic, and clinical characteristics.

RESULTS—Better metabolic control was independently associated with greater medication adherence, increasing age, white (versus African-American) race, and lower intensity of drug therapy. For each 10% increment in drug adherence, HbA1c decreased by 0.16% (P < 0.0001). Controlling for other demographic and clinical variables, the mean HbA1c of African-Americans was 0.29% higher than that of whites (P = 0.04). Additionally, the intensity of diabetes drug therapy for African-Americans was lower, as was their measured adherence to it. There was no association between metabolic control and gender, income, encounter frequency, frequency of HbA1c testing, or continuity of care.

CONCLUSIONS—Adherence to medication regimens for type 2 diabetes is strongly associated with metabolic control in an indigent population; African-Americans have lower adherence and worse metabolic control. Greater efforts are clearly needed to facilitate diabetes self-management behaviors of low-income populations and foster culturally sensitive and appropriate care for minority groups.
Young Men With High-Normal Blood Pressure Have Lower Serum Adiponectin, Smaller LDL Size, and Higher Elevated Heart Rate Than Those With Optimal Blood Pressure
Authors: Kazumi Tsutomu , Kawaguchi Akira , Sakai Keiko , Hirano Tsutomu , Yoshino Gen
Published: March 2007

OBJECTIVE—Three measures—heart rate, a global index of the influence of the autonomic nervous system on the heart; circulating concentrations of adiponectin, an adipose-specific protein; and C-reactive protein (CRP), a sensitive marker of inflammation—have been reported to be closely associated with insulin resistance. Patients with borderline hypertension are known to be more insulin resistant and dyslipidemic than those with normal blood pressure (BP). BP can be classified into three categories: optimal, normal, and high-normal. The present study examined whether those with high-normal BP have any of these three conditions as compared with those with optimal BP in young healthy men.

RESEARCH DESIGN AND METHODS—Anthropometric, blood pressure, heart rate, and blood tests, including tests for adiponectin and CRP, were conducted in 198 male students, ages 18–26 years, who had fasted overnight. Insulin resistance (IR) and insulin secretion (β-cell levels) were calculated using the homeostasis model assessment (HOMA), and LDL size was measured by PAGE.

RESULTS—Compared with the 90 men who had optimal BP, the 46 men with high-normal BP had increased heart rate, BMI, percent body fat, and serum leptin levels. In addition, they had greater serum insulin, HOMA IR, and β-cell levels, lower adiponectin levels, and comparable CRP levels. Furthermore, the 46 men with high-normal BP had higher serum triglyceride and apolipoprotein (apo) B levels, and smaller LDL size; however, there was no difference in LDL and HDL cholesterol and apoA-I between men with optimal and high-normal BP. After adjusting for BMI, differences were still significant in serum adiponectin, heart rate, and LDL particle size. As BP rose, there was an increase in heart rate (BMI-adjusted least square means were 63, 65, and 70 bpm in men with optimal, normal, and high-normal BP, respectively; P = 0.005), whereas serum adiponectin (7.5, 6.6, and 6.4 mg/l; P = 0.007) and LDL particle size (271, 269, and 269 Å; P = 0.008) decreased.

CONCLUSIONS—Young men with high-normal BP have a faster heart rate, lower serum adiponectin levels, and smaller LDL size than men with optimal BP, even after adjustment for BMI. These results suggest the necessity of preventing further development of cardiac and metabolic diseases in young people who have high-normal BP.
Longitudinal Association of Glycemia and Microalbuminuria
Authors: Meigs James B. , D’Agostino Ralph B. , Nathan David M. , Rifai Nader , Wilson Peter W.F.
Published: March 2007

OBJECTIVE—To assess current and long-term associations of glycemia with microalbuminuria, a marker of generalized endothelial injury.

RESEARCH DESIGN AND METHODS—We measured clinical characteristics, fasting plasma glucose, and the urinary albumin-to-creatinine ratio (UACR) in 1,311 men and 1,518 women attending the sixth examination cycle (1995–1998) of the Framingham Offspring Study. After excluding participants with diabetes or cardiovascular disease (CVD) at the baseline examination (1971–1974), we used fasting glucose measured at baseline, examination 6, and at least two additional examinations from 1974 to 1995 in regression models to predict risk for microalbuminuria (UACR ≥30 mg/g) associated with baseline, current, and 24-year time-integrated glycemia.

RESULTS—Microalbuminuria was present in 9.5% of men and 13.4% of women. Among men, age-adjusted odds ratios (95% CI) for microalbuminuria associated with each 0.28 mmol/l (5 mg/dl) increase in baseline, current, and time-integrated glucose levels were 1.12 (1.00–1.16), 1.08 (1.05–1.10), and 1.16 (1.11–1.21), respectively. These effects persisted after adjustment for systolic blood pressure and other confounders. Higher glucose levels also predicted incident diabetes and CVD. Mean time-integrated glucose levels were highest among men who developed both CVD and microalbuminuria (SE 6.82 ± 0.16 mmol/l), intermediate among men with either condition (6.03 ± 0.65 mmol/l), and lowest among men with neither condition (5.49 ± 0.02 mmol/l; P < 0.001 for all pairwise comparisons). We observed similar associations in women.

CONCLUSIONS—Long-term hyperglycemia and subdiabetic glycemia increase risk for microalbuminuria. Microalbuminuria, type 2 diabetes, and CVD seem to arise together over the course of decades, consistent with the hypothesis that they share a common antecedent.
A Prospective Study of Obesity and Risk of Coronary Heart Disease Among Diabetic Women
Authors: Cho Eunyoung , Manson Joann E. , Stampfer Meir J. , Solomon Caren G. , Colditz Graham A. , Speizer Frank E. , Willett Walter C. , Hu Frank B.
Published: March 2007

OBJECTIVE—To examine the relationship of obesity, measured as BMI, and weight change to incidence of coronary heart disease (CHD) among women with diabetes.

RESEARCH DESIGN AND METHODS—We followed 5,897 women with type 2 diabetes in the Nurses’ Health Study for ≤20 years. Women were aged 40–74 years and had no history of cardiovascular disease or cancer at the beginning of the follow-up period. BMI values from three time points (age 18 years, year 1976, and current) were derived from the reported height (1976) and corresponding reported weight. Weight changes between age 18 years and 1976 and after diagnosis of diabetes were calculated. Women reported diagnoses of diabetes and CHD every 2 years. Incident CHD cases were confirmed by medical record review.

RESULTS—During follow-up, we documented 418 incident cases of CHD (236 of nonfatal myocardial infarction and 182 of fatal CHD). After adjustment for age, smoking, and other coronary risk factors, current BMI was strongly associated with increased risk of CHD among diabetic women. The multivariate relative risks across increasing categories of BMI (<23.0, 23.0–24.9, 25.0–26.9, 27.0–29.9, 30.0–34.9, and ≥35.0 kg/m2) were 1.0, 1.58, 1.85, 1.95, 2.80, and 3.21, respectively (P for trend <0.001). Increasing BMI values from age 18 years to 1976, before diagnosis of diabetes, were also positively associated with risk of CHD. Weight gain before the diagnosis of diabetes was related to increased risk of CHD. In contrast, weight change after diagnosis of diabetes was not associated with risk of CHD.

CONCLUSIONS—These findings provide strong evidence that obesity and weight gain before diagnosis of diabetes are associated with future risk of CHD among women with type 2 diabetes.
Diabetes Care in the U.S. and Canada
Authors: Booth Gillian L. , Zinman Bernard , Redelmeier Donald A.
Published: March 2007

OBJECTIVE—To compare the glycemic control of patients with type 1 diabetes treated in the U.S. and Canada.

RESEARCH DESIGN AND METHODS—A large multicenter randomized clinical trial conducted in the U.S. and Canada was analyzed. Patients with type 1 diabetes, screened from 1983 to 1989 for enrollment in the Diabetes Control and Complications Trial (DCCT), were categorized as treated in the U.S. (n = 2,604) or Canada (n = 245). HbA1c levels were compared between U.S. and Canadian patients, both before and after adjustment for predictors of HbA1c.

RESULTS—In general, volunteers screened for the DCCT were highly educated and following healthy lifestyles. Canadians were somewhat younger (25 vs. 27 years of age, P = 0.002), less likely to be college educated (62 vs. 71%, P = 0.002), more likely to receive care through a family doctor (41 vs. 28%, P = 0.001), and had a higher frequency of out-patient visits (4 vs. 3 per year, P = 0.004). Despite these differences in health care delivery, the mean HbA1c at baseline was identical in the two countries (8.9 vs. 9.0, P = 0.40). Adjustment for demographic, lifestyle, and clinical predictors of HbA1c yielded similar findings (9.0 vs. 9.2, P = 0.15). Equal percentages of American and Canadian patients who were screened ultimately entered the trial (21 vs. 19%, P = 0.20), and those randomized to conventional care achieved similar mean HbA1c levels (9.1 vs. 9.2, P = 0.50).

CONCLUSIONS—Differences in care delivery patterns do not yield large differences in glycemic control for patients with type 1 diabetes who were recruited in the U.S. and Canada for a large randomized trial.
A Prospective Analysis of Marital Relationship Factors and Quality of Life in Diabetes
Authors: Trief Paula M. , Wade Michael J. , Britton Kirsten Dee , Weinstock Ruth S.
Published: March 2007

OBJECTIVE—To prospectively assess the relation between marital relationship domains (i.e., intimacy and adjustment) and health-related quality of life (HRQoL) and glycemic control of individuals with diabetes.

RESEARCH DESIGN AND METHODS—A previous cross-sectional study assessed the relationship between marital quality and adaptation to diabetes for 78 insulin-treated adults. Each participant completed two marital quality measures (Spanier Dyadic Adjustment Scale and Personal Assessment of Intimacy in Relationships Scale) at time 1 (T1). A total of 61 subjects were contacted two years later (time 2 [T2]) and re-administered four HRQoL measures (Diabetes Quality of Life Scale, Medical Outcomes Study Health Survey-SF36, Problem Areas in Diabetes Scale, and Positive and Negative Affect Schedule). Glycemic control was assessed by HbA1c. Demographic data (age, sex, type and duration of diabetes, years married, other medical problems, family history, and years of education) were gathered from charts and questionnaires. Linear regression analyses were used to assess the ability of the two marital measures at T1 to predict HRQoL at T2, controlling for confounding HRQoL and baseline subject variables.

RESULTS—Both of the marital quality measures at T1 were prospective predictors of aspects of HRQoL at T2. Less diabetes-related distress at T2 was predicted by better marital adjustment at T1. Greater satisfaction with aspects of the diabetes care regimen at T2 was predicted by better marital adjustment and greater perceived marital intimacy at T1. Neither marital measure predicted general HRQoL or glycemic control.

CONCLUSIONS—For insulin-treated adults with diabetes, quality of marriage prospectively predicts diabetes-related quality of life. This study highlights the sensitivity of diabetes-specific measures. Future work should explore the value of interventions that target the spouse and/or couple.