Longitudinal predictors of reduced mobility and physical disability in patients with type 2 diabetes: the Fremantle Diabetes Study

Effects of Diabetes and Attentional Focus on Learning of a Novel Balance Task

BACKGROUND AND PURPOSE

Chronic diabetes is a prevalent systemic disease that impairs neuromotor functioning and often leads to increased risk of falls. Adopting an external focus of attention during motor skill practice has been shown to improve learning outcomes; however, it has not been examined in this population. We examined how attentional focus instructions (internal vs external) affect balance performance and learning in older adults with and without diabetes.

METHODS

Fifty-three older adults (27 with diabetes, 63.7 ± 7.0 years) participated in the randomized, pre-post intervention study. The balance training involved 50 practice trials of a stabilometer task that was novel to all participants. Participants were randomized to receive either internal or external focus task instruction. Task performance was assessed at baseline, during training, and during a retention test. Primary outcomes were changes in balance task performance before and after training.

RESULTS

Participants who received external focus instruction showed a significantly greater increase in balance performance than individuals who received internal focus instruction (95% confidence interval, 0.02-4.05; P = 0.048). While participants with diabetes exhibited poorer baseline task performance (P = 0.02), both groups improved their relative task performance after training (95% confidence interval, 5.25-18.14; P < 0.0001).

DISCUSSION AND CONCLUSIONS

Adopting an external focus of attention benefits performance during short-term training of a novel balance task in older adults with and without diabetes. Participants with diabetes were capable of learning the challenging balance task with practice, at a relative rate similar to those without diabetes. This information may be useful for designing interventional strategies to improve physical function and mitigate fall risks in older adults with diabetes.

Effects of an Exercise and Lifestyle Education Program in Brazilians living with prediabetes or diabetes: study protocol for a multicenter randomized controlled trial

BACKGROUND

Patient education is a crucial strategy for promoting prevention and diabetes self-management since glycemic control achievement involves taking medications, medical nutrition therapy, physical exercise, and behavior changes. However, patient education programs are still barely implemented in low- and middle-income countries. This trial aims to investigate whether a lifestyle education intervention added to physical exercising is superior to sole physical exercising regarding functional capacity, disease-related knowledge, health behaviors, cardiometabolic health parameters, quality of life, depression, and diet quality in individuals with prediabetes or diabetes.

METHODS

Multicenter double-blinded randomized controlled trial with two parallel arms involving 12-week intervention and 6-month follow-up. The eligible individuals (≥ 18 years, living with prediabetes or diabetes, literate, no clinical decompensation and/or physical and/or mental limitations that contraindicate physical exercising, written physician permission for exercise, no cognitive impairment, no vision limitations for reading, no confirmed diagnosis of unstable coronary disease or heart failure, no pacemaker and/or implantable cardioverter-defibrillator, no complex ventricular arrhythmias, no intermittent claudication, no recent cardiovascular event or cardiac surgery, and no currently enrolled in a structured exercise program) were recruited from two Brazilian cities and randomized to either (1) an Exercise and Lifestyle Education Program (ExLE) or (2) an Exercise Program (Ex), which can be delivered on-site or remotely based on the participants' internet access and technology literacy. The primary outcomes will be changes in functional capacity and disease-related knowledge. The secondary outcomes will involve changes in health behaviors (health literacy, physical activity level, exercise self-efficacy, and medication adherence) and cardiometabolic health parameters (glycemic control, anthropometric measures, and cardiac autonomic control). Program adherence, satisfaction with the program, diabetes-related morbidity, and changes in quality of life, depression, and diet quality will be the tertiary outcomes. Assessments will occur at baseline, post-intervention, and after 6-month follow-up.

DISCUSSION

If superior effectiveness of ExLE compared to Ex program to improve the outcomes measures is found, this program could be delivered broadly in the Brazilian health system, especially in the primary care facilities where most individuals living with prediabetes and diabetes in our country are assisted.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03914924 . Registered on April 16, 2019.

Improvement in physical function and lipid profile following low-intensity resistance training and a lower limb conditioning program in people with diabetic neuropathy

BACKGROUND

Diabetic peripheral neuropathy (DPN) impairs glucose and fat metabolism and physical functioning. This study examined the effects of low-intensity resistance exercise training (LI-RT) and a lower limb conditioning program (LLCP) on physical function and lipid profile in DPN.

METHODS

Forty-five diabetic women with mild to moderate neuropathy (55.5 ± 3.1 y) were randomly assigned to one of three groups: LI-RT (n = 15), LLCP (n = 15), and control (n = 15). The LI-RT and LLCP groups trained 3 times/week (90 min/session) for 12 weeks. The LI-RT group completed 3 sets of 10 repetitions for ten exercises at 30-repetition maximum; the LLCP group performed 12 lower extremity motions designed for peripheral neuropathy; and the control group followed their routine daily activities. Physical function was assessed using the Timed Up and Go Test (TUG), Five Times Sit-to-Stand (FTSTS) test, and 6-min walking test (6MWT). Blood lipid profile was assessed.

RESULTS

Both the LI-RT and LLCP groups significantly improved in TUG scores compared to the control group (p ≤ 0.05). No significant changes between groups were observed for the FTSTS and 6MWT. The LI-RT and LLCP groups, compared to the control group, showed a significant reduction in low-density lipoprotein (p ≤ 0.05), and triglycerides (p ≤ 0.001). High-density lipoproteins showed non-significant changes.

CONCLUSION

Low intensity training involving resistance exercises or lower limb range of motion enhance physical function and lipid profile in patients with DPN. High intensity exercise could be risky and deter adherence. Hence, these gentler exercise programs offer viable options for enhancing health and fitness in DPN patients.

The impact of physical disability on the risk of gastric cancer incidence in elderly patients with diabetes: a focus on regional disparity

PURPOSE

Elderly patients with type 2 diabetes mellitus (T2DM) may have a higher risk of physical disability. This study investigated the incidence of gastric cancer according to physical disability status in elderly patients with T2DM.

METHODS

The National Health Insurance Service claims data were used. A total of 76,162 participants aged 60 years or above, diagnosed with T2DM, were included. The association between physical disability status and gastric cancer incidence was evaluated using the Cox regression analysis. Additionally, subgroup analysis was performed according to region.

RESULTS

A total of 9,154 (12.0%) individuals had physical disability. Gastric cancer incidence was more common in participants with physical disability (3.3%) than those without (2.4%). A higher risk of gastric cancer incidence was found in elderly T2DM patients with physical disability (Hazard Ratio (HR) 1.18, 95% Confidence Interval (95% CI) 1.04-1.34). Such tendencies were maintained regardless of region, although the effect of physical disability status on gastric cancer incidence was particularly significant in individuals residing in non-metropolitan areas (HR: 1.19, 95% CI: 1.01-1.40).

CONCLUSION

Elderly patients with T2DM who had physical disability showed a higher risk of gastric cancer incidence. The findings suggest a need to monitor elderly T2DM patients with disability as they may be susceptible to difficulties in accessing cancer-related healthcare.

Group-Based Trajectory Modelling of Changes in Mobility over Six Years in Type 2 Diabetes: The Fremantle Diabetes Study Phase II

To investigate temporal changes in mobility in community-based people with type 2 diabetes, Fremantle Diabetes Study Phase II (FDS2) data were analysed. The baseline assessment included the Timed Up and Go (TUG) test, which was repeated biennially for up to six years. Group-based trajectory modelling (GBTM) identified TUG trajectory groups in participants with ≥2 tests. Independent associates of group membership were assessed using multinomial regression. Of 1551 potential FDS2 participants, 1116 (72.0%; age 64.9 ± 11.0 years, 45.6% female) were included in the modelling. The best-fitting GBTM model identified two groups with linear, minimally changing trajectories (76.2% and 19.4% of participants; baseline TUG times 8 ± 2 and 12 ± 3 s, respectively), and a third (4.5%; baseline TUG 17 ± 5 s) with a TUG that increased over time then fell at Year 6, reflecting participant attrition. Both slower groups were older, more likely to be female, obese, and had greater diabetes-associated complications and comorbidities. Almost one-quarter of the FDS2 cohort had clinically relevant mobility impairment that persisted or worsened over six years, was multifactorial in origin, and was associated with excess late withdrawals and deaths. The TUG may have important clinical utility in assessing mobility and its consequences in adults with type 2 diabetes.

Feasibility of Remote Delivering an Exercise and Lifestyle Education Program for Individuals Living with Prediabetes and Diabetes in Brazil

This study aimed to test the feasibility of remote delivering a 12-week exercise and lifestyle education program (ExLE) or a 12-week exercise program (Ex) for individuals with prediabetes and diabetes in terms of acceptability, implementation, practicality, and limited efficacy. The programs were internet- or telephone-based delivered, depending on the participants' internet access and technology literacy. Of the 196 individuals screened, 15 were included in the study (internet-based delivery (n = 13); telephone-based delivery (n = 2)). Twelve participants completed the program they were randomized to, and most reported being satisfied with the study interventions (acceptability). Data collection procedures, weekly follow-up, study website visits, and educational materials were proper (implementation), and the adherence rate to study interventions ranged from 24% to 58% (practicality). Additionally, both programs (ExLE and Ex) seemed to promote beneficial changes in functional capacity (limited efficacy). The internet-based remote delivery of the interventions showed feasibility. Therefore, in future trials, exercise and educational interventions can be internet-based remote delivered to individuals with prediabetes and diabetes with internet access and technology literacy. In addition, some adjustments to eligibility criteria, study websites, more accessible ways of recording exercise sessions and using educational materials, and an initial supervised exercise session are recommended.

Long-Term Influence of Locus of Control and Quality of Life on Metabolic Profile in Elderly Subjects with Type 2 Diabetes

BACKGROUND

The Locus of Control (LOC) is a mental disposition indicating the individuals' belief that disease-related outcomes are under their own control (Internal), dependent on others (External), or dependent on chance (Chance). Quality of Life (QoL) and LOC may have complex effects on self-care activities and diabetes management in subjects with type 2 diabetes (T2D). The aim of the present study was to evaluate the predictive role of LOC and QoL scores on metabolic control in elderly T2D outpatients, secondly evaluating potential gender differences.

METHODS

An extensive set of questionnaires was administered to a group of consecutive elderly T2D outpatients on oral glucose-lowering drugs attending a single diabetes center. Personal and clinical variables were analyzed at baseline (between 1 February and 31 March 2015) and after 6 years of follow-up.

RESULTS

At baseline, study participants showed an overall good metabolic control. Diabetes Specific Quality of Life (DSQoL) scores indicated an overall good QoL in both genders, with a higher DSQoL satisfaction score in women. Both genders presented higher scores in the LOC-Internal domain, with men reaching higher scores in the LOC-External domain than women. At the 6-years follow-up, subjects with baseline higher LOC-External score presented better metabolic outcome. In the regression analysis, LOC-External score was an independent predictor of good metabolic control maintenance, but this result was only statistically significant in men.

CONCLUSIONS

LOC scores may influence long-term glycemic control in elderly T2D patients on oral glucose-lowering drugs.

The pattern of physical disability and determinants of activities of daily living among people with diabetes in Bangladesh

INTRODUCTION

Diabetes mellitus itself is a known predictor of physical disability and impairment in activities of daily living (ADL); however, there are existing controversies about the factors explaining the association between diabetes and disability. Therefore, we assessed the possible determinants associated with ADL impairment among people with diabetes in Dhaka city, Bangladesh.

METHODS

We conducted a cross-sectional study among 480 people with diabetes aged between 50 and 70 years, and attended a tertiary level hospital in Dhaka city. For determining the ADL impairment, we used the Katz Index Scoring (6 = no impairment; <6 = impairment). Age, sex, educational attainment, household expenditure, body mass index, the status of diabetes (controlled or uncontrolled), hypertension and medication adherence to anti-diabetic drugs were included in the statistical models, and we defined any ADL impairment (Katz score <6) as an event. Multivariable logistic regression was performed to assess the significance of relevant factors.

RESULTS

The mean age of the participants was 59.0 (standard deviation [SD], 7.0) years. The majority of the participants (76.3%) had at least some sort of physical disability. In multivariable logistic regression analysis after adjusting for all covariates simultaneously, age (odds ratio [95% confidence interval]: 1.35 [1.20 to 1.75] per 1-SD increment), BMI (1.32 [1.08 to 1.21] per 1-SD increment), higher educational attainment (0.34 [0.09-0.90]), multi-morbidity (2.79 [1.48-5.25]) and uncontrolled diabetes (1.35 [1.10-1.45]) were independently associated with ADL impairment.

CONCLUSIONS

Physical disability was common, and ADL impairment was associated with age, educational attainment, BMI, multi-morbidities and uncontrolled diabetes among the people with diabetes in Bangladesh.

Loneliness and functional limitations among older adults with diabetes: Comparing directional models

OBJECTIVE

Middle-aged and older adults with diabetes are at increased risk for loneliness and functional limitations. Cross-sectional and longitudinal associations between loneliness and functional limitations have been demonstrated among the general population, but have not been established among those with diabetes. The purpose of this study was to directly compare the following models describing the direction of the association between loneliness and functional limitations among people with diabetes: (1) loneliness leads to functional limitations, (2) functional limitations lead to loneliness, and (3) a bidirectional association between loneliness and functional limitations.

METHODS

Data came from the Health and Retirement Study. Participants were middle-aged and older individuals with diabetes in the United States (n = 2934). Loneliness and functional limitations were measured at baseline, 4-year follow-up, and 8-year follow-up. Path models for each of the three models, as well as a stability model, were created. Model fit was compared using Akaike's Information Criteria (AIC).

RESULTS

Participants were 54.6% female, 74.98% White, had a mean age of 69.66 years, had an average of 1.48 comorbid chronic conditions, and had diabetes for an average of 10.40 years. The bidirectional model best fit the data as evidenced by the lowest AIC value (AIC = 171,162.81). ∆AIC between the bidirectional model and the next best fitting model was 16.19, indicating strong support for selecting the bidirectional model. Higher levels of loneliness were associated with subsequent higher levels of functional limitations at some time points (βs = 0.07, 0.02) and higher levels of functional limitations were associated with subsequent higher levels of loneliness (βs = 0.13, 0.06) at all time points.

CONCLUSION

Results suggest that the association between loneliness and functional limitations among individuals with diabetes is bidirectional. This study demonstrates the value of directly comparing directional models.

Predictive factors of functional abilities in older patients with peripheral neuropathy

BACKGROUND AND AIMS

Little is known about the outcome predictors in peripheral neuropathy (PN). This prospective observational study aimed to identify possible factors predicting the functional abilities in older patients with PN undergoing motor rehabilitation.

METHODS

Data were collected in 80 PN patients, aged over 65 years, performing a standard inpatient motor rehabilitation program. The total Functional Independence Measure (FIM) score after rehabilitation, as well as efficiency and effectiveness in total-FIM, were the outcome measures. Backward multiple regression analyses identified the predictors of functional status.

RESULTS

At the end of rehabilitation, total-FIM score was 102.66 ± 10.75, efficiency in total-FIM 0.64 ± 0.29 and effectiveness in total-FIM 48.81 ± 15.35%. Katz index at admission was a predictor of the final total-FIM score (beta 0.46, p < 0.001) and efficiency in total-FIM (beta - 0.38, p = 0.001). Conversely, age was a predictor of the final total-FIM score (beta - 0.31, p = 0.002) and effectiveness in total-FIM (beta - 0.49, p < 0.001). The R2 values of the models were, respectively, 0.39, 0.15, and 0.24.

DISCUSSION

In PN patients, functional impairment at admission and age are important predictors of functional abilities at the end of rehabilitation.

CONCLUSIONS

These findings suggest the need for more intensive rehabilitation in older, more disabled PN patients because they risk achieving lower functional levels with standard rehabilitation programs.

Physical Rehabilitation in Older Patients Hospitalized with Acute Heart Failure and Diabetes: Insights from REHAB-HF

BACKGROUND

Prior studies showed an attenuated response to exercise training among patients with heart failure and type 2 diabetes mellitus. We explored the interaction between diabetes status and a novel, transitional, tailored, progressive rehabilitation intervention that improved physical function compared with usual care in the Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial.

METHODS

The effect of the intervention on 3-month Short Physical Performance Battery (SPPB) (primary endpoint), 6-minute walk distance (6MWD), modified Fried frailty criteria, and quality-of-life scores (Kansas City Cardiomyopathy Questionnaire [KCCQ] and EuroQoL Visual Analogue Scale [VAS]) was compared between participants with and without diabetes. Differences in 6-month clinical outcomes were also explored.

RESULTS

Of the 349 participants enrolled in REHAB-HF, 186 (53%) had diabetes. The prevalence of diabetes was higher in the intervention group (59% vs 48%). Participants with diabetes had worse baseline physical function by the SPPB and 6MWD, but similar frailty and quality-of-life scores. There was a consistent improvement with the intervention for 3-month SPPB, 6MWD, and VAS regardless of diabetes status (all interaction P value > .6), but participants with diabetes had significantly less improvement for frailty (P = .021) and a trend toward lower improvement in KCCQ (P = .11). There was no significant interaction by diabetes status for 6-month clinical event outcomes (all interaction P value > .3).

CONCLUSIONS

Participants with diabetes had worse baseline physical function but showed similar clinically meaningful improvements from the intervention. There was less benefit for frailty with the intervention in participants with diabetes.

Kidney Function and Risk of Physical and Cognitive Impairment in Older Persons with Type 2 Diabetes at an Outpatient Clinic with Geriatric Assessment Implementation

PURPOSE

Diabetes is associated with an increased risk of cognitive and physical functional decline that may impede disease self-management. By incorporating cognitive and physical function assessment, this study aimed to evaluate prevalence and factors associated with cognitive and physical dysfunction in older diabetic people.

METHODS

The cross-sectional study was performed from August 1, 2017 to November 30, 2018. The patients aged 65 years or older with type 2 diabetes mellitus were enrolled and the disease was routinely evaluated by blood hemoglobin A1c (A1C), blood pressure, lipids, and kidney function measured by estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine rate (UACR). Besides, cognitive dysfunction through Mini-mental State Examination (MMSE), and functional disabilities by Activities of Daily Living (ADL) questionnaire were assessed simultaneously.

RESULTS

Among 863 patients (48.3% men) with a median age of 72.0 years (interquartile range or IQR: 67.0-78.0 years), 159 (18.5%) had cognitive impairment assessed by MMSE, while 40 (4.6%) experienced at least one problem in ADL. With different A1C stratifications, it was shown that both MMSE and ADL scores were associated with glycemic control. Patients with impaired MMSE and ADL scores were older, had lower eGFR, lower blood pressure, and higher UACR levels. After adjustment of possible confounders, it was shown that age and eGFR predicted MMSE and ADL score impairment.

CONCLUSION

By incorporating physical and cognitive function screening program into routine care at a diabetes outpatient clinic, our study found that both cognitive and physical function impairment were common in older diabetic patients, and their relevant factors, including older age, and lower eGFR. It was recommended that in older individuals with diabetes, particularly those with risk factors, an additional assessment of cognitive and physical functions can be integrated into routine clinical process to provide more comprehensive management plans.

Quality of life among type II diabetic patients attending the primary health centers of King Saud Medical City in Riyadh, Saudi Arabia

Background/Aim

Type 2 diabetic patients (T2DM) have lower quality of life (QoL) compared to the general population. This study was conducted to determine QoL of T2DM patients and analyze factors that affect patients' QoL.

Methods

We conducted this cross-sectional study in January to February of 2019 at several primary care health centers (PCHC) in Riyadh, Saudi Arabia. All adult T2DM patients were invited to participate in the study. We used the EQ-5D-3L and EQ VAS tools to determine the patients' health state and their self-rated overall health.

Results

A total of 274 T2DM patients were surveyed, 149 (54.4%) were males. The mean age was 59.7 ± 10.4 years. Of the five EQ-5D-5L domains, self-care had the highest proportion that reported no problem (n = 183, 66.8%). The mobility domain had the highest proportion of reported severe problems (n = 37, 13.5%) and extreme problems (n = 7, 2.6%). Nineteen (6.9%) patients reported with a full state of health. The mean EQVAS was 65.9 ± 22.1, with only 24.1% reported as between 81-100%. Females, patients above 75 years old, those who are in the low socioeconomic income, unemployed, widow had lower EQ VAS.

Conclusion

Males, with higher socioeconomic status, employed, married and younger patients experience better QoL compared to their counterparts. The overall health related QoL among our diabetic patients is low. These findings suggest improvement of health-related QoL, and more efforts should be invested in patient education particularly among patients who are in the low socioeconomic status, the elderly, females and the unemployed.

Dosing Activity and Return to Preulcer Function in Diabetes-Related Foot Ulcer Remission

Diabetes-related foot ulcers are a leading cause of global morbidity, mortality, and health-care costs. People with a history of foot ulcers have a diminished quality of life attributed to limited walking and mobility. One of the largest concerns is ulceration recurrence. Approximately 40% of patients with ulcerations will have a recurrent ulcer in the year after healing, and most occur in the first 3 months after wound healing. Hence, this period after ulceration is called "remission" due to this risk of reulceration. Promoting and fostering mobility is an integral part of everyday life and is important for maintaining good physical health and health-related quality of life for all people living with diabetes. In this short perspective, we provide recommendations on how to safely increase walking activity and facilitate appropriate off-loading and monitoring in people with a recently healed foot ulcer, foot reconstruction, or partial foot amputation. Interventions include monitored activity training, dosed out in steadily increasing increments and coupled with daily skin temperature monitoring, which can identify dangerous "hotspots" prone to recurrence. By understanding areas at risk, patients are empowered to maximize ulcer-free days and to enable an improved quality of life. This perspective outlines a unified strategy to treat patients in the remission period after ulceration and aims to provide clinicians with appropriate patient recommendations based on best available evidence and expert opinion to educate their patients to ensure a safe transition to footwear and return to activity.

Association of Risk Factors with Receiving a Foot Check in People With Diabetes: NHANES 2013-2016

AIMS

The American Diabetes Association (ADA) recommends annual foot examinations for those with diabetes. The factors related to who receives an annual examination is not completely understood. This study aims to identify factors that influence whether individuals with diabtes had their feet checked for sores or irritations.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES), were analyzed to determine the factors that influence whether an annual foot check was performed.

RESULTS

Participants with abnormal A1C (> 6.5%) had higher odds of having their feet checked compared to those with a normal A1C (adjusted odds ratio [AOR] = 2.61; 95% confidence interval (CI): 1.28-5.30). The presence of retinopathy (AOR = 2.76; 95% CI:1.13-6.73) or kidney disease (AOR = 2.37; 95% CI:1.11-5.03) also increased the odds of a foot check. Finally, the number of risk factors for diabetic complications was significantly associated with having a foot check when modeled as a continuous variable (AOR = 1.36; 95% CI: 1.14-1.63).

CONCLUSIONS

Whether an individual received an annual foot check for sores or irritations was influenced by the number of risk factors they had, especially an elevated A1C value, and the presence of retinopathy or kidney disease.

Diabetes multimorbidity combinations and disability in the Mexican Health and Aging Study, 2012-2015

PURPOSE

The aim of this study was to investigate the relationship between specific combinations of chronic conditions and disability in Mexican older adults with diabetes.

METHODS

This was a prospective cohort study of Mexican adults (n = 2558) with diabetes and aged 51 or older that used data from the 2012 and 2015 waves of the Mexican Health and Aging Study. The main outcome was an index that measured ability to perform activities of daily living and instrumental activities of daily living. The main independent variables were diabetes multimorbidity combinations, defined as diabetes and at least one other chronic condition. The authors calculated the prevalence of each multimorbidity combination present in the sample in 2012 and used negative binomial regression models to estimate the association of the most prevalent of these combinations with disability incidence in 2015.

RESULTS

The three most prevalent combinations were: 1) diabetes-hypertension (n = 637, 31.9%) 2) diabetes-hypertension-depression (n = 388, 19.4%) and 3) diabetes-depression (n = 211, 10.6%). In fully adjusted models comparing participants with specific multimorbidity combinations to participants with diabetes alone, the combinations that had an increased association with disability were diabetes-hypertension-depression, diabetes-depression and diabetes-hypertension-arthritis-depression. In nested models, the addition of arthritis to combinations including depression increased this association.

CONCLUSIONS

Consistent with prior studies, multimorbidity combinations including depression were associated with increased risk of disability. However, the effect size of this relationship was lower than what had been previously been reported internationally. This highlights the need for globally oriented multimorbidity research.

Feasibility and behavioral effects of prolonged static and dynamic standing as compared to sitting in older adults with type 2 diabetes mellitus

Background

Physical inactivity is prevalent in older adults with type 2 diabetes mellitus (T2DM) and may exacerbate their clinical symptoms. The aim of this study was to examine the feasibility of 4-h regular versus more dynamic standing sessions while performing routine desktop activities as a non-exercise physical activity intervention in older adults with T2DM to increase non-exercise activity.

Methods

Twelve older adult patients with T2DM (3 female; age 71 ± 4 years; Body mass index 34 ± 5 kg/m²) completed three sessions (baseline sitting followed by “static” or “dynamic” desktop standing sessions). Participants stood behind a regular height-adjustable desk in the “static” standing session. An upright dynamic standing desk, which provides cues to make small weight-shifting movements, was used for the “dynamic” standing session. Oxygen consumption, cognitive performance, as well as net standing duration, total movement activity, and musculoskeletal discomfort were assessed during all three sessions.

Results

All participants were able to complete all sessions. Oxygen consumption and overall movements progressively increased from sitting to static and dynamic standing, respectively (p < 0.001). The duration of breaks during standing (p = 0.024) and rate of total musculoskeletal discomfort development (p = 0.043) were lower in the dynamic standing compared to static standing sessions. There was no evidence of executive cognitive worsening during either standing session compared to sitting.

Conclusions

Prolonged 4-h standing as a simple non-exercise physical intervention is feasible in older adults with T2DM and may have metabolic (oxygen consumption) benefits. Increasing movement during desktop standing may offer incremental benefits compared to regular standing. Prolonged desktop standing might provide an effective intervention in T2DM older participants to target sedentariness.

Trial registration

ClinicalTrials.gov (NCT04410055), retrospectively registered May 27, 2020.

In peripheral artery disease, diabetes is associated with reduced physical activity level and physical function and impaired cardiac autonomic control: A cross-sectional study

BACKGROUND

Diabetes has been considered a major risk factor for peripheral artery disease (PAD). The effect of diabetes on daily physical activity level and cardiovascular function in PAD patients is poorly known.

OBJECTIVE

To analyze the effect of diabetes on physical activity level, physical function and cardiovascular health parameters in patients with PAD and claudication symptoms.

METHODS

Cross-sectional study of 267 PAD patients, 146 without and 121 with diabetes. Physical activity levels were objectively measured by using an accelerometer, and time spent in sedentary (0-100 counts/min), light (101-1040 counts/min) and moderate to vigorous (≥1041 counts/min) physical activity was obtained. Physical function assessment included the 6-min walk test, handgrip strength test and short physical performance battery. Cardiovascular health parameters measured were brachial blood pressure, heart rate variability, and arterial stiffness.

RESULTS

Diabetic PAD patients spent more time in sedentary behavior (P=0.001, effect size [ES] 0.234) and less time in light (P=0.003, ES=0.206) and moderate-to-vigorous physical activity (P<0.001, ES=0.258) than non-diabetic PAD patients. Diabetic PAD patients presented lower 6-min walk distance (P=0.005, ES=0.194) and impaired cardiac autonomic modulation (standard deviation of all NN intervals [SDNN], P<0.001, ES=0.357; square root of the mean of the sum of the squares of differences between adjacent NN intervals [RMSSD], P<0.001, ES=0.280; and NN50 count divided by the total number of all NN intervals [pNN50], P<0.001, ES=0.291) as compared with non-diabetic PAD patients. After adjustment for confounders, diabetes remained associated with sedentary behavior (P=0.011), light (P=0.020) and moderate-to-vigorous physical activity (P=0.008), 6-min walk distance (P=0.030), SDNN (P<0.001), RMSSD (P=0.004), and PNN50 (P=0.004).

CONCLUSION

Diabetic PAD patients presented lower physical activity level, reduced physical function and impaired autonomic modulation as compared with non-diabetic PAD patients.

Short-term strength and balance training does not improve quality of life but improves functional status in individuals with diabetic peripheral neuropathy: a randomised controlled trial

AIMS/HYPOTHESIS

The aim of this study was to test the effectiveness of a structured strength and balance training intervention in improving health-related quality of life (HRQoL) and functional status in individuals with diabetic peripheral neuropathy (DPN).

METHODS

The study was a single-blind parallel-group randomised controlled trial comparing 2 months of once-weekly home-based strength and balance training against standard medical therapy. Participants were patients with physician-diagnosed type 2 diabetes and neuropathy recruited from five public sector institutions in Singapore between July 2014 and October 2017. Participants were block-randomised to intervention or control arms. Outcomes were assessed at baseline, 2 months and 6 months by a trained assessor blinded to group assignment. Primary outcomes were change in physical component summary (PCS) score of SF-36v2 (a 36-item generic HRQoL instrument that has been validated for use in Singapore) and EQ-5D-5L index score (derived from a five-item generic HRQoL instrument [EQ-5D-5L]) over 6 months. Secondary outcomes were change in functional status (timed up-and-go [TUG], five times sit-to-stand [FTSTS], functional reach, static balance, ankle muscle strength and knee range of motion) and balance confidence over 6 months. Mean differences in scores between groups were compared using mixed models.

RESULTS

Of the 143 participants randomised (intervention, n = 70; control, n = 73), 67 participants were included in each arm for the final intention-to-treat analysis. The two groups were similar, except in terms of sex. There were no significant differences between groups on the primary outcomes of PCS score (mean difference [MD] 1.56 [95% CI -1.75, 4.87]; p = 0.355) and EQ-5D-5L index score (MD 0.02 [95% CI -0.01, 0.06]; p = 0.175). There were significant improvements in TUG test performance (MD -1.14 [95% CI -2.18, -0.1] s; p = 0.032), FTSTS test performance (MD -1.31 [95% CI -2.12, -0.51] s; p = 0.001), ankle muscle strength (MD 4.18 [95% CI 0.4, 7.92] N; p = 0.031), knee range of motion (MD 6.82 [95% CI 2.87, 10.78]°; p = 0.001) and balance confidence score (MD 6.17 [95% CI 1.89, 10.44]; p = 0.005). No adverse events due to study participation or study intervention were reported.

CONCLUSIONS/INTERPRETATION

Short-term structured strength and balance training did not influence HRQoL but produced sustained improvements in functional status and balance confidence at 6 months. More intensive interventions may be needed to influence HRQoL in these individuals. However, this intervention may be a useful treatment option for individuals with DPN to reduce the risk of falls and injuries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02115932 FUNDING: This work was supported by the National Medical Research Council, Singapore.

Evaluation of the use of therapeutic footwear in people with diabetes mellitus - a scoping review

Foot ulcers are one of the major complications of Diabetes Mellitus and are associated with increasing rates of morbidity and mortality. It is estimated that 2% of diabetic patients present lesions in the feet, with relapse rates between 30% and 40% in the first year after healing of the first ulcerations. Therapeutic footwear is one of the main strategies to prevent foot ulceration.

OBJECTIVES

To identify in the literature aspects related to the recommendation of health professionals and the use of therapeutic footwear by patients with Diabetes Mellitus.

MATERIALS AND METHODS

Scoping review of literature in the Scopus, Scielo, Pubmed and Cochrane databases, using diabetic foot crosswords and therapeutic footwear.

RESULTS

Twenty-six articles were included in this review. The majority was systematic reviews (46.15%) with published date from 2016 (38.5%). Of the 26 articles included, 10 (38.5%) referred to adherence to the use of footwear, 10 (38.5%) the difficulty to evaluate the effectiveness of the intervention and 6 (23.0%) to changes in the balance and biomechanics patterns In the studies, the use of therapeutic footwear is linked to the reduction of the risk of ulceration or its recurrence in people with diabetes who already have diabetic neuropathy as chronic complication of the disease.

CONCLUSIONS

Therapeutic footwear for diabetics was able to produce significant reductions of peak plantar pressure in static and dynamic analysis, being more efficient than a common footwear, and could contribute to the prevention of injuries associated with diabetic foot.

Mobility in survivors with chemotherapy-induced peripheral neuropathy and utility of the 6-min walk test

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a significant and often lasting side effect of cancer treatment, with increasing CIPN severity associated with increasing deficits in balance, gait, and mobility. The 6-min walk test (6MWT) is a widely validated and utilized measure of general physical functioning and mobility, although its utility in a CIPN context is unclear. This study aimed to determine the utility of the 6MWT as an assessment of mobility deficits in a CIPN cohort and utilize the 6MWT to compare mobility data from CIPN patients to those of healthy and clinical populations.

METHODS

Cancer survivors exposed to neurotoxic chemotherapies (N = 100; mean 17 ± 13 months post-treatment; mean age 59 ± 13 years) completed a single cross-sectional assessment of patient-reported and objective CIPN, mobility (6MWT), and disability.

RESULTS

CIPN symptoms were reported in the majority of the cohort (87%). Increasing age, patient-reported and objective CIPN symptoms, and disability were associated with decreasing 6MWT distance (.48 ≤ R ≤ .63; p < .001) in bivariate models. Multiple regression models of 6MWT distance included age, sex, and patient-reported or objective CIPN severity as significant independent correlates (.62 ≤ R ≤ .64; p < .03). 6MWT distances in patients with CIPN symptom severity above the cohort mean were consistent with mean values reported in diabetic neuropathy and clinical populations.

CONCLUSIONS

Increased CIPN symptoms are associated with increased mobility deficits. The 6MWT demonstrates promising utility as a mobility assessment in a CIPN cohort.

IMPLICATIONS FOR CANCER SURVIVORS

The impact of the progression of CIPN on mobility deficits in survivors emphasizes the need for effective interventions to treat and prevent CIPN.

Impact of diabetes mellitus on functional exercise capacity and pulmonary functions in patients with diabetes and healthy persons

BACKGROUND

Chronic diabetic complications may afflict all organ tissues, including those of the respiratory system. The six-minute walk test (6MWT) is an alternative and widely used method of assessing functional capacity and is simple to perform. However, to our knowledge, the impact of diabetes mellitus on 6MWT performance has not been investigated previously. This research aimed to compare the functional exercise capacity and pulmonary functions in patients with diabetes and in healthy persons.

METHODS

The study included 131 participants: 64 patients with type 1 and 2 diabetes mellitus (DM) and 67 healthy participants (CG). All of the participants were nonsmoking and did not have pulmonary disorders that affected the pulmonary function tests or 6MWT. Metabolic parameters and biochemical markers of inflammation were assessed. Full lung function tests and a 6MWT were performed.

RESULTS

In the DM group, the walking distance was 109 m shorter than that in the CG (P < 0.001). Moreover, compared to the CG, the DM group showed lower values of forced expiratory volume in one second (FEV1 (l) 3.6 vs. 2.8, P < 0.001) and total lung capacity (TLC (l) 6.6 vs. 5.6, P < 0.001), as well as a decrease in diffusion capacity (DLCO (mmol/min/kPa), 10.0 vs. 8.6, P < 0.001).

CONCLUSIONS

The 6MWT is a valuable test that complements the assessment of daily physical capacity in patients with diabetes, irrespective of type. Pulmonary function and the capacity for physical exertion varied between patients with diabetes mellitus and the healthy participants in the CG.

The Association Between Handgrip Strength and Diabetes on Activities of Daily Living Disability in Older Mexican Americans

OBJECTIVE

The aim of this study is to determine the independent and joint effects of muscle weakness and diabetes on incident activities of daily living (ADL) disability in older Mexican Americans.

METHOD

A subsample of 2,270 Mexican Americans aged at least 65 years at baseline were followed for 19 years. Handgrip strength was normalized to body weight (normalized grip strength [NGS]). Weakness was defined as NGS ≤0.46 in males and ≤0.30 in females. Diabetes and ADL disability were self-reported.

RESULTS

Compared with participants that were not weak and did not have diabetes, those that had diabetes only, were weak only, and were both weak and had diabetes experienced a 1.94 (95% confidence interval [CI] = [1.89, 1.98]), 1.17 (CI = [1.16, 1.19]), and 2.12 (CI = [2.08, 2.16]) higher rate for ADL disability, respectively.

DISCUSSION

Muscle weakness and diabetes were independently and jointly associated with higher rates for ADL disability in older Mexican Americans.

Clinical risk factors for depressive syndrome in Type 2 diabetes: the Fremantle Diabetes Study

AIMS

To identify early clinical predictors of depressive syndrome in people with Type 2 diabetes.

METHODS

Depressive syndrome was assessed in 325 individuals with Type 2 diabetes 15 years after a baseline assessment, which included information on antidepressant use and depressive symptoms obtained using a quality-of-life scale. Follow-up current and lifetime depressive syndrome were assessed using the nine-item Patient Health Questionnaire and the Brief Lifetime Depression Scale and taking account of antidepressant use. Analyses were conducted inclusive and exclusive of antidepressant use where Patient Health Questionnaire criteria were not met.

RESULTS

At baseline, the participants were aged 57.2±9.3 years and the median (interquartile range) diabetes duration was 2.2 (0.6-6.0) years. After a mean of 14.7±1.1 years' follow-up, 81 participants (24.9%) had depressive syndrome (14.8% defined by the Patient Health Questionnaire, 10.2% defined by antidepressants) and 31.4% reported lifetime depression, and in 10.2% of participants this preceded diabetes onset. With logistic regression (inclusive of antidepressants), follow-up depressive syndrome was negatively associated with education level [odds ratio 0.39 (95% CI 0.20-0.75)] and antidepressant use [odds ratio 0.11 (95% CI 0.03-0.36)] and was positively associated with depression history before diabetes onset [odds ratio 2.79 (95% CI 1.24-6.27)]. In the model exclusive of antidepressants, depressive syndrome was positively associated with baseline depressive symptoms [odds ratio 2.57 (95% CI 1.32-5.03)] and antidepressant use [odds ratio 3.54 (95% CI 1.20-10.42)] and was negatively associated with education level [odds ratio 0.39 (95% CI 0.19-0.81)].

CONCLUSIONS

Risk factors for depressive syndrome can be identified early after the onset of Type 2 diabetes. The early presence of depressive symptoms or its treatment and/or history of depression are likely indicators of vulnerability. Early risk stratification for late depressive syndrome is feasible in people with Type 2 diabetes and could assist with depression treatment or prevention.

Impaired vibrotactile sense in children and adolescents with type 1 diabetes - Signs of peripheral neuropathy

Objective

To investigate whether multi-frequency vibrometry can identify individuals with elevated vibration perception thresholds (VPTs), reflecting impaired vibrotactile sense, among children and adolescents with type 1 diabetes.

Methods

In 72 pediatric patients with type 1 diabetes, VPTs were evaluated for seven frequencies on two sites of the hand, and five frequencies on two sites of the foot. Z-scores, based on previously collected reference data, were calculated. Perception to light touch was investigated using monofilaments. Subjects’ characteristics were analyzed in comparison to normal and impaired vibrotactile sense.

Results

Subjects’ median age, disease duration and age at disease onset were 12.8, 5.3 and 6.9 years, respectively. A total of 13 out of 72 (18%) subjects had impaired vibrotactile sense on at least one foot site. Impaired vibrotactile sense was more common among subjects treated with multiple daily insulin injections (MDI) compared to subjects treated with continuous subcutaneous insulin infusion (CSII) (p = 0.013). Age at disease onset was higher among subjects with impaired vibrotactile sense (p = 0.046). No significant correlations were found with gender, HbA1c or duration of diabetes.

Conclusions

Impaired vibrotactile sense, mirroring diabetic peripheral neuropathy, was found in 1/5 of the children and adolescents in the study, and was more common in patients treated with MDI than in subjects treated with CSII.

Metabolomics studies on db/db diabetic mice in skeletal muscle reveal effective clearance of overloaded intermediates by exercise

Type 2 diabetes mellitus (T2DM) is characterized by hyperinsulinemia, hyperglycemia and insulin resistance, which correlated with high mortality worldwide. Exercise is one of the effective lifestyle interventions in maintaining blood glucose level in the normal range and lowering risk factors. Metabolomics approaches are powerful tools in systematic study of overall metabolic changes in response to disease or interventions. In this study, mass spectrometry-based metabolomics studies were performed to investigate the regulatory effect of moderate intensity of exercise on db/db diabetic mice in skeletal muscle. Both liquid chromatography-mass spectrometry (LC-MS) and gas chromatography-mass spectrometry (GC-MS) have been carried out to monitor a wide range of regulated metabolites. Ninety-five metabolites were identified which contributing to the discrimination of db/m  + control and db/db diabetic mice. The regulatory effects of exercise on these metabolites were mainly focusing on attenuating the levels of long-chain fatty acids (C14 to C18) and medium-to long-chain acylcarnitines (C12 to C18), indicated that exercise might play a positive role in inhibiting the accumulation of excessive lipids, which is positively related to insulin resistance. In addition, uric acid, which is a risk factor for inflammation, cardiovascular complications, and fatty liver in diabetic patients, together with its intermediates (such as inosinic acid, hypoxanthine, etc.) in purine metabolism pathway, were also substantially down regulated after exercise, indicating exercise might also be protective against hyperuricemia related risks in T2DM. These findings reveal that moderate intensity of exercise might play a positive role in improving the efficiency of lipid metabolism in skeletal muscle and meanwhile enhancing uric acid clearance to prevent lipid accumulation, which might contribute to improved body fitness and body muscle composition.

The challenge of living with diabetes in women and younger adults: A structural equation model

BACKGROUND

Attitudes toward diabetes care are different between genders and age-groups. Furthermore, diabetes related challenges may cause psychosocial problems. Therefore, we were to compare the psychosocial status and glycemic control in women and men with type 2 diabetes (T2D) in different age-groups.

METHODS

441 adults with T2D were recruited. Demographic, self-care behavior, resources and affective variables as well as the health related quality of life (HRQoL) were measured. The median age of 55 was used as the cut-off for the age comparison. Structured equation modeling (SEM) investigated the relationship between age, gender, psychosocial factors and glycemic control.

RESULTS

Finally, 203 women and 177 men completed the study (86.1%). There was no significant difference in mean duration of T2D, or glycemic control between genders or age-groups. Women, especially those below the median age of 55, had significantly higher level of diabetes-related distress (2.16±0.94 vs. 1.92±0.81), depression (9.67±5.37 vs. 7.54±5.06), and anxiety (19.81±12.04 vs. 12.81±9.04, P<0.05 for all comparisons), while people above the age of 55 reported better self-management and patient-physician relationship. HRQoL was lower in women compared to men (0.77±0.23 vs. 0.81±0.18, P=0.02). The final SEM suggested that the effect (standardized β coefficient) of gender and age on affective variables was 0.25 and -0.19 (P<0.05), respectively, though psychosocial factors did not directly influence HbA1c.

CONCLUSIONS

This study shows that psychosocial factors are associated with age and gender in patients with T2D; with younger women demonstrating higher level of depressive symptoms, anxiety, and diabetes-related distress independent of status of glycemic control.

Experts' opinion on manual wheelchair adjustments for adults with diabetes

Diabetes is a global health concern that can lead to mobility limitations necessitating a wheelchair. However, there are currently no guidelines for wheelchair adjustments tailored to the diabetic population.

PURPOSE

To describe relevant manual wheelchair adjustments for adults with diabetes, and to explore how these adjustments apply to populations living in less-resourced countries.

METHODS

Semi-structured interviews were conducted with 13 wheelchair experts from five different countries working with adult with diabetes. Interviews were analyzed using the constant comparison method.

RESULTS

The most frequently mentioned wheelchair adjustments were related to neuropathies, skin integrity, decreased strength and amputations. Air cushions were preferred for managing seat sores. Lightweight wheelchairs could be advantageous for people with decreased strength and endurance. In less-resourced settings, wheelchair adjustment decisions prioritized durability and low maintenance.

DISCUSSION

The recommendation of lightweight wheelchairs for adults with diabetes may be limited by the lack of adjustment possibilities compared to regular weight wheelchairs. In less-resourced settings, prioritizing durability and low maintenance may limit prevention and management of conditions associated to diabetes.

CONCLUSION

This study represents a first step towards the development of guidelines for manual wheelchair adjustments specifically tailored to adults with diabetes, in a global health context. Implications of rehabilitation When prescribing manual wheelchairs to persons with diabetes, expert clinicians agree that skin integrity, neuropathies and decreased strength are their primary concerns. Compromises are often necessary when adjusting a wheelchair for a person with diabetes, due to the complexity of their symptoms: same modification can be indicated for one symptom but contraindicated for another. Diabetes prevalence is high in less-resourced settings. There is a need for increased availability of affordable wheelchair equipment that is durable, reliable and adapted to persons with diabetes.

Polyneuropathy relates to impairment in daily activities, worse gait, and fall-related injuries

OBJECTIVE

To extensively investigate the association of chronic polyneuropathy with basic and instrumental activities of daily living (BADL and IADL), falls, and gait.

METHODS

A total of 1,445 participants of the population-based Rotterdam Study (mean age 71 years, 54% women) underwent a polyneuropathy screening involving a symptom questionnaire, neurologic examination, and nerve conduction studies. Screening yielded 4 groups: no, possible, probable, and definite polyneuropathy. Participants were interviewed about BADL (Stanford Health Assessment questionnaire), IADL (Instrumental Activities of Daily Living scale), and frequency of falling in the previous year. In a random subset of 977 participants, gait was assessed with an electronic walkway. Associations of polyneuropathy with BADL and IADL were analyzed continuously with linear regression and dichotomously with logistic regression. History of falling was evaluated with logistic regression, and gait changes were evaluated with linear regression.

RESULTS

Participants with definite polyneuropathy had more difficulty in performing BADL and IADL than participants without polyneuropathy. Polyneuropathy related to worse scores of all BADL components (especially walking) and 3 IADL components (housekeeping, traveling, and shopping). Participants with definite polyneuropathy were more likely to fall, and these falls more often resulted in injury. Participants with polyneuropathy had worse gait parameters on the walkway, including lower walking speed and cadence, and more errors in tandem walking.

CONCLUSIONS

Chronic polyneuropathy strongly associates with impairment in the ability to perform daily activities and relates to worse gait and an increased history of falling.

Effect of diabetes mellitus on walking distance parameters after supervised exercise therapy for intermittent claudication: A systematic review

Some believe that certain patients with intermittent claudication may be unsuitable for supervised exercise therapy (SET), based on the presence of comorbidities and the possibly increased risks. We conducted a systematic review (MEDLINE, EMBASE and CENTRAL) to summarize evidence on the potential influence of diabetes mellitus (DM) on the response to SET. Randomized and nonrandomized studies that investigated the effect of DM on walking distance after SET in patients with IC were included. Considered outcome measures were maximal, pain-free and functional walking distance (MWD, PFWD and FWD). Three articles met the inclusion criteria ( n = 845). In one study, MWD was 111 meters (128%) longer in the non-DM group compared to the DM group after 3 months of follow-up ( p = 0.056). In a second study, the non-DM group demonstrated a significant increase in PFWD (114 meters, p ⩽ 0.05) after 3 months of follow-up, whereas there was no statistically significant increase for the DM group (54 meters). On the contrary, the largest study of this review did not demonstrate any adverse effect of DM on MWD and FWD after SET. In conclusion, the data evaluating the effects of DM on SET were inadequate to determine if DM impairs the exercise response. While trends in the data do not suggest an impairment, they are not conclusive. Practitioners should consider this limitation when making clinical decisions.

Postural sway in diabetic peripheral neuropathy among Indian elderly

Background & objectives:

Diabetic peripheral neuropathy (DPN) is a major complication of type 2 diabetes and have long term complications on the postural control of the affected population. The objectives of this study were to evaluate postural stability in patients with DPN and to examine correlation of Michigan Neuropathy Screening Instrument (MNSI) with duration of diabetes, age and postural stability measures.

Methods:

Participants were included if they had clinical neuropathy which was defined by MNSI. Sixty one patients gave their consent to participate in the study and were evaluated on posturography for postural stability measures in four conditions. Repeated measures of analysis of variance (RANOVA) was used to analyze the changes in postural stability measures in different conditions.

Results:

An increase in mean value of postural stability measures was observed for velocity moment 20.4±1.3, 24.3±2.2, 42.3±20.7, 59±43.03, mediolateral displacement 0.21±0.10, 0.22±0.18, 0.03±0.11, 0.34±0.18, and anteroposterior displacement 0.39 ± 0.09, 0.45±0.12, 0.47±0.13, 0.51±0.20 from EO to EC, EOF, and ECF, respectively. There was a significant difference (P<0.05) in participants with DPN, with greater sway amplitude on firm and foam surface in all the conditions. Moderate correlation of MNSI with age (r=0.43) and postural stability measures were also observed.

Interpretation & conclusions:

Evaluation of postural stability in Indian DPN population suggests balance impairments on either firm and foam surfaces, with greater likelihood of fall being on foam or deformable surfaces among elderly adults with neuropathy (CTRI/2011/07/001884).

Association Between Chronic Conditions and Physical Function Among Veteran and Non-Veteran Women With Diabetes

PURPOSE OF THE STUDY

To compare the number of chronic conditions among a list of 12 and their association with physical function among postmenopausal non-Veteran and Veteran women with diabetes.

DESIGN AND METHODS

Among women with diabetes from the Women's Health Initiative, we compared the average number of chronic conditions between non-Veterans and Veterans and the association between total number of chronic conditions on subsequent RAND-36 physical function. To examine associations between each condition and subsequent physical function, we compared women with diabetes plus one chronic condition to women with diabetes alone using linear regression in separate models for each condition and for non-Veterans and Veterans.

RESULTS

Both non-Veterans (N = 23,542) and Veterans (N = 618) with diabetes had a median of 3 chronic conditions. Decreases in physical function for each additional condition were larger among Veterans than non-Veterans (-6.3 vs. -4.1 points). Decreases in physical function among women with diabetes plus one chronic condition were greater than that reported for diabetes alone for all combinations and were more pronounced among Veterans (non-Veterans: -11.1 to -24.2, Veterans: -16.6 to -40.4 points). Hip fracture, peripheral artery disease, cerebrovascular disease, and coronary disease in combination with diabetes were associated with the greatest decreases in physical function.

IMPLICATIONS

Chronic conditions were common among postmenopausal women with diabetes and were associated with large declines in physical function, particularly among Veterans. Interventions to prevent and reduce the impact of these conditions and facilitate coordination of care among women with diabetes may help them maintain physical function.

Gait characteristics in older adults with diabetes and impaired fasting glucose: The Rotterdam Study

AIMS

To investigate the association of diabetes mellitus and impaired fasting glucose with gait in the general middle-aged and elderly population.

METHODS

We performed a cross-sectional study on 3019 participants from the population-based Rotterdam Study (aged >45years, 54% women). The presence of diabetes mellitus and impaired fasting glucose was evaluated by measuring serum glucose levels and by documenting anti-diabetic treatment. Participants underwent gait analysis using an electronic walkway. Thirty gait variables were summarized into five independent gait domains for normal walking (Rhythm, Variability, Phases, Pace and Base of Support), one for turning (Turning) and one for walking heel to toe (Tandem), which were averaged into Global Gait. Linear regression analyses were performed to determine the association of diabetes, impaired fasting glucose and continuous glucose levels within the normal range with gait.

RESULTS

Diabetes mellitus was associated with worse Global Gait (Z-score difference -0.19, 95% confidence interval (CI) -0.30; -0.07), worse Pace (-0.20, 95% CI -0.30; -0.10) and worse Tandem (-0.21, 95% CI -0.33; -0.09), after adjusting for age, sex, height and weight. The association with Tandem remained significant after additional adjustment for cardiovascular risk factors. Impaired fasting glucose and continuous glucose levels within the normal range were not associated with any of the gait domains.

CONCLUSION

In our population-based study diabetes mellitus was associated with worse Global Gait, which was mostly reflected in Pace and Tandem. These associations were partly driven by other cardiovascular risk factors, emphasizing the importance of optimal control of cardiovascular risk factor profiles in patients with diabetes.

Mobility-Related Consequences of Reduced Lower-Extremity Peripheral Nerve Function with Age: A Systematic Review

The objective of this study is to systematically review the relationship between lower-extremity peripheral nerve function and mobility in older adults. The National Library of Medicine (PubMed) was searched on March 23, 2015 with no limits on publication dates. One reviewer selected original research studies of older adults (≥65 years) that assessed the relationship between lower-extremity peripheral nerve function and mobility-related outcomes. Participants, study design and methods of assessing peripheral nerve impairment were evaluated and results were reported and synthesized. Eight articles were identified, including 6 cross-sectional and 2 longitudinal studies. These articles investigated 6 elderly cohorts (4 from the U.S. and 2 from Italy): 3 community-dwelling (including 1 with only disabled women and 1 without mobility limitations at baseline), 1 with both community-dwelling and institutionalized residents, 1 from a range of residential locations, and 1 of patients with peripheral arterial disease. Mean ages ranged from 71-82 years. Nerve function was assessed by vibration threshold (n=2); sensory measures and clinical signs and symptoms of neuropathy (n=2); motor nerve conduction (n=1); and a combination of both sensory measures and motor nerve conduction (n=3). Each study found that worse peripheral nerve function was related to poor mobility, although relationships varied based on the nerve function measure and mobility domain assessed. Six studies found that the association between nerve function and mobility persisted despite adjustment for diabetes. Evidence suggests that peripheral nerve function impairment at various levels of severity is related to poor mobility independent of diabetes. Relationships varied depending on peripheral nerve measure, which may be particularly important when investigating specific biological mechanisms. Future research needs to identify risk factors for peripheral nerve decline beyond diabetes, especially those common in late-life and modifiable. Interventions to preserve nerve function should be investigated with regard to their effect on postponing or preventing disability in older adults.

Diabetes, hypertension and mobility among Brazilian older adults: findings from the Brazilian National Household Sample Survey (1998, 2003 and 2008)

Background

The rapid population ageing has been accompanied by a growing number of older adults experiencing chronic conditions, especially diabetes and hypertension, which are conditions associated to the decline in physical functioning. The aim of this study was to investigate changes in the strength of the association between mobility and two chronic conditions (hypertension and diabetes) in a large representative sample of Brazilian older adults over a ten year period.

Methods

The data came from the Brazilian National Household Sample Survey (PNAD) of 1998, 2003 and 2008. The sample comprised 28,943 participants aged 60 years and older investigated in 1998, 35,042 in 2003 and 41,269 in 2008, totalling 105,254 older adults. The dependent variable was the physical mobility index (PMI) constructed based on the Item Response Theory (IRT) using five physical mobility indicators. The chronic conditions were self-reported and the confounders included: age, sex, schooling, ethnicity, family income, household composition, other co-morbidities and use of health services. The association between physical mobility (three different groups) and chronic conditions (hypertension and diabetes) was performed using multinomial logistic regression.

Results

Over the ten year period the prevalence of hypertension increased from 44 % (1998), 49 % (2003) to 53 % (2008) (p < 0.001). Similar pattern was observed for the prevalence of diabetes: 10 % in 1998, 13 % in 2003 and 16 % in 2008 (p < 0.001). Overall, physical mobility showed a statistical significant association with both chronic diseases studied even after adjusting for potential confounders. The time-disease interaction term was significant (p < 0.05) for the two chronic conditions studied, and the strength of the associations decreased over the first five years, but it was not sustained between 2003 and 2008.

Conclusions

Despite the increases observed in the prevalence of the hypertension and diabetes over the ten year period, the decrease in strength of the association with physical mobility during the first period could be explained by improvements in health services and treatment of older adults. Special attention should be given to the treatment and management of diabetes in order to avoid declines in physical mobility levels.

Longitudinal patient-oriented outcomes in neuropathy: Importance of early detection and falls

OBJECTIVE

To evaluate longitudinal patient-oriented outcomes in peripheral neuropathy over a 14-year time period including time before and after diagnosis.

METHODS

The 1996-2007 Health and Retirement Study (HRS)-Medicare Claims linked database identified incident peripheral neuropathy cases (ICD-9 codes) in patients ≥65 years. Using detailed demographic information from the HRS and Medicare claims, a propensity score method identified a matched control group without neuropathy. Patient-oriented outcomes, with an emphasis on self-reported falls, pain, and self-rated health (HRS interview), were determined before and after neuropathy diagnosis. Generalized estimating equations were used to assess differences in longitudinal outcomes between cases and controls.

RESULTS

We identified 953 peripheral neuropathy cases and 953 propensity-matched controls. The mean (SD) age was 77.4 (6.7) years for cases, 76.9 (6.6) years for controls, and 42.1% had diabetes. Differences were detected in falls 3.0 years before neuropathy diagnosis (case vs control; 32% vs 25%, p = 0.008), 5.0 years for pain (36% vs 27%, p = 0.002), and 5.0 years for good to excellent self-rated health (61% vs 74%, p < 0.0001). Over time, the proportion of fallers increased more rapidly in neuropathy cases compared to controls (p = 0.002), but no differences in pain (p = 0.08) or self-rated health (p = 0.9) were observed.

CONCLUSIONS

In older persons, differences in falls, pain, and self-rated health can be detected 3-5 years prior to peripheral neuropathy diagnosis, but only falls deteriorates more rapidly over time in neuropathy cases compared to controls. Interventions to improve early peripheral neuropathy detection are needed, and future clinical trials should incorporate falls as a key patient-oriented outcome.

Prevalence and influencing factors of co-morbid depression in patients with type 2 diabetes mellitus: a General Hospital based study

BACKGROUND

Depression and diabetes have been recognized as major public health issues in China, however, no studies to date examined the factors associated with the development of depression in patients with diabetes in China. This study aimed to estimate the prevalence of co-morbid depression among adults with type 2 diabetes mellitus (DM) and to examine the influence factors of co-morbid depression in a group of patients with type 2 DM.

METHODS

The study was conducted from March l to May 31, 2012, in the Department of Endocrinology of the First Affiliated Hospital of the General Hospital of the People's Liberation Army (PLA). A systematic random sample of 412 type 2 DM patients aged over 18 years was selected. A structured questionnaire was used for collecting the information about socio-demographic data, lifestyle factors and clinical characteristics. Depression and social support was evaluated by using the Chinese version of Beck Depression Inventory (BDI) and Social Support Rate Scale (SSRS), respectively. Weights and heights were measured. Hemoglobin A1c (HbA1c) was abstracted from each patient directly after the interview.

RESULTS

Of the total sample, 142 patients had depression according to the BDI scores (BDI scores ≥14), the prevalence of co-morbid depression in this study population was 5.7 % (142/2500). Of which, 56 had major depression (BDI ≥ 21), and 86 had moderate depression (BDI ≥ 14&BDI < 21). Logistic regression analysis indicated that a high HbA1c level, a high BMI, low quality health insurance, and being single, were significantly associated with the development of depression. However, a family history of diabetes and a high social support level are likely protective factors.

CONCLUSIONS

The prevalence of co-morbid depression was 5.7 % among Chinese subjects with type 2 DM in this study. High HbA1c level, high BMI score, being single, low social support level, and low quality health insurance were associated with the presence of depression. These findings support a recommendation for routine screening and management in China for depression in patients with diabetes, especially for those in primary care, to reduce the number of the depressed or the misrecognized depressed diabetic patients.

Assessment of an Expanded Functional Disability Scale for Older Adults With Diabetes

Although prior literature has shown the plausibility of combining the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) items to form an expanded scale for measuring the degree of functional decline, this has not been shown in older adults with diabetes who are disproportionately affected by functional disability. Using the 2009 Medicare Current Beneficiary Survey data, we evaluated the factor structure of the pooled ADL and IADL items. Based on our study comprising 2,158 community-dwelling older adults (≥65 years) with diabetes, the unidimensional model exhibited good fit. Despite well-fitting indices, high correlations were observed between the latent constructs (>.70) of the multi-factor models, suggesting a lack of discriminant validity. These findings provide empirical support for a combined scale that can comprehensively and efficiently characterize the extent of functional disability in older adults with diabetes for research, risk adjustment, and evaluation in patient-centered medical homes.

Incident Diabetes and Mobility Limitations: Reducing Bias Through Risk-set Matching

BACKGROUND

Increased prevalence of diabetes in the U.S. population could contribute substantially to increases in disability at older ages. Previous studies have examined the association between prevalent diabetes and various impairments and disabilities. Methods considering incident, rather than prevalent, diabetes as the exposure of interest can reduce bias in estimates of these associations.

METHODS

Risk-set matching, a type of propensity score matching meant to handle time-varying exposures, was used to estimate the relationship between incident diabetes and mobility limitations among adults in the Health and Retirement Study. This approach ensures that covariates precede diabetes onset rather than follow it.

RESULTS

Individuals who were diagnosed with diabetes during the study period accumulated more subsequent mobility limitations than were accumulated by matched controls. Among observationally similar pairs of individuals, those who developed diabetes reported an average of 24.9% more mobility limitations at study exit than those who did not.

CONCLUSIONS

The magnitude of the relationship between diabetes and limitations estimated in this article is smaller than that presented in previous studies, but the method presented here is likely to provide a less-biased estimate of the association between diabetes and accumulation of mobility limitations.

Depression, diabetic complications and disability among persons with comorbid schizophrenia and type 2 diabetes

BACKGROUND

People with schizophrenia are at increased risk for type 2 diabetes, its complications, depression, and disability. However, little is known about the interrelationships of these 3 factors in adults with schizophrenia and type 2 diabetes.

OBJECTIVE

We sought to assess the number of diabetic complications and depressive symptom severity as predictors of disability and evaluate depressive symptom severity as a mediator of the relationship between diabetic complications and disability in a sample of 62 adults with schizophrenia and type 2 diabetes.

METHODS

Two- and 3-step sequential regression models were used to evaluate the relationship of depression and number of diabetic complications with disability. Path analysis with bootstrapping was used to evaluate depressive symptom severity as a mediator of the relationship between complications and disability.

RESULTS

Diabetic complications significantly predicted disability scores when controlling for age, gender, socioeconomic status, hemoglobin A1C, positive symptom severity, and negative symptom severity. The addition of depression severity scores resulted in a significant increase in explained variance in disability scores. In the final model, only depression severity scores were significantly associated with disability scores. The full model accounted for 56.2% of the variance in disability scores. Path analysis revealed a significant indirect association of diabetic complications to disability through depression severity scores while controlling for all covariates. The association between complications and disability was nonsignificant when depressive symptom severity was included in the model.

CONCLUSIONS

Depressive symptoms may present an important and tractable target for interventions aimed at reducing disability in people with schizophrenia and type 2 diabetes.

Predictors of physical inactivity in men and women with type 2 diabetes from the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study

PURPOSE

The purpose of this secondary analysis was to determine changes in physical inactivity from baseline to 5 years and to identify factors associated with and predictive of physical inactivity among individuals with type 2 diabetes enrolled in the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study.

METHODS

DIAD was a prospective randomized screening trial that assessed the prevalence of silent ischemia in asymptomatic patients with type 2 diabetes. Subjects were recruited from diabetes and primary care practices at 14 centers throughout the United States and Canada. This is a secondary data analysis of the physical activity data (type and hours/week) collected. No intervention was conducted.

RESULTS

In all subjects, physical inactivity rose from 24% at baseline to 33% at 5 years (S = 28.93; P < .0001). This change was significant in both men (S = 11.44; P < .0001), increasing from 23% to 31%, and women (S = 18.05; P < .0001), increasing from 25% to 36%. Gender differences were noted in several factors associated with baseline physical inactivity as well as in factors predictive of physical inactivity at 5 years. Important factors associated at both time points included lower level of education, current employment, presence of peripheral and autonomic neuropathy, and indicators of overweight/obesity. Baseline physical inactivity was strongly predictive of physical inactivity at 5 years (odds ratio, 3.27; 95% confidence interval, 2.36-4.54; P < .0001).

CONCLUSIONS

Gender-related differences were noted in factors associated with and predictive of physical inactivity.

Microalbuminuria, kidney function, and daily physical activity

The present study was carried out to investigate independent relationship between daily physical activity, microalbuminuria, and kidney function. The demographic characteristics and laboratory parameters were recorded for all patients. The determination of daily activities was carried out by Nottingham Extended Activities of Daily Living Scale (NEADLS) which was performed for each patient in an interview. Totally 139 patients were enrolled. In the whole group NEADLS score was correlated with age (rho: −0.759, P < 0.0001), clinical systolic blood pressure (rho: −0.212, P: 0.018), blood urea nitrogen (rho: −0.516, P < 0.0001), creatinine (rho: −0.501, P < 0.0001), uric acid (rho: −0.308, P < 0.0001), albumin (rho: 0.382, P < 0.0001), total cholesterol (rho: −0.194, P: 0.022), LDL-cholesterol (rho: −0.230, P: 0.008), hemoglobin (rho: 0.256, P: 0.002), creatinine clearance (rho: 0.565, P < 0.0001), 24-hour urinary protein excretion (rho: −0.324, P < 0.0001), and 24-hour urinary albumin excretion (UAE) (rho: −0.483, P < 0.0001). The multivariate linear regression of independent factors corelated with logarithmically converted NEADLS score (as a dependent variable) has shown that age (P < 0.0001), presence of coronary artery disease (P: 0.011), hemoglobin (P: 0.020), 24-hour creatinine clearance (P: 0.004), and 24-hour urinary albumin excretion (P < 0.0001) were independently corelated with NEADLS score. In conclusion, both UAE and kidney function were independently associated with daily physical activity.