Impact of the population at risk of diabetes on projections of diabetes burden in the United States: an epidemic on the way

The burden of illness of hypertension and comorbid diabetes

OBJECTIVE

To compare the impact of comorbid hypertension and diabetes on resource utilization and costs compared to diabetes mellitus (DM) or hypertension (HTN) alone.

METHODS

A retrospective claims analysis assessed economic trends in patients without pre-existing CV disease in three cohorts: newly-treated HTN-only, DM-only, and newly-treated HTN and DM (comorbid cohort). Total, CV-specific, and DM-specific costs measured for up to 24 months were classified into five categories: inpatient, outpatient, emergency department (ED), physician, and other medical. Costs were compared using linear regression, controlling for age, gender, comorbidities, and non-CV- or DM-related prescriptions at baseline.

RESULTS

The comorbid cohort had the highest inpatient ($1920), outpatient ($1664), ED ($126), other medical ($218), and pharmacy costs ($2388), plus significantly higher CV- and DM-specific costs. At 24 months, for HTN-related costs for the HTN cohort equaled $1604, while DM-related costs for the DM cohort totaled $2023. Comparatively, HTN-related costs for patients with HTNT + DM were $2678 while DM-related costs were $3094, being over $1000 and $1800 more than each individual cohort, respectively. A post-hoc analysis of CV events found the comorbid cohort had significantly more myocardial infarctions (MIs) and acute ischemic events than did the HTN-only cohort.

CONCLUSION

Higher cost and resource utilization is associated with comorbid HTN and DM. Higher average disease-specific costs over 24 months indicate an intensity of care for patients with comorbid disease that is beyond that of simply managing an additional disease state. Study limitations include patient selection biases, which are possible with any administrative commercial database analysis.

Incidence and prognostic implication of unrecognized myocardial scar characterized by cardiac magnetic resonance in diabetic patients without clinical evidence of myocardial infarction

BACKGROUND

Silent myocardial infarctions (MIs) are prevalent among diabetic patients and inflict significant morbidity and mortality. Although late gadolinium enhancement (LGE) imaging by cardiac magnetic resonance (CMR) can provide sensitive characterization of myocardial scar, its prognostic significance in diabetic patients without any clinical evidence of MI is unknown.

METHODS AND RESULTS

We performed clinically indicated CMR imaging in 187 diabetic patients who were grouped by the absence (study group, n=109) or presence (control group, n=78) of clinical evidence of MI (clinical history of MI or Q waves on ECG). CMR imaging and follow-up were successful in 107 study patients (98%) and 74 control patients (95%). Cox regression analyses were performed to associate LGE with major adverse cardiovascular events (MACE), including death, acute MI, new congestive heart failure or unstable angina, stroke, and significant ventricular arrhythmias. LGE by CMR was present in 30 of 107 study patients (28%). At a median follow-up of 17 months, 38 of 107 patients (36%) experienced MACE, which included 18 deaths. Presence of LGE was associated with a >3-fold hazards increase for MACE and for death (hazard ratio, 3.71 and 3.61; P<0.001 and P=0.007, respectively). Adjusted to a model that combines patient age, sex, ST or T changes on ECG, and left ventricular end-systolic volume index, LGE maintained a >4-fold hazards increase for MACE (adjusted hazard ratio, 4.13; 95% confidence interval, 1.74 to 9.79; P=0.001). In addition, LGE provided significant prognostic value with MACE and with death adjusted to a diabetic-specific risk model for 5-year events. The presence of LGE was the strongest multivariable predictor of MACE and death by stepwise selection in the study patients.

CONCLUSIONS

CMR imaging can characterize occult myocardial scar consistent with MI in diabetic patients without clinical evidence of MI. This imaging finding demonstrates strong association with MACE and mortality hazards that is incremental to clinical, ECG, and left ventricular function combined.

Incretin mimetics and dipeptidyl peptidase-4 inhibitors: innovative treatment therapies for type 2 diabetes

The prevalence of diabetes and impaired glucose tolerance is predicted to dramatically increase over the next two decades. Clinical therapies for type 2 diabetes mellitus (T2DM) have traditionally included lifestyle modification, oral anti-diabetic agents, and ultimately insulin initiation. In this report, we review the clinical trial results of two innovative T2DM treatment therapies that are based on the glucoregulatory effects of incretin hormones. Incretin mimetics are peptide drugs that mimic several of the actions of glucagon-like peptide-1 (GLP-1) and have been shown to lower glycated hemoglobin (A1C) levels in patients with T2DM. Additionally, incretin mimetics lower postprandial and fasting glucose, suppress elevated glucagon release, and are associated with progressive weight reduction. Dipeptidyl peptidase-4 (DPP-4) inhibitors increase endogenous GLP-1 levels by inhibiting the enzymatic degradation of GLP-1. Clinical studies in patients with T2DM have shown that DPP-4 inhibitors reduce elevated A1C, lower postprandial and fasting glucose, suppress glucagon release, and are weight neutral. Collectively, these new drugs, given in combination with other antidiabetic agents, such as metformin, sulfonylureas, and/or thiazolidinediones, can help restore glucose homeostasis in poorly controlled patients with T2DM.

Management of hypertension in patients with chronic kidney disease and diabetes mellitus

Treatment of patients at high risk for developing cardiovascular disease aims at controlling blood pressure, optimizing blood glucose levels, and providing renoprotection. Chronic kidney disease (CKD) and diabetes mellitus are prevalent causes of cardiovascular disease owing to associations with major cardiovascular risk factors, such as hypertension, and they are substantial health burdens. Even mild-to-moderate CKD and prehypertension increase cardiovascular risk. First-line agents for reducing cardiovascular risk are inhibitors of the renin-angiotensin system: angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). In clinical trials, treatment of high-risk patients with ACE inhibitors and ARBs delays or prevents the onset of diabetes and prevents progression of renal disease and cardiovascular events, including cardiovascular mortality. Current evidence indicates that the clinical efficacy of these end points includes effects that may be beyond blood pressure reduction.

The cost-effectiveness of insulin glargine vs. neutral protamine Hagedorn insulin in type 2 diabetes: a focus on health economics

Diabetes mellitus is a major public health problem, in particular because of long-term complications affecting essential organs, such as the eyes and kidneys, which can lead to a reduction in life expectancy and high healthcare costs. The number of individuals with diabetes mellitus is projected to rise worldwide from 171 million people in 2000 to 366 million people in 2030. With the number of patients with diabetes continually growing, the burden of pressure on worldwide health systems is huge. Accordingly, regulatory and marketing approvals of new medicines are beginning to incorporate economic evaluation techniques to determine their cost-effectiveness. Overall, the studies included in this review show that the initiation of insulin glargine is cost-effective and is expected to lead to substantial improvements in both life years (LYs) and quality-adjusted LYs compared with neutral protamine Hagedorn insulin.

Diabetes mellitus and prostate cancer risk

BACKGROUND

Epidemiological evidence suggests that diabetes mellitus (DM) is associated with a decrease in risk for prostate cancer (PCa). The objective of this study was to examine the association between PCa risk and several characteristics of DM (duration, age at diagnosis, treatment) in data from two population-based, case-control studies of PCa.

METHODS

PCa cases (n = 1,752), and controls (n = 1,644) were residents of King County, Washington identified using the Surveillance, Epidemiology, and End Results Seattle-Puget Sound cancer registry and random digit dialing, respectively. The majority of PCa patients had localized stage disease (78%). Using self-reported on DM, logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (95% CI) for associations between DM characteristics and PCa risk.

RESULTS

After adjustment for confounding factors, DM status was not significantly associated with PCa risk (OR = 0.98; 95% CI = 0.76-1.27). However, early-onset DM (diagnosed before age 30) showed a significant inverse association with PCa risk (OR = 0.27; 95% CI = 0.07-0.97). Time since DM diagnosis (median = 6 years) and DM treatment types (i.e., diet changes, oral medications, and insulin) did not show significant associations with PCa risk.

CONCLUSIONS

These data suggest that DM is not associated with PCa risk; however, early-onset DM, possibly reflecting insulin dependent DM (type 1), may be an important component of the previously reported inverse association between DM on PCa risk, but these findings are based on a small number of observations and require further investigation.

Cognition and diabetes: a lifespan perspective

Diabetes mellitus is associated with cognitive dysfunction and abnormalities that can be seen with brain imaging. Recent studies provide important new insights into the nature and severity of these cerebral complications that help to explain why some patients with diabetes have clinically relevant neurocognitive morbidity, whereas most are apparently unaffected. This Personal View investigates the hypothesis that clinically relevant diabetes-related cognitive decrements mainly occur at two crucial periods in life: when the brain is developing in childhood, and when the brain undergoes neurodegenerative changes associated with ageing. Outside of these periods cognitive decrements mainly occur in patients with notable diabetes-related comorbidities, in particular microvascular or macrovascular complications. The identification of crucial periods and conditions for the development of diabetes-related cognitive decrements helps to draw the attention of physicians to individuals at risk and can direct future studies into the mechanisms that underlie these conditions.

Acculturation and healthy lifestyle among Latinos with diabetes

PURPOSE

Latinos have a high prevalence of diabetes and disproportionately experience diabetic complications. We sought to examine the association of acculturation on healthy lifestyle habits among the Latino population in the United States with diabetes.

METHODS

We studied Latino adults (aged >or=20 years) with previously diagnosed diabetes in the 1999-2004 National Health and Nutrition Examination Survey (unweighted N = 467; weighted N = 1,957,778). Healthy lifestyle habits were those consistent with recommendations of the American Diabetes Association (ADA) regarding exercise, smoking, obesity, and diet. Acculturation was measured with the Short Acculturation Scale, a validated 5-item scale assessing use of the Spanish language. Logistic regression analyses of acculturation and healthy behaviors were computed controlling for access to care, demographics, and disease characteristics.

RESULTS

In bivariate analyses, compared with their less-acculturated counterparts, individuals who were more-acculturated to any extent were less likely to have a higher fiber intake (9.4% vs 35.4%, P = .001) and lower saturated fat intake (17.2% vs 46.5%, P = .03). More-acculturated individuals were more likely to report leisure time exercise (59.2% vs 19.3%, P <.001), whereas the proportion of individuals who smoked did not differ. In logistic regression analyses using the 1994 ADA dietary guidelines, more-acculturated individuals were less likely than their less-acculturated counterparts to meet dietary criteria for saturated fat consumption (odds ratio, 0.13; 95% confidence interval [CI], 0.04-0.41). When using the stricter 2006 ADA dietary guidelines, more-acculturated individuals were less likely to have recommended consumption of both saturated fat (odds ratio, 0.06; 95% CI, 0.02-0.20) and fiber (odds ratio, 0.19; 95% CI, 0.08-0.48). Acculturation did not significantly influence exercise and smoking status in logistic regression analyses.

CONCLUSIONS

These results suggest that acculturation among diabetic Latinos to the general US culture is associated with adoption of some less desirable dietary habits.

Blood glucose monitor quick reference guides: are they suitable for patients?

BACKGROUND

The purpose of this study was to assess readability and related characteristics of English-language Quick Reference Guides (QRGs) accompanying home blood glucose monitors (HBGMs), including reading grade level, dimensions, text point size, illustrations, and layout features.

METHODS

Using the 2006 Diabetes Forecast Resource Guide, we identified HBGMs currently available in the United States. Reading grade level was calculated using Flesch Reading Ease (FRE). Text point size was determined by measuring the distance from the ascent line to the descent line with a C-Thru (Bloomfield, CT) Ruler. Total number of illustrations per QRG was tallied. Illustration dimensions were measured to the nearest millimeter. We also assessed layout features-derived from the Suitability of Materials Assessment and User-Friendliness Tool-including, font style type, use of white space, sentence structure, language style, limited math skill, focus on "Need to Know," and appropriateness of illustrations.

RESULTS

FRE scores ranged from 5(th) to approximately 13(th) grade, while text point size averaged 9.9 +/- 1.6 (range, 8-12). QRGs averaged 15.8.2 +/- 6.0 (range, 6-25) clear and realistic illustrations, most slightly larger than a quarter. Most QRGs avoided use of specialty fonts (85.7%) and limited information to "Need to Know" (92.9%). All instructions required little math skill; however, ample white space was used in five (35.7%) QRGs.

CONCLUSIONS

HBGM manufacturers should increase the size of QRG fold-outs, thereby allowing for larger text size and illustrations, and increasing the amount of white space. Making these relatively small formatting changes would ensure that all patients with diabetes, particularly those with visual impairments, are able to follow HBGM instructions.

Supratherapeutic doses of angiotensin receptor blockers to decrease proteinuria in patients with chronic kidney disease

An important endpoint in treating chronic kidney disease, a prevalent disease that can lead to kidney failure and cardiovascular disease, is reducing proteinuria. Proteinuria is an independent risk factor for disease progression and the development of cardiovascular disease and is a key factor that can be used to guide therapy designed to maximize kidney protection. Proteinuria is targeted by using pharmacologic agents that suppress the renin-angiotensin-aldosterone system (RAAS), a regulator of intravascular volume and blood pressure; this has been shown to decrease proteinuria, slow disease progression, and improve coronary disease outcome, independent of effects on blood pressure. The efficacy of RAAS blockers, including angiotensin receptor blockers and angiotensin-converting enzyme inhibitors, may be limited by currently recommended doses, which are based on treatment of hypertension. Data are now emerging from clinical trials demonstrating that use of 'supratherapeutic doses' (doses greater than those approved for lowering blood pressure), compared with standard doses, has favorable safety, tolerability, and efficacy in reducing proteinuria in both diabetic and nondiabetic patients with chronic kidney disease. Supratherapeutic dosing may be a valuable approach for optimizing RAAS blockade and providing renoprotection.

A quantitative trait locus on chromosome 13q affects fasting glucose levels in Hispanic children

OBJECTIVE

The prevalence of childhood obesity has increased dramatically in the United States. Early presentation of type 2 diabetes has been observed in children and adolescents, especially in the Hispanic population. The genetic contribution of glucose homeostasis related to childhood obesity is poorly understood. The objective of this study was to localize quantitative trait loci influencing fasting serum glucose levels in Hispanic children participating in the Viva La Familia Study.

DESIGN

Subjects were 1030 children ascertained through an overweight child from 319 Hispanic families. Fasting serum glucose levels were measured enzymatically, and genetic linkage analyses were conducted using SOLAR software.

RESULTS

Fasting glucose was heritable, with a heritability of 0.62 +/- 0.08 (P < 0.01). Genome-wide scan mapped fasting serum glucose to markers D13S158-D13S173 on chromosome 13q (LOD score of 4.6). A strong positional candidate gene is insulin receptor substrate 2, regulator of glucose homeostasis and a candidate gene for obesity. This region was reported previously to be linked to obesity- and diabetes-related phenotypes.

CONCLUSIONS

A quantitative trait locus on chromosome 13q contributes to the variation in fasting serum glucose levels in Hispanic children at high risk for obesity.