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Munch L, Bennich B, Arreskov AB, Overgaard D, Konradsen H, Knop FK, Vilsbøll T, Røder ME. Shared care management of patients with type 2 diabetes across the primary and secondary healthcare sectors: study protocol for a randomised controlled trial. Trials 2016; 17:277. [PMID: 27259669 PMCID: PMC4893266 DOI: 10.1186/s13063-016-1409-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/26/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The prevalence of type 2 diabetes (T2D) is growing globally and hospital-based outpatient clinics are burdened with increasing numbers of patients. To ensure high quality treatment and care, it is necessary to structurally reorganise the management of patients with T2D. The objective of this study is to test if T2D patients (who are at intermediate risk of or are already having incipient diabetic complications) jointly managed by a hospital-based outpatient clinic and general practitioners (shared care programme) have a non-inferior outcome compared to an established programme in a specialised (hospital based) outpatient diabetes clinic. METHODS The study is designed as a randomised controlled trial. The shared care model will be tested during a period of 3 years, with data collection at baseline and at 12, 24 and 36 months. All patients will be offered four medical visits a year; the shared care intervention consists of one annual comprehensive check-up at the outpatient clinic and three quarterly visits at the general practitioners' office. The control group will be followed with four quarterly visits at the outpatient clinic, including an annual comprehensive check-up. In the outpatient clinic, the patients will be treated by a specialised diabetes team, including an endocrinologist. On the basis of a predefined stratification model, we will recruit patients stratified to be at intermediate risk of or already having incipient diabetic complications. We plan to include 140 patients. The primary outcome is glycated haemoglobin. Other outcome measures include (1) the proportion of patients who meet the Danish standard indicators reflecting quality of care; (2) quality of life measured by Short Form 36; and (3) the functionality of the patients' families measured by Family Assessment Measure III. The experiences of the patients and families when participating in the shared care program will be explored by collecting dyadic interviews. DISCUSSION This study will evaluate the quality of a shared care programme for patients with T2D, and provide evidence about advantages and disadvantages compared with a programme in a specialised outpatient clinic. The results may provide important information on how to organise the care for patients with T2D in the future. TRIAL REGISTRATION This trial was registered with Clinicaltrials.gov on 21 October 2015, registration number: NCT02586545 .
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Affiliation(s)
- Lene Munch
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark
- Institute of Nursing, Metropolitan University College, Copenhagen, Denmark
| | - Birgitte Bennich
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark
- Institute of Nursing, Metropolitan University College, Copenhagen, Denmark
| | - Anne B Arreskov
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark
| | - Dorthe Overgaard
- Institute of Nursing, Metropolitan University College, Copenhagen, Denmark
| | - Hanne Konradsen
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Hundinge, Sweden
| | - Filip K Knop
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark
- NNF Center for Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tina Vilsbøll
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark
| | - Michael E Røder
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.
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102
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Gregg EW, Sattar N, Ali MK. The changing face of diabetes complications. Lancet Diabetes Endocrinol 2016; 4:537-47. [PMID: 27156051 DOI: 10.1016/s2213-8587(16)30010-9] [Citation(s) in RCA: 332] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 03/22/2016] [Accepted: 03/23/2016] [Indexed: 12/16/2022]
Abstract
The global increase in type 2 diabetes prevalence is well documented, but international trends in complications of type 2 diabetes are less clear. The available data suggest large reductions in classic complications of type 2 diabetes in high-income countries over the past 20 years, predominantly reductions in myocardial infarction, stroke, amputations, and mortality. These trends might be accompanied by less obvious, but still important, changes in the character of morbidity in people with diabetes. In the USA, for example, substantial reductions in macrovascular complications in adults aged 65 years or older mean that a large proportion of total complications now occur among adults aged 45-64 years instead, rates of renal disease could persist more than other complications, and obesity-related type 2 diabetes could have increasing effect in youth and adults under 45 years of age. Additionally, the combination of decreasing mortality and increasing diabetes prevalence has increased the overall mean years lived with diabetes and could lead to a diversification of diabetes morbidity, including continued high rates of renal disease, ageing-related disability, and cancers. Unfortunately, data on trends in diabetes-related complications are limited to only about a dozen countries, most of which are high income, leaving the changing character for countries of low and middle income ambiguous.
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Affiliation(s)
- Edward W Gregg
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mohammed K Ali
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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103
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Harding JL, Shaw JE, Peeters A, Davidson S, Magliano DJ. Age-Specific Trends From 2000-2011 in All-Cause and Cause-Specific Mortality in Type 1 and Type 2 Diabetes: A Cohort Study of More Than One Million People. Diabetes Care 2016; 39:1018-26. [PMID: 27208325 DOI: 10.2337/dc15-2308] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 03/28/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To analyze changes by age-group in all-cause and cause-specific mortality rates from 2000-2011 in people with diabetes. RESEARCH DESIGN AND METHODS A total of 1,189,079 (7.3% with type 1 diabetes) Australians with diabetes registered on the National Diabetes Service Scheme between 2000 and 2011 were linked to the National Death Index. Mortality rates in the total population were age standardized to the 2001 Australian population. Mortality rates were calculated for the following age-groups: 0 to <40 years, ≥ 40 to <60 years, and ≥60 to ≤85 years. Annual mortality rates were fitted using a Poisson regression model including calendar year as a covariate and age and sex where appropriate, with Ptrend reported. RESULTS For type 1 diabetes, all-cause, cardiovascular disease (CVD), and diabetes age-standardized mortality rates (ASMRs) decreased each year by 0.61, 0.35, and 0.14 per 1,000 person-years (PY), respectively, between 2000 and 2011, Ptrend < 0.05, while cancer mortality remained unchanged. By age, significant decreases in all-cause, CVD, and diabetes mortality rates were observed in all age-groups, excluding diabetes mortality in age-group 0-40 years. For type 2 diabetes, all-cause, CVD, and diabetes ASMRs decreased per year by 0.18, 0.15, and 0.03 per 1,000 PY, respectively, Ptrend < 0.001, while cancer remained unchanged. By age, these decreases were observed in all age-groups, excluding 0-40 years, where significant increases in all-cause and cancer mortality were noted and no change was seen for CVD and diabetes mortality. CONCLUSIONS All-cause, CVD, and diabetes ASMRs in type 1 and type 2 diabetes decreased between 2000 and 2011, while cancer ASMRs remained unchanged. However, younger populations are not benefiting from the same improvements as older populations. In addition, the absence of a decline in cancer mortality warrants urgent attention.
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Affiliation(s)
- Jessica L Harding
- Department of Clinical Diabetes and Epidemiology, Baker IDI Heart and Diabetes Institute, Melbourne, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jonathan E Shaw
- Department of Clinical Diabetes and Epidemiology, Baker IDI Heart and Diabetes Institute, Melbourne, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anna Peeters
- School of Health and Social Development, Faculty of Health, Deakin University, Burwood, Australia
| | | | - Dianna J Magliano
- Department of Clinical Diabetes and Epidemiology, Baker IDI Heart and Diabetes Institute, Melbourne, Australia Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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104
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Abstract
Prevention of cardiovascular morbidity and mortality remains the key factor in the treatment of type 2 diabetes (T2DM). In the early phase of T2DM, multifactorial intervention is mandatory and glucose levels should be near normal, in particular in younger patients presenting with the highest cardiovascular risk. Anti-diabetic drugs without any risk for hypoglycaemia should be preferred in order to reduce clinical inertia and increase the long-term adherence to the treatment. In patients already presenting with cardiovascular disease, the best outcome may be expected with the triple oral therapy of metformin, pioglitazone, and empagliflozin, although a controlled prospective study versus insulin therapy is needed to confirm the expectation.
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Affiliation(s)
| | - G-H Schernthaner
- Department of Medicine II, Division of Angiology, Medical University Vienna, Wien, Österreich
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105
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Munch L, Arreskov AB, Sperling M, Overgaard D, Knop FK, Vilsbøll T, Røder ME. Risk stratification by endocrinologists of patients with type 2 diabetes in a Danish specialised outpatient clinic: a cross-sectional study. BMC Health Serv Res 2016; 16:124. [PMID: 27061722 PMCID: PMC4826533 DOI: 10.1186/s12913-016-1365-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 03/24/2016] [Indexed: 12/20/2022] Open
Abstract
Background To target optimised medical care the Danish guidelines for diabetes recommend stratification of patients with type 2 diabetes (T2D) into three levels according to risk and complexity of treatment. The aim was to describe the T2D population in an outpatient clinic, measure the compliance of the endocrinologists’ to perform risk stratification, and investigate the level of concordance between stratification performed by the endocrinologists and objective assessments. Methods A cross-sectional study with data collected from medical records and laboratory databases. The Danish risk stratification model contained the following criteria: HbA1c, blood pressure, metabolic complications, microvascular and macrovascular complications. Stratification levels encompassed: level 1 (uncomplicated), level 2 (intermediate risk) and level 3 (high risk). Objective assessments were conducted independently by two health professionals, and compared with the endocrinologists’ assessments. In order to test the degree of concordance, we conducted Cohen's kappa, McNemar’s test for marginal homogeneity, and Bowker’s test for symmetry. Results Of 245 newly referred patients, 209 (85 %) were stratified by the endocrinologists to level 1 (16 %), level 2 (55 %) and level 3 (29 %). By objective assessments, 4 % were stratified to level 1, 51 % to level 2 and 45 % to level 3. Of 419 long-term follow-up patients, 380 (91 %) were stratified by the endocrinologists to level 1 (5 %), level 2 (57 %), level 3 (38 %). By objective assessments, 3 % were stratified to level 1, 58 % to level 2 and 39 % to level 3. The concordance rate between endocrinologists’ and objective assessments was 63 % among newly referred (kappa 0.39; fair agreement) and 67 % for long-term follow-up (kappa 0.45; moderate agreement). Among newly referred patients, the endocrinologists stratified less patients at level 3 compared to objective assessments (p < 0.0001). There were no significant differences in marginal distribution within long-term follow-up patients. Conclusion Type 2 diabetes patients, newly referred to or allocated for long-term follow-up in the out-patient clinic, were mainly intermediate and high-risk, complicated patients (96 % and 95 %, respectively). Compliance of stratification by endocrinologists was high. The concordance between endocrinologists’ and objective assessments was not strong. Our data suggest that clinician-support for stratification level categorisation might be needed.
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Affiliation(s)
- Lene Munch
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.,Institute of Nursing, University College Metropol, Tagensvej 86, DK-2200, Copenhagen, Denmark
| | - Anne B Arreskov
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark
| | | | - Dorthe Overgaard
- Institute of Nursing, University College Metropol, Tagensvej 86, DK-2200, Copenhagen, Denmark
| | - Filip K Knop
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.,NNF Center for Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen, Denmark
| | - Tina Vilsbøll
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark
| | - Michael E Røder
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.
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106
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Leong A, Porneala B, Dupuis J, Florez JC, Meigs JB. Type 2 Diabetes Genetic Predisposition, Obesity, and All-Cause Mortality Risk in the U.S.: A Multiethnic Analysis. Diabetes Care 2016; 39:539-46. [PMID: 26884474 PMCID: PMC4806775 DOI: 10.2337/dc15-2080] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 12/27/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Type 2 diabetes (T2D) is associated with increased mortality in ethnically diverse populations, although the extent to which this association is genetically determined is unknown. We sought to determine whether T2D-related genetic variants predicted all-cause mortality, even after accounting for BMI, in the Third National Health and Nutrition Examination Survey. RESEARCH DESIGN AND METHODS We modeled mortality risk using a genetic risk score (GRS) from a weighted sum of risk alleles at 38 T2D-related single nucleotide polymorphisms. In age-, sex-, and BMI-adjusted logistic regression models, accounting for the complex survey design, we tested the association with mortality in 6,501 participants. We repeated the analysis within ethnicities (2,528 non-Hispanic white [NHW], 1,979 non-Hispanic black [NHB], and 1,994 Mexican American [MA]) and within BMI categories (<25, 25-30, and ≥30 kg/m(2)). Significance was set at P < 0.05. RESULTS Over 17 years, 1,556 participants died. GRS was associated with mortality risk (OR 1.04 [95% CI 1.00-1.07] per T2D-associated risk allele, P = 0.05). Within ethnicities, GRS was positively associated with mortality risk in NHW and NHB, but not in MA (0.95 [0.90-1.01], P = 0.07). The negative trend in MA was largely driven by those with BMI <25 kg/m(2) (0.91 [0.82-1.00]). In NHW, the positive association was strongest among those with BMI ≥30 kg/m(2) (1.07 [1.02-1.12]). CONCLUSIONS In the U.S., a higher T2D genetic risk was associated with increased mortality risk, especially among obese NHW. The underlying genetic basis for mortality likely involves complex interactions with factors related to ethnicity, T2D, and body weight.
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Affiliation(s)
- Aaron Leong
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA Harvard Medical School, Boston, MA
| | - Bianca Porneala
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Josée Dupuis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Jose C Florez
- Harvard Medical School, Boston, MA Center for Human Genetic Research and Diabetes Unit, Massachusetts General Hospital, Boston, MA Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - James B Meigs
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA Harvard Medical School, Boston, MA
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107
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Yamada Y. [The 43rd Scientific Meeting: Perspectives of Internal Medicine; Genetic predisposition and related life-style underlying metabolic disorders; 4. Prevention and Therapeutic Treatment; 3) Community healthcare in super-aged society]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2016; 105:417-421. [PMID: 27319185 DOI: 10.2169/naika.105.417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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108
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Rosella LC, Lebenbaum M, Fitzpatrick T, O'Reilly D, Wang J, Booth GL, Stukel TA, Wodchis WP. Impact of diabetes on healthcare costs in a population-based cohort: a cost analysis. Diabet Med 2016; 33:395-403. [PMID: 26201986 PMCID: PMC5014203 DOI: 10.1111/dme.12858] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2015] [Indexed: 11/30/2022]
Abstract
AIMS To estimate the healthcare costs attributable to diabetes in Ontario, Canada using a propensity-matched control design and health administrative data from the perspective of a single-payer healthcare system. METHODS Incident diabetes cases among adults in Ontario were identified from the Ontario Diabetes Database between 2004 and 2012 and matched 1:3 to control subjects without diabetes identified in health administrative databases on the basis of sociodemographics and propensity score. Using a comprehensive source of administrative databases, direct per-person costs (Canadian dollars 2012) were calculated. A cost analysis was performed to calculate the attributable costs of diabetes; i.e. the difference of costs between patients with diabetes and control subjects without diabetes. RESULTS The study sample included 699 042 incident diabetes cases. The costs attributable to diabetes were greatest in the year after diagnosis [C$3,785 (95% CI 3708, 3862) per person for women and C$3,826 (95% CI 3751, 3901) for men], increasing substantially for older age groups and patients who died during follow-up. After accounting for baseline comorbidities, attributable costs were primarily incurred through inpatient acute hospitalizations, physician visits and prescription medications and assistive devices. CONCLUSIONS The excess healthcare costs attributable to diabetes are substantial and pose a significant clinical and public health challenge. This burden is an important consideration for decision-makers, particularly given increasing concern over the sustainability of the healthcare system, aging population structure and increasing prevalence of diabetic risk factors, such as obesity.
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Affiliation(s)
- L C Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Public Health Ontario, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | | | | | - D O'Reilly
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- PATH Research Institute, St Joseph's Healthcare, Hamilton, Canada
| | - J Wang
- Public Health Ontario, Toronto, Canada
| | - G L Booth
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- St. Michael's Hospital, Toronto, Canada
- Institute of Health Management Policy and Evaluation, University of Toronto, Toronto, Canada
| | - T A Stukel
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Institute of Health Management Policy and Evaluation, University of Toronto, Toronto, Canada
| | - W P Wodchis
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Institute of Health Management Policy and Evaluation, University of Toronto, Toronto, Canada
- Toronto Rehabilitation Institute, Toronto, Canada
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109
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Hartwig S, Kluttig A, Tiller D, Fricke J, Müller G, Schipf S, Völzke H, Schunk M, Meisinger C, Schienkiewitz A, Heidemann C, Moebus S, Pechlivanis S, Werdan K, Kuss O, Tamayo T, Haerting J, Greiser KH. Anthropometric markers and their association with incident type 2 diabetes mellitus: which marker is best for prediction? Pooled analysis of four German population-based cohort studies and comparison with a nationwide cohort study. BMJ Open 2016; 6:e009266. [PMID: 26792214 PMCID: PMC4735317 DOI: 10.1136/bmjopen-2015-009266] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To compare the association between different anthropometric measurements and incident type 2 diabetes mellitus (T2DM) and to assess their predictive ability in different regions of Germany. METHODS Data of 10,258 participants from 4 prospective population-based cohorts were pooled to assess the association of body weight, body mass index (BMI), waist circumference (WC), waist-to-hip-ratio (WHR) and waist-to-height-ratio (WHtR) with incident T2DM by calculating HRs of the crude, adjusted and standardised markers, as well as providing receiver operator characteristic (ROC) curves. Differences between HRs and ROCs for the different anthropometric markers were calculated to compare their predictive ability. In addition, data of 3105 participants from the nationwide survey were analysed separately using the same methods to provide a nationally representative comparison. RESULTS Strong associations were found for each anthropometric marker and incidence of T2DM. Among the standardised anthropometric measures, we found the strongest effect on incident T2DM for WC and WHtR in the pooled sample (HR for 1 SD difference in WC 1.97, 95% CI 1.75 to 2.22, HR for WHtR 1.93, 95% CI 1.71 to 2.17 in women) and in female DEGS participants (HR for WC 2.24, 95% CI 1.91 to 2.63, HR for WHtR 2.10, 95% CI 1.81 to 2.44), whereas the strongest association in men was found for WHR among DEGS participants (HR 2.29, 95% CI 1.89 to 2.78). ROC analysis showed WHtR to be the strongest predictor for incident T2DM. Differences in HR and ROCs between the different markers confirmed WC and WHtR to be the best predictors of incident T2DM. Findings were consistent across study regions and age groups (<65 vs ≥ 65 years). CONCLUSIONS We found stronger associations between anthropometric markers that reflect abdominal obesity (ie, WC and WHtR) and incident T2DM than for BMI and weight. The use of these measurements in risk prediction should be encouraged.
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Affiliation(s)
- Saskia Hartwig
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Alexander Kluttig
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Daniel Tiller
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Julia Fricke
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute for Social Medicine, Epidemiology and Health Economics, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Grit Müller
- Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany
| | - Sabine Schipf
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Henry Völzke
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Michaela Schunk
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany
| | - Christa Meisinger
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
- Institute of Epidemiology II, Helmholtz Zentrum München, Neuherberg, Germany
| | - Anja Schienkiewitz
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Christin Heidemann
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Susanne Moebus
- Institute for Medical Informatics, Biometry, and Epidemiology, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Sonali Pechlivanis
- Institute for Medical Informatics, Biometry, and Epidemiology, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Karl Werdan
- Department of Medicine III, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Oliver Kuss
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
- Institute of Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University, Düsseldorf, Germany
| | - Teresa Tamayo
- Institute of Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University, Düsseldorf, Germany
| | - Johannes Haerting
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Karin Halina Greiser
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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Polonsky WH, Henry RR. Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Patient Prefer Adherence 2016; 10:1299-307. [PMID: 27524885 PMCID: PMC4966497 DOI: 10.2147/ppa.s106821] [Citation(s) in RCA: 392] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
At least 45% of patients with type 2 diabetes (T2D) fail to achieve adequate glycemic control (HbA1c <7%). One of the major contributing factors is poor medication adherence. Poor medication adherence in T2D is well documented to be very common and is associated with inadequate glycemic control; increased morbidity and mortality; and increased costs of outpatient care, emergency room visits, hospitalization, and managing complications of diabetes. Poor medication adherence is linked to key nonpatient factors (eg, lack of integrated care in many health care systems and clinical inertia among health care professionals), patient demographic factors (eg, young age, low education level, and low income level), critical patient beliefs about their medications (eg, perceived treatment inefficacy), and perceived patient burden regarding obtaining and taking their medications (eg, treatment complexity, out-of-pocket costs, and hypoglycemia). Specific barriers to medication adherence in T2D, especially those that are potentially modifiable, need to be more clearly identified; strategies that target poor adherence should focus on reducing medication burden and addressing negative medication beliefs of patients. Solutions to these problems would require behavioral innovations as well as new methods and modes of drug delivery.
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Affiliation(s)
- William H Polonsky
- Behavioral Diabetes Institute, San Diego
- University of California, San Diego
- Correspondence: William H Polonsky, Behavioral Diabetes Institute, PO Box 2148, Del Mar, CA 92014, USA, Tel +1 760 525 5256, Email
| | - Robert R Henry
- University of California, San Diego
- Center for Metabolic Research, VA San Diego Healthcare System, San Diego, CA, USA
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Tancredi M, Rosengren A, Svensson AM, Kosiborod M, Pivodic A, Gudbjörnsdottir S, Wedel H, Clements M, Dahlqvist S, Lind M. Excess Mortality among Persons with Type 2 Diabetes. N Engl J Med 2015; 373:1720-32. [PMID: 26510021 DOI: 10.1056/nejmoa1504347] [Citation(s) in RCA: 673] [Impact Index Per Article: 74.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The excess risks of death from any cause and death from cardiovascular causes among persons with type 2 diabetes and various levels of glycemic control and renal complications are unknown. In this registry-based study, we assessed these risks according to glycemic control and renal complications among persons with type 2 diabetes. METHODS We included patients with type 2 diabetes who were registered in the Swedish National Diabetes Register on or after January 1, 1998. For each patient, five controls were randomly selected from the general population and matched according to age, sex, and county. All the participants were followed until December 31, 2011, in the Swedish Registry for Cause-Specific Mortality. RESULTS The mean follow-up was 4.6 years in the diabetes group and 4.8 years in the control group. Overall, 77,117 of 435,369 patients with diabetes (17.7%) died, as compared with 306,097 of 2,117,483 controls (14.5%) (adjusted hazard ratio, 1.15; 95% confidence interval [CI], 1.14 to 1.16). The rate of cardiovascular death was 7.9% among patients versus 6.1% among controls (adjusted hazard ratio, 1.14; 95% CI, 1.13 to 1.15). The excess risks of death from any cause and cardiovascular death increased with younger age, worse glycemic control, and greater severity of renal complications. As compared with controls, the hazard ratio for death from any cause among patients younger than 55 years of age who had a glycated hemoglobin level of 6.9% or less (≤52 mmol per mole of nonglycated hemoglobin) was 1.92 (95% CI, 1.75 to 2.11); the corresponding hazard ratio among patients older than 75 years of age or older was 0.95 (95% CI, 0.94 to 0.96). Among patients with normoalbuminuria, the hazard ratio for death among those younger than 55 years of age with a glycated hemoglobin level of 6.9% or less, as compared with controls, was 1.60 (95% CI, 1.40 to 1.82); the corresponding hazard ratio among patients older than 75 years of age or older was 0.76 (95% CI, 0.75 to 0.78), and patients 65 to 75 years of age also had a significantly lower risk of death (hazard ratio, 0.87; 95% CI, 0.84 to 0.91). CONCLUSIONS Mortality among persons with type 2 diabetes, as compared with that in the general population, varied greatly, from substantial excess risks in large patient groups to lower risks of death depending on age, glycemic control, and renal complications. (Funded by the Swedish government and others.).
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Affiliation(s)
- Mauro Tancredi
- From the Department of Molecular and Clinical Medicine, University of Gothenburg (M.T., A.R., S.G., M.L.), Center of Registers in Region Västra Götaland (A.-M.S.), Statistiska Konsultgruppen (A.P.), and Nordic School of Public Health (H.W.), Gothenburg, and the Department of Medicine, NU Hospital Group, Trollhättan and Uddevalla (M.T., S.D., M.L.) - all in Sweden; Saint Luke's Mid America Heart Institute (M.K.) and Children's Mercy Hospital (M.C.), University of Missouri-Kansas City School of Medicine, Kansas City; and the University of Kansas School of Medicine, Kansas City (M.C.)
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112
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Jansson SPO, Fall K, Brus O, Magnuson A, Wändell P, Östgren CJ, Rolandsson O. Prevalence and incidence of diabetes mellitus: a nationwide population-based pharmaco-epidemiological study in Sweden. Diabet Med 2015; 32:1319-28. [PMID: 25662570 DOI: 10.1111/dme.12716] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2015] [Indexed: 01/19/2023]
Abstract
AIM To investigate the changes in prevalence and incidence of pharmacologically and non-pharmacologically treated diabetes in Sweden during 2005 to 2013. METHODS We obtained data on gender, date of birth and pharmacologically and non-pharmacologically treated diabetes from national registers for all Swedish residents. RESULTS During the study period a total of 240 871 new cases of pharmacologically treated diabetes was found. The age-standardized incidence during the follow-up was 4.34 and 3.16 per 1000 individuals in men and women, respectively. A decreasing time trend in incidence for men of 0.6% per year (0.994, 95% CI 0.989-0.999) and for women of 0.7% per year (0.993, 95% CI 0.986-0.999) was observed. The age-standardized prevalence increased from 41.9 and 29.9 per 1000 in 2005/2006 to 50.8 and 34.6 in 2012/2013 in men and women, respectively. This corresponds to an annually increasing time trend for both men (1.024, 95% CI 1.022-1.027) and women (1.019, 95% CI 1.016-1.021). The total age-standardized prevalence of pharmacologically and non-pharmacologically treated diabetes (2012) was 46.9 per 1000 (55.6 for men and 38.8 for women). This corresponds to an annually increasing time trend (2010-2012) for both men (1.017, 95% CI 1.013-1.021) and women (1.012, 95% CI 1.008-1.016). CONCLUSIONS The prevalence of pharmacologically treated diabetes increased moderately during 8 years of follow-up, while the incidence decreased modestly. This is in contrast to the results reported by most other studies. The total prevalence of diabetes (both pharmacologically and non-pharmacologically treated) in Sweden is relatively low, from a global viewpoint.
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Affiliation(s)
- S P O Jansson
- Family Medicine Research Centre, Örebro County Council, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - K Fall
- Clinical Epidemiology and Biostatistics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - O Brus
- Clinical Epidemiology and Biostatistics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - A Magnuson
- Clinical Epidemiology and Biostatistics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - P Wändell
- Department of Neurobiology, Care Sciences and Society, Unit of Family Medicine, Karolinska Institutet, Huddinge, Sweden
| | - C J Östgren
- Division of Community Medicine, Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Department of Local Care West, County Council of Östergötland, Linköping, Sweden
| | - O Rolandsson
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
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113
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Haroon NN, Austin PC, Shah BR, Wu J, Gill SS, Booth GL. Risk of dementia in seniors with newly diagnosed diabetes: a population-based study. Diabetes Care 2015. [PMID: 26216873 DOI: 10.2337/dc15-0491] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To study whether diabetes onset in late life is a risk factor for dementia. RESEARCH DESIGN AND METHODS We conducted a population-based matched cohort study using provincial health data from Ontario, Canada. Seniors with (n = 225,045) and without newly diagnosed diabetes (n = 668,070) between April 1995 and March 2007 were followed until March 2012 for a new diagnosis of dementia. Cox proportional hazards modeling was used to compare the risk of dementia between groups after adjusting for baseline cardiovascular disease, chronic kidney disease (CKD), hypertension, and other risk factors. RESULTS Over this period, we observed 169,114 new cases of dementia. Individuals with diabetes had a modestly higher incidence of dementia (2.68 vs. 2.62 per 100 person-years) than those without diabetes. In the fully adjusted Cox model, the risk of dementia was 16% higher among our subgroup with diabetes (hazard ratio [HR] 1.16 [95% CI 1.15-1.18]). Adjusted HRs for dementia were 1.20 (95% CI 1.17-1.22) and 1.14 (95% CI 1.12-1.16) among men and women, respectively. Among seniors with diabetes, the risk of dementia was greatest in those with prior cerebrovascular disease (HR 2.03; 95% CI 1.88-2.19), peripheral vascular disease (HR 1.47; 95% CI 1.19-1.82), and CKD (HR 1.44; 95% CI 1.38-1.51), and those with one or more hospital visits for hypoglycemia (HR 1.73; 95% CI 1.62-1.84). CONCLUSIONS In this population-based study, newly diagnosed diabetes was associated with a 16% increase in the risk of dementia among seniors. Preexisting vascular disease and severe hypoglycemia were the greatest risk factors for dementia in seniors with diabetes.
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Affiliation(s)
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada
| | - Baiju R Shah
- Department of Medicine, University of Toronto, Toronto, Canada Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada
| | - Jianbao Wu
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada
| | - Sudeep S Gill
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada Department of Medicine, Queen's University, Kingston, Canada
| | - Gillian L Booth
- Department of Medicine, University of Toronto, Toronto, Canada Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada
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Snell-Bergeon JK. Possible Computer Model for Predicting Cardiovascular Disease in Type 2 Diabetes. Diabetes Technol Ther 2015; 17:679-81. [PMID: 26355755 DOI: 10.1089/dia.2015.0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Janet K Snell-Bergeon
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus , Aurora, Colorado
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115
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Brugnara L, Mallol R, Ribalta J, Vinaixa M, Murillo S, Casserras T, Guardiola M, Vallvé JC, Kalko SG, Correig X, Novials A. Improving Assessment of Lipoprotein Profile in Type 1 Diabetes by 1H NMR Spectroscopy. PLoS One 2015; 10:e0136348. [PMID: 26317989 PMCID: PMC4552656 DOI: 10.1371/journal.pone.0136348] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 08/01/2015] [Indexed: 11/21/2022] Open
Abstract
Patients with type 1 diabetes (T1D) present increased risk of cardiovascular disease (CVD). The aim of this study is to improve the assessment of lipoprotein profile in patients with T1D by using a robust developed method 1H nuclear magnetic resonance spectroscopy (1H NMR), for further correlation with clinical factors associated to CVD. Thirty patients with T1D and 30 non-diabetes control (CT) subjects, matched for gender, age, body composition (DXA, BMI, waist/hip ratio), regular physical activity levels and cardiorespiratory capacity (VO2peak), were analyzed. Dietary records and routine lipids were assessed. Serum lipoprotein particle subfractions, particle sizes, and cholesterol and triglycerides subfractions were analyzed by 1H NMR. It was evidenced that subjects with T1D presented lower concentrations of small LDL cholesterol, medium VLDL particles, large VLDL triglycerides, and total triglycerides as compared to CT subjects. Women with T1D presented a positive association with HDL size (p<0.005; R = 0.601) and large HDL triglycerides (p<0.005; R = 0.534) and negative (p<0.005; R = -0.586) to small HDL triglycerides. Body fat composition represented an important factor independently of normal BMI, with large LDL particles presenting a positive correlation to total body fat (p<0.005; R = 0.505), and total LDL cholesterol and small LDL cholesterol a positive correlation (p<0.005; R = 0.502 and R = 0.552, respectively) to abdominal fat in T1D subjects; meanwhile, in CT subjects, body fat composition was mainly associated to HDL subclasses. VO2peak was negatively associated (p<0.005; R = -0.520) to large LDL-particles only in the group of patients with T1D. In conclusion, patients with T1D with adequate glycemic control and BMI and without chronic complications presented a more favourable lipoprotein profile as compared to control counterparts. In addition, slight alterations in BMI and/or body fat composition showed to be relevant to provoking alterations in lipoproteins profiles. Finally, body fat composition appears to be a determinant for cardioprotector lipoprotein profile.
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Affiliation(s)
- Laura Brugnara
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Barcelona, Spain
| | - Roger Mallol
- Metabolomics Platform, Universitat Rovira i Virgili (URV), Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili (IISPV), Reus, Spain
| | - Josep Ribalta
- Unitat de Recerca en Lípids i Arteriosclerosi (URLA), Hospital Universitari Sant Joan de Reus, Universitat Rovira i Virgili (URV), Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili (IISPV), Reus, Spain
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Barcelona, Spain
| | - Maria Vinaixa
- Metabolomics Platform, Universitat Rovira i Virgili (URV), Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili (IISPV), Reus, Spain
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Barcelona, Spain
| | - Serafín Murillo
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Barcelona, Spain
| | - Teresa Casserras
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Bioinformatics Core Facility, Barcelona, Spain
| | - Montse Guardiola
- Unitat de Recerca en Lípids i Arteriosclerosi (URLA), Hospital Universitari Sant Joan de Reus, Universitat Rovira i Virgili (URV), Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili (IISPV), Reus, Spain
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Barcelona, Spain
| | - Joan Carles Vallvé
- Unitat de Recerca en Lípids i Arteriosclerosi (URLA), Hospital Universitari Sant Joan de Reus, Universitat Rovira i Virgili (URV), Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili (IISPV), Reus, Spain
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Barcelona, Spain
| | - Susana G. Kalko
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Bioinformatics Core Facility, Barcelona, Spain
| | - Xavier Correig
- Metabolomics Platform, Universitat Rovira i Virgili (URV), Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili (IISPV), Reus, Spain
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Barcelona, Spain
| | - Anna Novials
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Barcelona, Spain
- * E-mail:
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Navaneethan SD, Schold JD, Arrigain S, Jolly SE, Nally JV. Cause-Specific Deaths in Non-Dialysis-Dependent CKD. J Am Soc Nephrol 2015; 26:2512-20. [PMID: 26045089 DOI: 10.1681/asn.2014101034] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 03/31/2015] [Indexed: 11/03/2022] Open
Abstract
CKD is associated with higher risk of death, but details regarding differences in cause-specific death in CKD are unclear. We examined the leading causes of death among a non-dialysis-dependent CKD population using an electronic medical record-based CKD registry in a large healthcare system and the Ohio Department of Health mortality files. We included 33,478 white and 5042 black patients with CKD who resided in Ohio between January 2005 and September 2009 and had two measurements of eGFR<60 ml/min per 1.73 m(2) obtained 90 days apart. Causes of death (before ESRD) were classified into cardiovascular, malignancy, and non-cardiovascular/non-malignancy diseases and non-disease-related causes. During a median follow-up of 2.3 years, 6661 of 38,520 patients (17%) with CKD died. Cardiovascular diseases (34.7%) and malignant neoplasms (31.8%) were the leading causes of death, with malignancy-related deaths more common among those with earlier stages of kidney disease. After adjusting for covariates, each 5 ml/min per 1.73 m(2) decline in eGFR was associated with higher risk of death due to cardiovascular disease (hazard ratio [HR], 1.10; 95% confidence interval [95% CI], 1.08 to 1.12) and non-cardiovascular/non-malignancy diseases (HR, 1.12; 95% CI, 1.09 to 1.14) but not to malignancy. In the adjusted models, blacks had overall-mortality hazard ratios similar to those of whites but higher hazard ratios for cardiovascular deaths. Further studies to confirm these findings and explain the mechanisms for differences are warranted. In addition to lowering cardiovascular burden in CKD, efforts to target known risk factors for cancer at the population level are needed.
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Affiliation(s)
- Sankar D Navaneethan
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of CWRU, Cleveland, Ohio; and
| | - Jesse D Schold
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio; Departments of Quantitative Health Sciences, and
| | | | - Stacey E Jolly
- Cleveland Clinic Lerner College of Medicine of CWRU, Cleveland, Ohio; and General Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph V Nally
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of CWRU, Cleveland, Ohio; and
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Cea Soriano L, Johansson S, Stefansson B, Rodríguez LAG. Cardiovascular events and all-cause mortality in a cohort of 57,946 patients with type 2 diabetes: associations with renal function and cardiovascular risk factors. Cardiovasc Diabetol 2015; 14:38. [PMID: 25909295 PMCID: PMC4409775 DOI: 10.1186/s12933-015-0204-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 04/03/2015] [Indexed: 12/21/2022] Open
Abstract
Background Diabetes and chronic kidney disease (CKD) are independent predictors of death and cardiovascular events and their concomitant prevalence has increased in recent years. The aim of this study was to characterize the effect of the estimated glomerular filtration rate (eGFR) and other factors on the risk of death and cardiovascular events in patients with type 2 diabetes. Methods A cohort of 57,946 patients with type 2 diabetes who were aged 20–89 years in 2000–2005 was identified from The Health Improvement Network, a UK primary care database. Incidence rates of death, myocardial infarction (MI), and ischemic stroke or transient ischemic attack (IS/TIA) were calculated overall and by eGFR category at baseline. eGFR was calculated using the Modification of Diet in Renal Disease (MDRD) study equation. Death, MI and IS/TIA cases were detected using an automatic computer search and IS/TIA cases were further ascertained by manual review of medical records. Hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) for death, MI, and IS/TIA associated with eGFR category and other factors were estimated using Cox regression models adjusted for potential confounders. Results Overall incidence rates of death (mean follow-up time of 6.76 years), MI (6.64 years) and IS/TIA (6.56 years) were 43.65, 9.26 and 10.39 cases per 1000 person-years, respectively. A low eGFR (15–29 mL/min) was associated with an increased risk of death (HR: 2.79; 95% CI: 2.57–3.03), MI (HR: 2.33; 95% CI: 1.89–2.87) and IS/TIA (HR: 1.77; 95% CI: 1.43–2.18) relative to eGFR ≥ 60 mL/min. Other predictors of death, MI and IS/TIA included age, longer duration of diabetes, poor control of diabetes, hyperlipidemia, smoking and a history of cardiovascular events. Conclusions In patients with type 2 diabetes, management of cardiovascular risk factors and careful monitoring of eGFR may represent opportunities to reduce the risks of death, MI and IS/TIA. Electronic supplementary material The online version of this article (doi:10.1186/s12933-015-0204-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lucia Cea Soriano
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Almirante 28-2, E 28004, Madrid, Spain.
| | | | | | - Luis A García Rodríguez
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Almirante 28-2, E 28004, Madrid, Spain.
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Martinez-Laguna D, Tebe C, Javaid MK, Nogues X, Arden NK, Cooper C, Diez-Perez A, Prieto-Alhambra D. Incident type 2 diabetes and hip fracture risk: a population-based matched cohort study. Osteoporos Int 2015; 26:827-33. [PMID: 25488807 DOI: 10.1007/s00198-014-2986-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 11/27/2014] [Indexed: 12/28/2022]
Abstract
SUMMARY There is scarce data on the association between early stages of type 2 diabetes and fracture risk. We report a 20% excess risk of hip fracture in the first years following disease onset compared to matched non-diabetic patients. INTRODUCTION Type 2 diabetes mellitus (T2DM) is a chronic disease that affects several target organs. Data on the association between T2DM and osteoporotic fractures is controversial. We estimated risk of hip fracture in newly diagnosed T2DM patients, compared to matched non-diabetic peers. METHODS We conducted a population-based parallel cohort study using data from the Sistema d'Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP) database. Participants were all newly diagnosed T2DM patients registered in SIDIAP in 2006-2011 (T2DM cohort). Up to two diabetes-free controls were matched to each T2DM participant on age, gender, and primary care practice. Main outcome was incident hip fracture in 2006-2011, ascertained using the tenth edition of the International Classification of Diseases (ICD-10) codes. We used Fine and Gray survival modelling to estimate risk of hip fracture according to T2DM status, accounting for competing risk of death. Multivariate models were adjusted for body mass index, previous fracture, and use of oral corticosteroids. RESULTS During the study period (median follow-up 2.63 years), 444/58,483 diabetic patients sustained a hip fracture (incidence rate 2.7/1,000 person-years) compared to 776/113,448 matched controls (2.4/1,000). This is equivalent to an unadjusted (age- and gender-matched) subhazard ratio (SHR) 1.11 [0.99-1.24], and adjusted SHR 1.20 [1.06-1.35]. The adjusted SHR for major osteoporotic and any osteoporotic fractures were 0.95 [0.89-1.01] and 0.97 [0.92-1.02]. CONCLUSIONS Newly diagnosed T2DM patients are at a 20% increased risk of hip fracture even in early stages of disease, but no for all fractures. More data is needed on the causes for an increased fracture risk in T2DM patients as well as on the predictors of osteoporotic fractures among these patients.
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Affiliation(s)
- D Martinez-Laguna
- GREMPAL Research Group, Idiap Jordi Gol Primary Care Research Institute, Universitat Autonoma de Barcelona, Barcelona, Spain
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Lind M, Svensson AM, Kosiborod M, Gudbjörnsdottir S, Pivodic A, Wedel H, Dahlqvist S, Clements M, Rosengren A. Glycemic control and excess mortality in type 1 diabetes. N Engl J Med 2014; 371:1972-82. [PMID: 25409370 DOI: 10.1056/nejmoa1408214] [Citation(s) in RCA: 576] [Impact Index Per Article: 57.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The excess risk of death from any cause and of death from cardiovascular causes is unknown among patients with type 1 diabetes and various levels of glycemic control. We conducted a registry-based observational study to determine the excess risk of death according to the level of glycemic control in a Swedish population of patients with diabetes. METHODS We included in our study patients with type 1 diabetes registered in the Swedish National Diabetes Register after January 1, 1998. For each patient, five controls were randomly selected from the general population and matched according to age, sex, and county. Patients and controls were followed until December 31, 2011, through the Swedish Register for Cause-Specific Mortality. RESULTS The mean age of the patients with diabetes and the controls at baseline was 35.8 and 35.7 years, respectively, and 45.1% of the participants in each group were women. The mean follow-up in the diabetes and control groups was 8.0 and 8.3 years, respectively. Overall, 2701 of 33,915 patients with diabetes (8.0%) died, as compared with 4835 of 169,249 controls (2.9%) (adjusted hazard ratio, 3.52; 95% confidence interval [CI], 3.06 to 4.04); the corresponding rates of death from cardiovascular causes were 2.7% and 0.9% (adjusted hazard ratio, 4.60; 95% CI, 3.47 to 6.10). The multivariable-adjusted hazard ratios for death from any cause according to the glycated hemoglobin level for patients with diabetes as compared with controls were 2.36 (95% CI, 1.97 to 2.83) for a glycated hemoglobin level of 6.9% or lower (≤52 mmol per mole), 2.38 (95% CI, 2.02 to 2.80) for a level of 7.0 to 7.8% (53 to 62 mmol per mole), 3.11 (95% CI, 2.66 to 3.62) for a level of 7.9 to 8.7% (63 to 72 mmol per mole), 3.65 (95% CI, 3.11 to 4.30) for a level of 8.8 to 9.6% (73 to 82 mmol per mole), and 8.51 (95% CI, 7.24 to 10.01) for a level of 9.7% or higher (≥83 mmol per mole). Corresponding hazard ratios for death from cardiovascular causes were 2.92 (95% CI, 2.07 to 4.13), 3.39 (95% CI, 2.49 to 4.61), 4.44 (95% CI, 3.32 to 5.96), 5.35 (95% CI, 3.94 to 7.26), and 10.46 (95% CI, 7.62 to 14.37). CONCLUSIONS In our registry-based observational study, patients with type 1 diabetes and a glycated hemoglobin level of 6.9% or lower had a risk of death from any cause or from cardiovascular causes that was twice as high as the risk for matched controls. (Funded by the Swedish Society of Medicine and others.).
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Affiliation(s)
- Marcus Lind
- From the Department of Medicine, NU-Hospital Organization, Uddevalla (M.L., S.D.), Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg (M.L., S.G., A.R.), Center of Registers in Region Västra Götaland (A.-M.S.), Statistiska Konsultgruppen (A.P.), Nordic School of Public Health (H.W.), and Sahlgrenska University Hospital (A.R.), Gothenburg - all in Sweden; Saint Luke's Mid America Heart Institute (M.K.), University of Missouri-Kansas City School of Medicine (M.K., M.C.), and Children's Mercy Hospital (M.C.), Kansas City, MO; and the University of Kansas School of Medicine, Kansas City, KS (M.C.)
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Gregg EW, Zhuo X, Cheng YJ, Albright AL, Narayan KMV, Thompson TJ. Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985-2011: a modelling study. Lancet Diabetes Endocrinol 2014; 2:867-74. [PMID: 25128274 DOI: 10.1016/s2213-8587(14)70161-5] [Citation(s) in RCA: 207] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Diabetes incidence has increased and mortality has decreased greatly in the USA, potentially leading to substantial changes in the lifetime risk of diabetes. We aimed to provide updated estimates for the lifetime risk of development of diabetes and to assess the effect of changes in incidence and mortality on lifetime risk and life-years lost to diabetes in the USA. METHODS We incorporated data about diabetes incidence from the National Health Interview Survey, and linked data about mortality from 1985 to 2011 for 598 216 adults, into a Markov chain model to estimate remaining lifetime diabetes risk, years spent with and without diagnosed diabetes, and life-years lost due to diabetes in three cohorts: 1985-89, 1990-99, and 2000-11. Diabetes was determined by self-report and was classified as any diabetes, excluding gestational diabetes. We used logistic regression to estimate the incidence of diabetes and Poisson regression to estimate mortality. FINDINGS On the basis of 2000-11 data, lifetime risk of diagnosed diabetes from age 20 years was 40·2% (95% CI 39·2-41·3) for men and 39·6% (38·6-40·5) for women, representing increases of 20 percentage points and 13 percentage points, respectively, since 1985-89. The highest lifetime risks were in Hispanic men and women, and non-Hispanic black women, for whom lifetime risk now exceeds 50%. The number of life-years lost to diabetes when diagnosed at age 40 years decreased from 7·7 years (95% CI 6·5-9·0) in 1990-99 to 5·8 years (4·6-7·1) in 2000-11 in men, and from 8·7 years (8·4-8·9) to 6·8 years (6·7-7·0) in women over the same period. Because of the increasing diabetes prevalence, the average number of years lost due to diabetes for the population as a whole increased by 46% in men and 44% in women. Years spent with diabetes increased by 156% in men and 70% in women. INTERPRETATION Continued increases in the incidence of diagnosed diabetes combined with declining mortality have led to an acceleration of lifetime risk and more years spent with diabetes, but fewer years lost to the disease for the average individual with diabetes. These findings mean that there will be a continued need for health services and extensive costs to manage the disease, and emphasise the need for effective interventions to reduce incidence. FUNDING None.
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Affiliation(s)
- Edward W Gregg
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Xiaohui Zhuo
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yiling J Cheng
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ann L Albright
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - K M Venkat Narayan
- Hubert Department of Global Health-Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Theodore J Thompson
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Affiliation(s)
- Gillian L Booth
- Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Bernard Zinman
- Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
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122
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Lind M, Pivodic A, Cea-Soriano L, Nerman O, Pehrsson NG, Garcia-Rodriguez LA. Changes in HbA1c and frequency of measuring HbA1c and adjusting glucose-lowering medications in the 10 years following diagnosis of type 2 diabetes: a population-based study in the UK. Diabetologia 2014; 57:1586-94. [PMID: 24811709 DOI: 10.1007/s00125-014-3250-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 04/11/2014] [Indexed: 10/25/2022]
Abstract
AIMS/HYPOTHESIS The aim of this work was to study levels of HbA1c and patterns of adjusting glucose-lowering drugs in patients with impaired glycaemic control over 10 years after diagnosis of type 2 diabetes. METHODS We studied 4,529 individuals in The Health Improvement Network Database newly diagnosed with type 2 diabetes in the year 2000. RESULTS From 6 months to 10 years after diagnosis, the HbA1c increased from 7.04% (53.4 mmol/mol) to 7.49% (58.3 mmol/mol) (average annual change: 0.047% [0.51 mmol/mol]). The greatest annual change occurred between 6 months and 2 years (0.21% [2.30 mmol/mol] increase per year, p < 0.001), followed by the 2-5 year time period (0.033% [0.36 mmol/mol] increase per year, p < 0.001). No significant increase in HbA1c occurred between 5 and 10 years (p = 0.20). In multivariable analyses, patients who were younger (p < 0.001), with higher BMI (p = 0.033) and who were current insulin users (p = 0.024) at diagnosis had greater increases in HbA1c between 6 months and 2 years. For individuals with HbA1c above 7.0% (53 mmol/mol) the mean time to next measurement of HbA1c was 0.53 years and increase in doses or changes to other glucose-lowering medications were performed in 26% of cases. CONCLUSIONS/INTERPRETATION HbA1c increases by approximately 0.5% (5 mmol/mol) over 10 years after diagnosis of type 2 diabetes, with the main increase appearing in the first years after diagnosis. More frequent monitoring of HbA1c and adjustments of glucose-lowering drugs may be essential to prevent the decline.
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Affiliation(s)
- Marcus Lind
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden,
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123
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Ritsinger V, Malmberg K, Mårtensson A, Rydén L, Wedel H, Norhammar A. Intensified insulin-based glycaemic control after myocardial infarction: mortality during 20 year follow-up of the randomised Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI 1) trial. Lancet Diabetes Endocrinol 2014; 2:627-33. [PMID: 24831989 DOI: 10.1016/s2213-8587(14)70088-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The benefits of intensified glycaemic control after acute myocardial infarction are uncertain. We report the 20 year follow-up results of the first Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI 1) trial. METHODS DIGAMI 1 was a prospective, randomised, open-label trial with blinded endpoint evaluation (PROBE) done at coronary care units in 19 Swedish hospitals between Jan 1, 1990 and Dec 31, 1993. Patients with and without previously diagnosed diabetes and with blood glucose concentrations of more than 11 mmol/L who had had a suspected acute myocardial infarction in the previous 24 h were randomly assigned (1:1), with sealed envelopes, to intensified insulin-based glycaemic control for at least 3 months, or to a control group prescribed conventional glucose-lowering treatment. Masking was not considered feasible or safe on the basis of insulin use. The primary endpoint was mortality, in both the original study and the present follow-up analysis. Analysis was by intention to treat. FINDINGS 620 patients were randomised to intensified insulin-based glycaemic control (n=306) or the control group (n=314). During a mean follow-up period of 7·3 years (SD 6·6; range 0·0-21·8) years, 271 patients (89%) died in the intensified glycaemic control group and 285 (91%) patients died in the standard glycaemic control group. Median survival time was 7·0 years (IQR 1·8-12·4) in patients in the intensified glycaemic control group and 4·7 (1·0-11·4) in those in the standard group (hazard ratio 0·83, 95% CI 0·70-0·98; p=0·027). The effect of intensified glycaemic control was apparent during 8 years after randomisation, increasing survival by 2·3 years. INTERPRETATION Intensified insulin-based glycaemic control after acute myocardial infarction in patients with diabetes and hyperglycaemia at admission had a long-lasting effect on longevity. Although the effect of glucose lowering might be less apparent with presently available, more effective lipid-lowering and blood-pressure-lowering drugs, improved glycaemic control might still be important for longevity after acute myocardial infarction. FUNDING Swedish Heart-Lung Foundation, Kronoberg County Council.
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Affiliation(s)
- Viveca Ritsinger
- Karolinska Institute, Department of Medicine, Cardiology Unit, Karolinska University Hospital, Stockholm; Unit for Research and Development Kronoberg County Council, Växjö, Sweden.
| | - Klas Malmberg
- Karolinska Institute, Department of Medicine, Cardiology Unit, Karolinska University Hospital, Stockholm
| | | | - Lars Rydén
- Karolinska Institute, Department of Medicine, Cardiology Unit, Karolinska University Hospital, Stockholm
| | - Hans Wedel
- Nordic School of Public Health, Gothenburg, Sweden
| | - Anna Norhammar
- Karolinska Institute, Department of Medicine, Cardiology Unit, Karolinska University Hospital, Stockholm
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124
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Schernthaner G, Sattar N. Lessons from SAVOR and EXAMINE: some important answers, but many open questions. J Diabetes Complications 2014; 28:430-3. [PMID: 24713467 DOI: 10.1016/j.jdiacomp.2014.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 02/17/2014] [Accepted: 02/18/2014] [Indexed: 01/22/2023]
Affiliation(s)
- Guntram Schernthaner
- Department of Medicine I, Rudolfstiftung Hospital, Vienna, Austria; Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University Of Glasgow.
| | - Naveed Sattar
- Department of Medicine I, Rudolfstiftung Hospital, Vienna, Austria; Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University Of Glasgow
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125
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Færch K, Carstensen B, Almdal TP, Jørgensen ME. Improved survival among patients with complicated type 2 diabetes in Denmark: a prospective study (2002-2010). J Clin Endocrinol Metab 2014; 99:E642-6. [PMID: 24483155 DOI: 10.1210/jc.2013-3210] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT It is unclear to what extent recent advances in diabetes care have reduced the excess mortality in patients with complicated type 2 diabetes. OBJECTIVE The aim of this study was to estimate time trends in mortality among patients with complicated type 2 diabetes at the Steno Diabetes Center relative to the general Danish background population. DESIGN, SETTING, AND STUDY PARTICIPANTS: We performed a longitudinal follow-up study from 2002 to 2010 of 5844 patients with type 2 diabetes at the Steno Diabetes Center, Denmark. All-cause and cause-specific mortality was identified from the national death register. MAIN OUTCOME MEASURES Poisson regression was used to model mortality rates by sex, age, age of diabetes onset, and calendar time. RESULTS A total of 1341 deaths occurred (802 men and 539 women) during 32,913 person-years of follow-up. Total mortality rates in the diabetes population decreased by 5.5% (95% confidence interval 2.9%-8.0%) per year in men and by 3.3% (0.0%-6.4%) per year in women. Among men but not women, this decline was significantly steeper than the decline in mortality in the Danish background population (men, -3.0% [-5.6% to -0.4%]; women, -1.4 [-4.6% to 2.0%]). The decline in overall mortality was explained by a decline in cardiovascular mortality for both men and women. CONCLUSION Overall and cardiovascular mortality have decreased during the last decade among Danish patients with complicated type 2 diabetes, and for men, the decline in mortality was more pronounced than in the general population.
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Petrie JR. The cardiovascular safety of incretin-based therapies: a review of the evidence. Cardiovasc Diabetol 2013; 12:130. [PMID: 24011363 PMCID: PMC3847044 DOI: 10.1186/1475-2840-12-130] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 08/21/2013] [Indexed: 12/18/2022] Open
Abstract
Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in people with diabetes and therefore managing cardiovascular (CV) risk is a critical component of diabetes care. As incretin-based therapies are effective recent additions to the glucose-lowering treatment armamentarium for type 2 diabetes mellitus (T2D), understanding their CV safety profiles is of great importance. Glucagon-like peptide-1 (GLP-1) receptor agonists have been associated with beneficial effects on CV risk factors, including weight, blood pressure and lipid profiles. Encouragingly, mechanistic studies in preclinical models and in patients with acute coronary syndrome suggest a potential cardioprotective effect of native GLP-1 or GLP-1 receptor agonists following ischaemia. Moreover, meta-analyses of phase 3 development programme data indicate no increased risk of major adverse cardiovascular events (MACE) with incretin-based therapies. Large randomized controlled trials designed to evaluate long-term CV outcomes with incretin-based therapies in individuals with T2D are now in progress, with the first two reporting as this article went to press.
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Affiliation(s)
- John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK.
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127
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Sheikh A. Direct cardiovascular effects of glucagon like peptide-1. Diabetol Metab Syndr 2013; 5:47. [PMID: 23988189 PMCID: PMC3765965 DOI: 10.1186/1758-5996-5-47] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 08/28/2013] [Indexed: 02/08/2023] Open
Abstract
Current gold standard therapeutic strategies for T2DM target insulin resistance or β cell dysfunction as their core mechanisms of action. However, the use of traditional anti-diabetic drugs, in most cases, does not significantly reduce macrovascular morbidity and mortality. Among emerging anti-diabetic candidates, glucagon like peptide-1 (GLP-1) based therapies carry special cardiovascular implications, exerting both direct as well as indirect effects. The direct cardiovascular effects of GLP-1 and its analogs remain the focus of this review.
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Affiliation(s)
- Asfandyar Sheikh
- Dow Medical College, Dow University of Health Sciences, Baba-e-Urdu Road, Karachi, Pakistan.
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