Diabetes, hypertension, and cardiovascular derangements: Pathophysiology and management

Potential utilization of ferulic acid and its derivatives in the management of metabolic diseases and disorders: An insight into mechanisms

Metabolic diseases are abnormal conditions that impair the normal metabolic process, which involves converting food into energy at a cellular level, and cause difficulties like obesity and diabetes. The study aimed to investigate how ferulic acid (FA) and its derivatives could prevent different metabolic diseases and disorders and to understand the specific molecular mechanisms responsible for their therapeutic effects. Information regarding FA associations with metabolic diseases and disorders was compiled from different scientific search engines, including Science Direct, Wiley Online, PubMed, Scopus, Web of Science, Springer Link, and Google Scholar. This review revealed that FA exerts protective effects against metabolic diseases such as diabetes, diabetic retinopathy, neuropathy, nephropathy, cardiomyopathy, obesity, and diabetic hypertension, with beneficial effects on pancreatic cancer. Findings also indicated that FA improves insulin secretion by increasing Ca2+ influx through the L-type Ca2+ channel, thus aiding in diabetes management. Furthermore, FA regulates the activity of inflammatory cytokines (TNF-α, IL-18, and IL-1β) and antioxidant enzymes (CAT, SOD, and GSH-Px) and reduces oxidative stress and inflammation, which are common features of metabolic diseases. FA also affects various signaling pathways, including the MAPK/NF-κB pathways, which play an important role in the progression of diabetic neuropathy and other metabolic disorders. Additionally, FA regulates apoptosis markers (Bcl-2, Bax, and caspase-3) and exerts its protective effects on cellular destruction. In conclusion, FA and its derivatives may act as potential medications for the management of metabolic diseases.

Inter-relationships between cardiovascular, renal and metabolic diseases: Underlying evidence and implications for integrated interdisciplinary care and management

Cardiovascular, renal and metabolic (CaReMe) diseases are individually among the leading global causes of death, and each is associated with substantial morbidity and mortality. However, as these conditions commonly coexist in the same patient, the individual risk of mortality and morbidity is further compounded, leading to a considerable healthcare burden. A number of pathophysiological pathways are common to diseases of the CaReMe spectrum, including neurohormonal dysfunction, visceral adiposity and insulin resistance, oxidative stress and systemic inflammation. Because of the shared pathology and common co-occurrence of the CaReMe diseases, the value of managing these conditions holistically is increasingly being realized. A number of pharmacological and non-pharmacological approaches have been shown to offer simultaneous metabolic, cardioprotective and renoprotective benefits, leading to improved patient outcomes across the CaReMe spectrum. In addition, increasing value is being placed on interdisciplinary team-based and coordinated care models built on greater integration between specialties to increase the rate of early diagnosis and adherence to practice guidelines, and improve clinical outcomes. This interdisciplinary approach also facilitates integration between primary and specialty care, improving the patient experience, optimizing resources, and leading to efficiencies and cost savings. As the burden of CaReMe diseases continues to increase, implementation of innovative and integrated care delivery models will be essential to achieve effective and efficient chronic disease management and to ensure that patients benefit from the best care available across all three disciplines.

Clinical and Demographic Characteristics of Patients with Coexistent Hypertension, Type 2 Diabetes Mellitus, and Dyslipidemia: A Retrospective Study from India

BACKGROUND

Coexisting hypertension, type 2 diabetes mellitus (T2DM), and dyslipidemia (triple disease) can lead to greater risk of cardiovascular morbidity and mortality. The present study sought to comprehend the prevalence, demographic traits, clinical traits, and treatment patterns in Indian patients with these coexisting conditions.

METHODS

An electronic medical record (EMR)-based, retrospective, multicenter, cross-sectional study was conducted, and data were collected for patients who were diagnosed with coexistent hypertension, T2DM, and dyslipidemia. Baseline patient variables evaluated were the percentage of patients with triple comorbidity, demographic characteristics, diagnostic laboratory parameters, and treatment pattern details.

RESULTS

Data from 4793 centers (clinics) were included, with a total of 6,722,173 patients. Of these, 427,835 (6.36%) patients were found to have coexistent hypertension, T2DM, and dyslipidemia. Most of the patients belonged to the 40-64 year age group (62.10%) and were males (57.00%), while 27.40% patients had a body mass index (BMI) within normal limits, 43.30% patients were pre-obese, and 20.90% patients were class 1 obese. Further, 3402 patients (0.80%) had a recorded history of smoking. Mean glycated hemoglobin (HbA1c) for the patients included in the study was 8.35 ± 1.96 g%. Mean systolic blood pressure (SBP) was 138.81 ± 19.59 mm Hg, while mean diastolic blood pressure (DBP) was 82.17 ± 10.35 mm Hg; 27.60% cases had SBP < 130 mm Hg, while 28.37% cases had DBP < 80 mm Hg. The mean low-density lipoprotein (LDL), total cholesterol, and high-density lipoprotein (HDL) in mg/dl were 98.38 ± 40.39, 174.75 ± 46.73, and 44.5 ± 10.05, respectively. Of the enrolled cases, 55.64% had serum LDL below 100 mg/dl, 72.03% cases had serum cholesterol below 200 mg/dl, and 44.15% males and 71.77% females had serum HDL below the normal prescribed range. The most common monotherapy used for managing hypertension was angiotensin receptor blockers (ARB) (24.80%), followed by beta-blockers (24.30%). The most common combinations administered for management of hypertension were antihypertensives with diuretics (14.30%), followed by ARB plus calcium channel blockers (CCB) (13.30%). For dyslipidemia, the majority of patients (56.60%) received lipid-lowering medication in combination with drugs for other comorbidities. The most common antidiabetic agents prescribed were biguanides (74.60%).

CONCLUSIONS

Coexistence of triple disease is not uncommon in the Indian population, with middle-aged patients diagnosed as pre-obese and obese being affected more commonly and receiving treatment for the same. The present study highlights that, though there are medications against the three chronic conditions, the rate of uncontrolled cases of hypertension, T2DM, and dyslipidemia remains high. Coexistence of triple disease increases the risk of cardiovascular and renal complications, which need to be closely monitored and effectively treated.

Adipocyte-Derived Exosomal LINC00968 Promotes Mouse Retina Microvascular Endothelial Cell Dysfunction in a High-Glucose Environment by Modulating the miR-361-5p/TRAF3 Axis

As a major cause of mortality, cardiovascular disease is associated with obesity and diabetes. However, the molecular mechanism by which diabetes-obesity causes cardiovascular complications is largely unknown. In this study, the crosstalk mediated by 3T3-L1 preadipocytes and mouse retina microvascular endothelial cells (mRMECs) was determined after co-culturing performed with a Transwell system or measuring exosome uptake by mRMECs. CCK-8 assays, EdU incorporation assays, TUNEL staining, and ELISAs were used to evaluate the functions of mRMECs. Related protein markers were analyzed by western blotting. Our results showed that LINC00968 levels were significantly elevated in the exosomes derived from H-Glu-induced 3T3-L1 preadipocytes. Both H-Glu treatment and co-culture with 3T3-L1 cells damaged mRMECs, as indicated by lower rates of proliferation and higher rates of apoptosis and cell adhesion molecule expression, as well as by induced inflammation and oxidative stress, which were enhanced by combined H-Glu and co-culture treatment. Furthermore, H-Glu and co-culture treatment increased LINC00968 expression in mRMECs, and the exosomes collected from 3T3-L1 cells had a similar effect. Functionally, LINC00968 inhibition protected mRMECs against the effects of H-Glu and co-culture treatment, while LINC00968 played the opposite role. LINC00968 was found to target miR-361-5p, and TRAF3 was identified as a target gene of miR-361-5p. Finally, miR-361-5p overexpression alleviated the effects of LINC00968 on H-Glu-induced mRMEC dysfunction in vitro. In conclusion, our results indicated that in an H-glu environment, adipocyte exosomes damage microvascular endothelial cells via a LINC00968/miR-361-5p/TRAF3 signaling pathway, which could possibly serve as a target for treating diabetes-obesity-triggered microvascular complications.

A Detroit Student-Run Free Clinic’s Management of Select Chronic Diseases

Aim: The Cass Clinic is a student-run free clinic in Detroit, Michigan that treats chronic diseases including hypertension (HTN), diabetes mellitus (DM), and obesity. Our study aims to quantify the effectiveness of our clinic in managing chronic diseases.

Subject and methods: This study assessed selected health outcomes for 137 patients who visited our clinic between September 1, 2017 and August 31, 2018 based on initial and most recent surrogate markers including manual blood pressure, hemoglobin A1c (HbA1c), and body mass index (BMI) recorded in the clinic’s medical record system dating back to 2012.

Results: Patients were divided into two groups: occasionally seen patients (OSP) and frequently seen patients (FSP). FSP with HTN had systolic blood pressure (SBP) decreased by an average of 14.1 mmHg and diastolic blood pressure (DBP) decreased by 9.8 mmHg, which were statistically associated with the number of clinic visits. Additionally, all patients treated at Cass Clinic saw a decrease in their HbA1c and BMI. HbA1c in OSP decreased by 0.50%. HbA1c in the FSP decreased by 1.7%. Patients with at least two recorded BMIs (n=73) saw a decrease of 0.13 kg/m².

Conclusion: The data from our analysis support that a student-run free clinic model like Cass Clinic provides long-term value for patients who frequently utilize the clinic. These clinics also act as an important resource for the community by making positive strides toward better health in multiple measurable outcomes, including HTN and DM management.

Prevalence of hypertension among individuals with diabetes and its determinants: Evidences from the National Family Health Survey 2015-16, India

BACKGROUND

The incidence of Diabetes mellitus (DM) has escalated in recent decades, and the risk of diabetes-related mortality has increased dramatically due to the co-existence of hypertension (HTN). DM and HTN, having similar aetiology and disease mechanism, are influenced by lifestyle factors and greatly contribute to critical health complications.

AIM

The present study attempted to explore the co-existence of DM-HTN and the potential determinants considering rapid upsurge of both the diseases.

SUBJECTS AND METHODS

National Family Health Survey data were used, which included 7092 adult diabetic individuals, to find out the prevalence rate of HTN in diabetic persons in India. Appropriate statistical analyses were performed to accomplish the study objectives.

RESULTS

Prevalence rate of HTN in diabetic individuals was approximately 37%. Higher BMI was associated with DM-HTN co-existence. In males, increased age, higher BMI, alcohol consumption, poorest wealth index, and non-smoking (tobacco) were the significant determinants of the co-existence of DM-HTN, while in females, they were increased age, higher BMI, and geographical region.

CONCLUSION

This study unveiled the significance of healthy lifestyle maintenance and equitable health care services to prevent HTN among the diabetics, along with promotion of the awareness and management of DM and HTN through appropriate pharmacological treatments.

The impact of type-2 diabetes mellitus on cardiac rehabilitation outcomes: a meta-analysis

OBJECTIVE

To determine the impact of cardiac rehabilitation (CR) on changes in functional capacity (FC) among patients with CVD and a type-2 diabetes mellitus (T2DM) co-morbidity compared to non-T2DM patients.

DATA SOURCE

A systematic review and meta-analysis of randomized control trials were completed using PubMed, CINAHL, and Web of Science in January 2021.

STUDY SELECTION

Articles were included if they compared CR patients with T2DM to those without T2DM (non-T2DM).

DATA EXTRACTION

The primary outcome variable was FC change from pre to post CR reported as maximal or peak oxygen consumption (VO₂max, VO₂peak), and peak metabolic equivalent (METs). Risk of bias was assessed using the Cochrane risk of bias tool. A random-effects model sub-group meta-analysis was conducted. A diabetes co-morbidity was selected for the subgroup analysis with CVD patients being reported as T2DM or non-T2DM.

DATA SYNTHESIS

Twelve studies with total sample of 15,672 patients were extracted. Average change in peak METs was 1.41±1.76 among non-T2DM and 1.08±1.57 among T2DM patients after CR. Change in FC was significantly lower among T2DM patients (Z-value=2.14; g = -0.42; 95% CI [-0.86 - 0.01]; p=0.03).

CONCLUSION

CVD patients with T2DM experience less robust improvements in FC in response to CR compared to patients with CVD alone. A better understanding of the relationship between T2DM and FC vital step in informing exercise prescription in CR for patients with T2DM and CVD. The lack of understanding the role of T2DM onset and progression is a limitation to this study.

Metabolic profile of patients with isolated systolic hypertension

PURPOSE/OBJECTIVE

While hypertension is an important contributor to cardiovascular disease (CVD) and its treatment has well-established mortality benefits, there is uncertainty as regards the management of isolated systolic hypertension (ISH). Furthermore, the association of ISH with CVD and mortality has been established, but the metabolic characteristics of the affected population have not as yet been adequately described. The aim of this study was to describe the metabolic profiles of patients with ISH.

METHODS

An observational study of patients attending the Hypertension Unit of the University Hospital of Heraklion, Crete, Greece, was performed.

RESULTS

In total, 809 hypertensive patients not on any antihypertensive treatment were identified. Among them, 44.7% were men, aged 55.6 ± 12.5 years, while 29.7% of both men and women were smokers. Systolic blood pressure was 161.3 ± 15.8 mmHg and diastolic blood pressure was 96.1 ± 11.3 mmHg. Body mass index (BMI) was 31 ± 5.3 kg/m², while 9.6% had type 2 diabetes (T2D). A comparison of patients with ISH with those with hypertension, but not ISH, revealed that patients with ISH were older and had lower SBP and higher pulse pressure, while they also had lower total cholesterol and LDL and were more likely to have T2D, albeit they had a slightly lower BMI. On the other hand, they did not have any difference in terms of gender, smoking status, HDL, triglycerides, liver biochemistry, uric acid, or prevalence of impaired fasting glucose.

CONCLUSION

Patients with ISH were older, with lower SBP, total cholesterol, and LDL and higher pulse pressure and higher prevalence of diabetes.

Biological activities of Pleurotus spp. polysaccharides: A review

Mushrooms are consumed for their nutrients and therapeutic bioactive compounds and are used medicinally in Chinese and Japanese medicine traditions since time immemorial. Members of the genus Pleurotus form a heterogeneous group of edible species with outstanding nutritional profiles rich in fiber, vitamins (thiamine, riboflavin, ascorbic acid, ergosterine, and niacin), micro and macro-elements (phosphorus and iron), and carbohydrates. Pleurotus is one of the most diversified medicinal and edible mushrooms related to the composition of chemical structures such as polysaccharides, glycoproteins, and secondary metabolites such as alkaloids and betalains. The cultivation of Pleurotus spp. on lignocellulosic wastes represents one of the most economically and cost-effective organic recycling processes, especially for the utilization of different feasible and cheap recyclable residues. Also, several Pleurotus spp. have the ability to remove phenolic compounds from wastewater with the action of phenoloxidase activity. Here, we have reviewed the chemistry of such polysaccharides and their reported biological activities, namely, anti-inflammatory, immunomodulatory, anti-diabetic, anti-tumor, antioxidant, etc. The mechanism of action and effects of novel polysaccharides extracted from various species of Pleurotus have been studied. The current study will be beneficial for guiding future research projects on the above concept and investigating more deeply the health of human beings. PRACTICAL APPLICATIONS: Mushrooms are one of the most delicious foods around the globe and have many medicinal properties for decades. Various Pleurotus species have been in focus in recent years because of their palatability and medicinal importance too. It contains many bioactive compounds among which polysaccharides are valued to a great extent. Many biological activities are exerted by polysaccharides derived from the Pleurotus spp., namely, anti-tumor, antioxidant, and many more. They are responsible for significant physiological responses in animals, animal-alternative in vitro models, and humans. Their important physicochemical characteristics benefit their use in the food industry as well. So, the biological activities of these Pleurotus spp. polysaccharides will provide an insight to develop Pleurotus spp. as functional foods, because of their nutritional value and presence of bioactive components.

Anti-diabetic activity of crude polysaccharide and rhamnose-enriched polysaccharide from G. lithophila on Streptozotocin (STZ)-induced in Wistar rats

The aim of the present study was to elucidate the anti-diabetic effects of the crude polysaccharide and rhamnose-enriched polysaccharide derived from G. lithophila on streptozotocin (STZ)-induced diabetic Wistar rats. Treatment with crude polysaccharide and rhamnose-enriched polysaccharide showed increases in body weight and pancreatic insulin levels and a decrease in blood glucose levels compared with control diabetic rats. The blood concentrations of total cholesterol (TC), triglycerides (TGs), low-density lipoprotein (LDL) and very-low-density lipoprotein (VLDL) decreased, and high-density lipoprotein (HDL) increased both in the crude polysaccharide- and rhamnose-enriched polysaccharide-treated rats. Superoxide dismutase (SOD) and glutathione peroxidase (GPx) levels increased, and malondialdehyde (MDA) levels decreased in the livers, kidneys and pancreases of crude polysaccharide- and rhamnose-enriched polysaccharide-treated rats. Immunohistological examination further confirmed that restoration of the normal cellular size of the islets of Langerhans and the rebirth of β-cells were found to be greater in the body region than in the head and tail regions of the pancreas. The crude polysaccharide- and rhamnose-enriched polysaccharide-treated diabetic rats showed normal blood glucose levels and insulin production, and reversed cholesterol levels and enzymatic actions. Therefore, rhamnose-enriched polysaccharide from G. lithophila acts as a potent anti-diabetic agent to treat diabetes and can lead to the development of an alternative medicine for diabetes in the future.

Can Antidiabetic Drugs Improve Male Reproductive (Dys)Function Associated with Diabetes?

The alarming increase in the number of diabetic patients worldwide raises concerns regarding the impact of the disease on global health, not to mention on social and economic aspects. Furthermore, the association of this complex metabolic disorder with male reproductive impairment is worrying, mainly due to the increasing chances that young individuals, at the apex of their reproductive window, could be affected by the disease, further contributing to the disturbing decline in male fertility worldwide. The cornerstone of diabetes management is glycemic control, proven to be effective in avoiding, minimizing or preventing the appearance or development of disease-related complications. Nonetheless, the possible impact of these therapeutic interventions on male reproductive function is essentially unexplored. To address this issue, we have made a critical assessment of the literature on the effects of several antidiabetic drugs on male reproductive function. While the crucial role of insulin is clear, as shown by the recovery of reproductive impairments in insulin-deficient individuals after treatment, the same clearly does not apply to other antidiabetic strategies. In fact, there is an abundance of controversial reports, possibly related to the various study designs, experimental models and compounds used, which include biguanides, sulfonylureas, meglitinides, thiazolidinediones/glitazones, bile acid sequestrants, amylin mimetics, as well as sodiumglucose co-transporter 2 (SGLT2) inhibitors, glucagon-like peptide 1 (GLP1), α-glucosidase inhibitors and dipeptidyl peptidase 4 (DPP4) inhibitors. These aspects constitute the focus of the current review.

Blood pressure control in diabetes-the Indian perspective

A tremendous increase in the coexistence of diabetes and hypertension has been observed recently in India. Apart from lifestyle and genetic factors, socioeconomic status, age, gender, occupation and lack of awareness are also contributing to the tremendous increases in the prevalence of both the diseases. Hypertension has been long recognised as one of the major risk factors for chronic disease burden, morbidity and mortality in India, attributable to 10.8% of all deaths in the country. Even though microvascular complications are frequently linked to hyperglycaemia, studies have also proven the critical involvement of hypertension in the development of these co-morbidities. The co-occurrence of hypertension in diabetic patients considerably escalates the risks of coronary heart disease, stroke, nephropathy and retinopathy. The annual expenditure for diabetes for the Indian population was estimated to be 1541.4 billion INR ($31.9 billion) in 2010. The expense of diabetes care further escalates in the presence of complications or co-morbidities. Generally, a diabetic patient with hypertension spent an average of 1.4 times extra than a diabetic patient without hypertension. Even though diabetes and hypertension are considered as important risk factors for cardiovascular and chronic kidney diseases, the awareness about the prevention, treatment and control of these diseases remains alarmingly low in the developing countries like India. The healthcare system in India should focus on better hypertension screening and control, especially in diabetic patients, to minimise the burden of the dual epidemic.

Antidiabetic therapies and male reproductive function: where do we stand?

Diabetes mellitus has been increasing at alarming rates in recent years, thus jeopardizing human health worldwide. Several antidiabetic drugs have been introduced in the market to manage glycemic levels, and proven effective in avoiding, minimizing or preventing the appearance or development of diabetes mellitus-related complications. However, and despite the established association between such pathology and male reproductive dysfunction, the influence of these therapeutic interventions on such topics have been scarcely explored. Importantly, this pathology may contribute toward the global decline in male fertility, giving the increasing preponderance of diabetes mellitus in young men at their reproductive age. Therefore, it is mandatory that the reproductive health of diabetic individuals is maintained during the antidiabetic treatment. With this in mind, we have gathered the available information and made a critical analysis regarding the effects of several antidiabetic drugs on male reproductive function. Unlike insulin, which has a clear and fundamental role on male reproductive function, the other antidiabetic therapies' effects at this level seem incoherent. In fact, studies are highly controversial possibly due to the different experimental study approaches, which, in our opinion, suggests caution when it comes to prescribing such drugs to young diabetic patients. Overall, much is still to be determined and further studies are needed to clarify the safety of these antidiabetic strategies on male reproductive system. Aspects such as the effects of insulin levels variations, consequent of insulin therapy, as well as what will be the impact of the side effect hypoglycemia, common to several therapeutic strategies discussed, on the male reproductive system are still to be addressed.

Bioactivity-Guided Fractionation of Pine Needle Reveals Catechin as an Anti-hypertension Agent via Inhibiting Angiotensin-Converting Enzyme

Hypertension has been recognized as one of the highest risk factors for cardiovascular diseases. Anti-hypertension agent screening and development has been recognized as a pharmaceutical therapy approach for the cardiovascular diseases treatment. Many kinds of traditional Chinese medicines, such as pine needle, have been used for the treatment of hypertension for a long time, but the bioactive ingredients which responsible for their therapeutic effectiveness are remain unclear. Therefore, screening bioactive chemicals in natural sources is still the most straightforward strategy for novel Angiotensin-converting enzyme inhibitor (ACEi)-based anti-hypertension agents discovery. In this study, we demonstrated a bioactivity-guided fractionation strategy for identifying bioactive fractions and chemicals from pine needle based on LC/MS assay as well as elucidating their mechanisms of pharmacological activity. And we found out the compound in pine needle extracts being ACE-inhibitory active is catechin. When ACE activity was assayed in rat tissue membranes, it was observed that catechin demonstrate ACE inhibition in kidney, lung and testes tissue. All these presents catechin in pine needle could be a potential cardiovascular medicine.

Sodium and Its Role in Cardiovascular Disease - The Debate Continues

Guidelines have recommended significant reductions in dietary sodium intake to improve cardiovascular health. However, these dietary sodium intake recommendations have been questioned as emerging evidence has shown that there is a higher risk of cardiovascular disease with a low sodium diet, including in individuals with type 2 diabetes. This may be related to the other pleotropic effects of dietary sodium intake. Therefore, despite recent review of dietary sodium intake guidelines by multiple organizations, including the dietary guidelines for Americans, American Diabetes Association, and American Heart Association, concerns about the impact of the degree of sodium restriction on cardiovascular health continue to be raised. This literature review examines the effects of dietary sodium intake on factors contributing to cardiovascular health, including left ventricular hypertrophy, heart rate, albuminuria, rennin-angiotensin-aldosterone system activation, serum lipids, insulin sensitivity, sympathetic nervous system activation, endothelial function, and immune function. In the last part of this review, the association between dietary sodium intake and cardiovascular outcomes, especially in individuals with diabetes, is explored. Given the increased risk of cardiovascular disease in individuals with diabetes and the increasing incidence of diabetes worldwide, this review is important in summarizing the recent evidence regarding the effects of dietary sodium intake on cardiovascular health, especially in this population.

Review: Renin-angiotensin-aldosterone system intervention in the cardiometabolic syndrome and cardio-renal protection

The metabolic syndrome, also known as the cardiometabolic syndrome (CMS), is a state of metabolic and vascular dysregulation that is associated with activation of the renin-angiotensin-aldosterone system (RAAS). Clinical components of the CMS include central or visceral obesity, hypertension (HTN), dyslipidemia, insulin resistance/hyperinsulinemia, and microalbuminuria that collectively convey increases in oxidative stress, inflammation, and subsequent endothelial dysfunction. The cardio-renal inflammation and oxidative stress enhanced in the CMS increases the risk for cardiovascular disease (CVD) and renal disease end-points such as stroke, congestive heart failure, and chronic kidney disease (CKD). The development of proteinuria is known to herald progressive kidney disease (e.g. CKD) and both are now well accepted as CVD risk factors. Evidence suggests a role for visceral obesity, insulin resistance/hyperinsulinemia, HTN, and other components of the CMS lead to an increased risk for proteinuria and progressive loss of renal function. Intervention with agents that block the RAAS (e.g. ACE inhibitors and Angiotensin type 1 receptor blockers) have been shown to reduce proteinuria, CKD progression, and CVD events. Herein, we will examine the relationship between RAAS intervention and reductions in CKD and CVD events.

Effect of Lercanidipine on Kidney Microanatomy in Cohen-Rosenthal Diabetic Hypertensive Rats

The study was undertaken to determine the effect of treatment with the dihydropyridine-type calcium antagonist lercanidipine on the renal vasculature in Cohen-Rosenthal diabetic hypertensive rats, a genetic model of hypertension associated with type 2 diabetes mellitus. Eight animals were given a daily oral dose of 3 mg/kg lercanidipine in drinking water for 8 weeks, and 6 control animals received no treatment. The effects on blood pressure, glucose level, and kidney microanatomy were evaluated. Lercanidipine reduced systolic blood pressure and glucose level. In the control group small arteries and glomerular arterioles exhibited wall thickening and luminal narrowing. Lercanidipine administration prevented the changes in small-sized arteries and glomerular arterioles. The glomerular changes observed in the untreated Cohen-Rosenthal diabetic hypertensive rats were not seen in the lercanidipine-treated animals. Lercanidipine also had beneficial effects on the renal vasculature, suggesting that the compound may be considered for treating hypertension associated with diabetes.

Variations in 7-day/24-h circadian pattern of ambulatory blood pressure and heart rate of type 2 diabetes patients

AIMS/INTRODUCTION

Diabetes has profound consequences on the cardiovascular system leading to cardiovascular morbidity and mortality in diabetic patients. Blood pressure (BP) has a characteristic and reproducible circadian pattern, with high values during the day and low values at night. A 7-day timed analysis of BP through ambulatory blood pressure monitoring has been used not only to diagnose day and night dipping patterns of blood pressure, but also to measure day-to-day variability and the circadian hyper-amplitude-tension, a condition in which excessive circadian BP amplitude precedes the chronic established hypertension. Our objective was to assess the 7-day/24-h circadian pattern of BP and heart rate in diabetic patients, as it could be helpful in the diagnosis and prevention of cardiovascular morbidity.

MATERIALS AND METHODS

A total of 50 diabetic patients with type 2 diabetes and 50 non-diabetic participants were recruited for the study. General health records were individually maintained, and 7-day/24-h ambulatory blood pressure monitoring using an ambulatory blood pressure monitor was carried out.

RESULTS

The rhythmic parameters of systolic and diastolic BP, heart rate, double amplitude, acrophase and 3-h fractionated hyperbaric index were found to be significantly high in diabetic patients. A total of 12 participants were diagnosed with circadian hyper-amplitude-tension. These data suggest that diabetic patients have certain variations in the circadian pattern of blood pressure and heart rate, which can result in disturbed vascular events, and thus are at greater risk of cardiovascular morbidity.

CONCLUSION

Seven-day/24-h monitoring might be useful as an early predictive tool in assessing future cardiovascular risk, guiding treatment and management of these patients.

Inhibition of angiotensin-converting enzyme by aqueous extract of tomato

PURPOSE

To investigate the presence of anti-angiotensin converting enzyme (ACE) factors in aqueous extract of tomato.

METHODS

The bio-guided fractionation of the aqueous extract of tomato produced a sugar-free, heat-stable fraction with molecular mass <1,000 Da from tomatoes. The sugar-free tomato extract (TE) was tested for its anti-ACE activity using human plasma and rabbit lung pure ACE. In addition, its effect on human platelet aggregation induced by ADP, collagen or arachidonic acid was determined. The mechanism of platelet inhibitory action of TE was investigated by measuring platelet factor 4 (PF4) release and cAMP synthesis by platelets.

RESULTS

Typically, 100 g tomatoes produced 72.2 ± 4.7 mg of TE. This extract inhibited both platelet aggregation and plasma ACE activity in a dose-dependent manner. It inhibited platelet aggregation in response to ADP, collagen or arachidonic acid, and inhibitory action was mediated in part by reducing platelet PF4 release and by stimulating cAMP synthesis. The IC50 value of TE for ADP-induced platelet aggregation was 0.4 ± 0.02 mg/ml, whereas the IC50 value for ACE enzyme inhibition was 1.40 ± 0.04 mg/ml. Both the TE and commercially available sugar-free TE, Fruitflow(®)-2 had similar amount of catechin, and also had equal inhibitory potencies against platelet aggregation and plasma ACE activity.

CONCLUSION

Together these data indicate that aqueous extract of tomatoes contain anti-ACE factors in addition to previously described anti-platelet factors.

The effect of green tea and sour tea on blood pressure of patients with type 2 diabetes: a randomized clinical trial

INTRODUCTION

The use of herbal medicines including different types of tea is among the different strategies for preventing and controlling the side-effects of diabetes. The aim of the present study was to compare the effect of sour tea and green tea on mildly hypertensive patients with diabetes.

METHODS

The present study was a randomized clinical trial in which 100 mildly hypertensive patients with diabetes were randomly assigned into sour tea group (ST) and green tea group (GT). They were instructed to drink sour tea and green tea infusion, respectively, three times a day 2 hr after each meal for 4 weeks. The participants' blood pressure was measured at days 1, 15, and at the end of study.

RESULTS

The systolic pressure of both groups statistically decreased at the end of the study; it decreased from 123.1 ± 15.5 to 116.8 ± 16.3 mmHg in the ST and from 119.4 ± 15.1 to 114.8 ± 15.9 mmHg in the GT. The diastolic pressure of both groups statistically decreased by the end of the study; it decreased from 79.4 ± 11.1 to 74.5 ± 9.3 mmHg in the ST and from 78.9 ± 8.3 to 75.3 ± 7.7 mmHg in the GT. The therapeutic effectiveness of tea drinking by the end of intervention was 43.5% in the ST and 39.6% in the GT compared to the beginning.

CONCLUSIONS

The present study revealed that mildly hypertensive type 2 diabetic individuals who drink three glasses of green or sour tea daily for 4 weeks show significant decreased systolic and diastolic blood pressures.

Therapeutic interventions for hypertension in metabolic syndrome: a comprehensive approach

Hypertension is a major component of the metabolic syndrome and a major cardiovascular risk factor. Both disorders are rapidly increasing in frequency, with hypertension affecting nearly 60 million Americans and over 1 billion people worldwide, and metabolic syndrome affecting 44% of the US population above the age of 60 years. Sedentary lifestyle, together with obesity and aging of the population, are the major contributing factors for this growing epidemic. Hypertension in metabolic syndrome possesses unique pathophysiological aspects that have considerable implications on therapy of this disease. In this article, we review the pathophysiology and provide a rationale for the current therapeutic options in light of the most recent clinical trials in the field.

Aliskiren as add-on therapy in the treatment of hypertensive diabetic patients inadequately controlled with valsartan/HCT combination: a placebo-controlled study

BACKGROUND

Hypertension frequently coexists with diabetes mellitus, resulting in increased cardiovascular risk. Thus, BP control is crucial in decreasing morbidity and mortality in this difficult-to-treat patient population.

OBJECTIVE

The objective of this study was to evaluate the efficacy and safety of aliskiren in hypertensive patients with diabetes not adequately responsive to the combination of valsartan and hydrochlorothiazide (HCT).

METHODS

After a 1- to 4-week washout period, patients with a mean sitting diastolic BP (msDBP) ≥95 mmHg were treated with valsartan 160 mg for 2 weeks followed by valsartan/HCT 160 mg/25 mg for an additional 4 weeks (single-blind active run-in period). Patients whose msDBP remained ≥85 mmHg after the active run-in period were randomized (1 : 1) to receive aliskiren 150 mg (n = 184) or placebo (n = 179) as add-on therapy for 6 weeks. Aliskiren was then force-titrated to 300 mg once daily for another 6 weeks. Efficacy variables were: the change in msDBP and mean sitting systolic BP (msSBP) from baseline to week 12 endpoint, diastolic response (msDBP <80 mmHg or reduction of at least 10 mmHg), and BP control rate (<130/80 mmHg).

RESULTS

Of the 363 patients randomized, 328 (90.4%) completed the study (aliskiren and placebo groups: 89.7% and 91.1%, respectively). At week 12 endpoint, the least squares mean (LSM) changes in msDBP (aliskiren vs placebo: -5.8 vs -4.8 mmHg; p = 0.2767) and msSBP (aliskiren vs placebo: -7.3 vs -4.8 mmHg; p = 0.0725) were numerically greater in patients treated with aliskiren compared with those treated with placebo; however, this difference was not statistically significant. The proportion of diastolic responders (aliskiren and placebo: 68.5% and 72.9%, respectively; p = 0.8482) and patients achieving BP control (aliskiren and placebo: 16.0% and 16.4%, respectively; p = 0.7511) were similar for both groups. Overall, 63 (34%) and 59 (33%) patients in the aliskiren and placebo groups, respectively, experienced adverse events (AEs). The most commonly reported AEs were headache (placebo group: 6.1%) and dizziness (aliskiren group: 4.4%). Aliskiren was well tolerated.

CONCLUSION

The reductions in BP with aliskiren added to valsartan/HCT in this study were numerically greater compared with placebo added to valsartan/HCT, although not statistically significant.

Independent association between type 2 diabetes mellitus and hypertension over a period of 10 years in a large inpatient population

Diabetes mellitus (DM) and hypertension (HTN) are common risk factors for heart disease in the population. The goal of this study was to evaluate independent association between type 2 DM and HTN using a very large database. We used ICD-9 codes for type 2 DM (250.00, 250.02) and HTN (401.0, 401.1, 401.9) from the Nationwide Inpatient Sample (NIS) database. We randomly selected the years in the database between 1992 and 2002. We used uni- and multi-variate analysis to evaluate any association between type 2 DM and HTN adjusting for co-morbid conditions. The 1992 database contained a total of 6,195,744 patients. Type 2 DM was associated with 37.5% of patients with HTN vs. 11.4% of the control group (odds ratio (OR): 4.63, Confidence interval (CI) 4.61-4.693, p < 0.001). The 2002 database contained a total of 7,853,982 patients. Type 2 DM was associated with 57.2% of patients with HTN vs. 22.9% of the control group (OR: 4.49, CI 4.47-4.52, p < 0.001). Using multivariate analysis adjusting for age, gender, hyperlipidemia, obesity, smoking, and chronic renal failure, type 2 DM remained independently associated with HTN in both years (for the year 1992: OR: 2.49, CI: 2.47-2.51, p < 0.001 and for the year 2002 OR: 2.19, CI: 2.18-2.20, p < 0.001). The same association was persistently found using samples for each year between 1992 and 2002. The presence of type 2 DM is strongly associated with HTN. This association is independent of co-morbid conditions and was persistent with similar odds ratio over a period of 10 years.

Linking diabetes and atherosclerosis

Cardiovascular diseases are the major causes of morbidity and mortality in people with diabetes. Macroangiopathy in diabetes is manifested by more accelerated and progressive atherosclerosis, which is more widely distributed. The pathogenesis of this accelerated atherosclerosis is multifactorial and includes very complex interactions. Several abnormalities - such as hyperglycemia, dyslipidemia, hypertension, endothelial dysfunction, renin-angiotensin system activation and chronic subclinical inflammation - all appear to play important roles in the development of diabetes-induced atherosclerosis. Treatment of the residual risk, other than glycemia, blood pressure and low-density lipoprotein cholesterol, remains important as the rate of diabetes increases worldwide. A synergistic multifactorial approach against both conventional cardiovascular risk factors and emerging risk factors, such as vasoactive systems, the AGE-RAGE axis, novel proteins, such as TRAIL, and the complement system, as well as oxidative stress and inflammation, may be a promising way to prevent macrovascular disease in diabetes. In this review we focus on the major causes and mechanisms of atherosclerotic disease in patients with diabetes and highlight emerging targets for therapeutic intervention.

Cardiovascular disease and modifiable cardiometabolic risk factors

Cardiovascular disease (CVD) is the leading cause of death in the United States and many parts of the world. Potentially modifiable risk factors for CVD include tobacco use, physical inactivity, hypertension, elevated low-density lipoprotein cholesterol, and a cluster of interrelated metabolic risk factors. Over the last several decades, efforts to prevent or treat CVD risk factors have resulted in significantly lower rates of CVD-related mortality. However, many patients never achieve adequate control of CVD risk factors even when these factors have been identified. In addition, the growing prevalence of obesity and type 2 diabetes mellitus (DM) threatens to undermine the improvements in CVD that have been achieved. In the United States, approximately two thirds of adults are overweight or obese, and even modest excess body weight is associated with a significantly increased risk of CVD-related mortality. Lifestyle interventions to promote weight loss reduce the risk of CVD-related illness but are difficult for patients to sustain over long periods of time. The increased incidence of obesity has also contributed to significant increases in the prevalence of other important CVD risk factors, including hypertension, dyslipidemia, insulin resistance, and type 2 DM. Pharmacologic therapies are currently available to address individual CVD risk factors, and others are being evaluated, including endocannabinoid receptor antagonists, inhibitors of peroxisome proliferator-activated receptor subtypes alpha and gamma, and several agents that modulate the activity of glucagon-like peptide-1. The new agents have the potential to significantly improve several CVD risk factors with a single medication and may provide clinicians with several new strategies to reduce the long-term risk of CVD.

Chronic type 1 diabetes in spontaneously hypertensive rats leads to exacerbated cardiac fibrosis

INTRODUCTION

Diabetes in human subjects is often associated with hypertension. The aim of this study was to examine the development of cardiac fibrosis following induction of type 1 diabetes in genetically hypertensive rats.

METHODS

Diabetes was induced by streptozotocin (STZ) injection in 8-week-old normotensive Wistar-Kyoto (WKY) rats and spontaneously hypertensive rats (SHRs) for a duration of 16 or 24 weeks. Aged-matched, nondiabetic WKY and SHRs were used as controls. At termination of treatment, the rats were anaesthetized, hearts arrested in diastole and perfusion fixed. A comprehensive examination of cardiac fibrosis throughout the right and left ventricles was undertaken in picrosirius red-stained sections, using image analysis and by undertaking collagen type I and type III immunohistochemistry.

RESULTS

Induction of diabetes in the SHRs led to a marked increase in the levels of interstitial fibrosis in the left ventricle plus septum (LV+S) at both 16 and 24 weeks duration (59% and 43% increase, respectively) and also in the right ventricle after 24 weeks duration of diabetes (35% increase compared to the nondiabetic SHR). Exacerbated perivascular fibrosis was also observed in the LV+S in the diabetic-hypertensive rats at the later time point. These effects of induction of diabetes were not observed in the normotensive strain.

CONCLUSIONS/INTERPRETATION

Our findings clearly demonstrate elevations in cardiac fibrosis when type 1 diabetes is combined with hypertension. Our findings thus stress the importance of closely monitoring both blood pressure and glucose levels in type 1 diabetic patients in order to prevent myocardial collagen deposition.

Assessment of genomic instability in normal and diabetic rats treated with metformin

To examine if a single or multiple oral administration of metformin, a member of the biguanide class of anti-diabetic agents, has any genotoxic and cytotoxic potential in normal and diabetic rats, a mammalian model, cytogenetic assays through several endpoints such as induction of micronuclei, chromosome aberrations, mitotic activity of bone marrow cells, sperm-head anomaly and assays of some oxidative stress markers have been conducted by the use of standard techniques. Diabetes was induced by streptozotocin injection. Metformin was administrated to both diabetic and non-diabetic rats in single doses of 100, 500 or 2500 mg/kg along with vehicle control groups for diabetic and non-diabetic rats. The animals were killed by cervical dislocation at 24h after treatment, and then bone marrow cells were sampled. Also, a multiple dose study has done in which diabetic and non-diabetic animals were treated with 100 or 500 mg/kg of metformin daily for 4 or 8 weeks after which the animals were killed by cervical dislocation, and then bone marrow and sperm cells were collected. Concurrent control groups were also included in each experiment. The obtained results revealed that metformin was neither genotoxic nor cytotoxic for the rats in all groups at all tested doses. Moreover, metformin significantly reduced the diabetes-induced genomic instability and cell proliferation changes in somatic and germinal cells in a dose-dependent manner (2500, 500, >100mg/kg). In addition, diabetes induced marked biochemical alterations characteristic of oxidative stress including, enhanced lipid peroxidation and reduction in the reduced glutathione level. Treatment with metformin ameliorated these biochemical markers. In conclusion, metformin is a non-genotoxic or cytotoxic compound and may protect from genomic instability induced by hyperglycemia. Apart from its well-known anti-diabetic effect, the antigenotoxic effect of metformin could be possibly ascribed to its radical scavenger effect that modulated the genomic instability responses and cell proliferation changes induced by hyperglycemia.

[Combined antihypertensive and antilipemic therapy as one of the pillars in the poly-pharmacologic preventive strategy for patients with high cardiovascular risk]

Hypertension is a highly prevalent disease and a strong risk factor for cardiovascular disease in industrialized countries in Europe and North America. About 40-50% of hypertensive patients have some other cardiovascular risk factors as smoking, dyslipidemia, glucose intolerance, metabolic syndrome and diabetes. The realization of optimal therapy of these patients is a difficult task, and reaching target blood pressure values is almost impossible by monotherapy. It was realized that the simultaneous normalization of blood pressure and that of abnormal lipid profile with 2-3 or more drugs have great importance for preventing atherosclerotic complications.We started an open-formed study with about 1000 hypertensive patients complicated with dyslipidemia, visceral obesity, metabolic syndrome and diabetes type 2. The base of our therapeutic strategy was a typical poly-pharmacologic treatment with ACE inhibitor (lisinopril), calcium antagonist (amlodipine), statin (atorvastatin) and antiplatelet therapy (if it was necessary).

Effective management of hypertension with dihydropyridine calcium channel blocker-based combination therapy in patients at high cardiovascular risk

The increasing prevalence of hypertension, owing to modern lifestyles and the increasing elderly population, is contributing to the global burden of cardiovascular (CV) disease. Although effective antihypertensive therapies are available, blood pressure (BP) is generally poorly controlled. In addition, the full benefits of antihypertensive therapy can only be realised when target BP is achieved. International guidelines and clinical trial evidence support the use of combination therapy to manage hypertension. In high-risk patients, such as those with coronary artery disease, diabetes and renal dysfunction, BP targets are lower and there is a need for intensive management with combination therapy to control BP and provide additional CV risk reduction benefits. Combinations of antihypertensive agents with different but complementary modes of action improve BP control and may also provide vascular-protective effects. Calcium channel blockers (CCBs) have been shown to be effective in combination with a range of antihypertensive drugs and in different patient populations. As part of a first-line combination strategy, CCBs can provide CV benefits beyond BP control, even in patients at increased CV risk. Benefits include protection against end-organ damage and serious CV events. Indeed, in major intervention trials, these benefits have already been clearly demonstrated. Ongoing studies will provide further data to support the clinical benefits of combination therapy as a first-line treatment approach. Implementation of this approach in clinical practice, together with adherence to global hypertension management guidelines will help ensure patients achieve and sustain BP targets, and reduce the risk of CV events.

Glycaemic control and control of risk factors in diabetes patients in an ophthalmology clinic: what lessons have we learned from the UKPDS and DCCT studies?

PURPOSE

The Diabetes Control and Complications Trial (DCCT) and UK Prospective Diabetes Study (UKPDS) have studied glycaemic control as well as other risk factors in preventing the progression of diabetic end-organ disease, including diabetic retinopathy. We wished to determine to what extent a cross-section of diabetes patients attending our eye clinic met the targets laid down by recent landmark studies.

METHODS

We prospectively assessed 44 consecutive diabetes patients attending outpatient clinics for assessment of diabetic retinopathy. Each patient had HbA1c levels, serum cholesterol and blood pressure checked. A proforma was completed for each patient.

RESULTS

Of the 44 patients studied, 11 had type 1 diabetes mellitus (DM) and 33 had type 2 DM (11 insulin-dependent DM [IDDM], 22 non-insulin-dependent DM [NIDDM]). The mean age of type 1 DM patients was 43 years; that of type 2 DM patients was 62 years. Five of 11 (46%) type 1 DM patients had poorly controlled diabetes (HbA1c > 9%) compared with four of 33 (12%) type 2 DM patients. Overall, 27 of 44 (62%) patients were on antihypertensive medication. The prevalence of poorly controlled blood pressure (> 150/85 mmHg treated; > 160/90 mmHg untreated) was 16 of 44 (36%) patients overall, and was higher for type 2 DM patients (13/33, 39%) than for type 1 DM patients (3/11, 27%). Random serum cholesterol levels > 5.2 were found in 10 of 44 (23%) patients overall (4/11 [36%] type 1 and 6/33 [18%] type 2 DM patients).

CONCLUSIONS

Control of HbA1c, hypertension and hypercholesterolaemia can slow progression of retinopathy and other DM end-points. Many of our patients were poorly controlled in terms of these risk factors. More attention should be addressed to these primary preventative factors in the management of diabetes patients.

Insulin causes renal dopamine D1 receptor desensitization via GRK2-mediated receptor phosphorylation involving phosphatidylinositol 3-kinase and protein kinase C

The renal dopamine system plays an important role in sodium homeostasis and a defect in dopamine D1 receptor (D1R) function is present in hypertension, diabetes, and aging. Our previous studies in hyperinsulinemic animals and in renal cell cultures treated with insulin showed decrease in D1R number and defective coupling to G proteins; however, the exact mechanisms remained unknown. Therefore, we investigated insulin-mediated D1R desensitization and underlying molecular mechanism in opossum kidney (OK) cells. Chronic exposure (24 h) of OK cells to 10 nM insulin caused significant decrease in D1R number and agonist affinity. The D1R was hyperserine phosphorylated, uncoupled from G proteins and SKF38393 , a D1R agonist, failed to stimulate G proteins and inhibit Na-K-ATPase activity. Insulin increased protein kinase C (PKC) activity and caused G protein-coupled receptor kinase 2 (GRK2) translocation to the membranes. Tyrosine kinase inhibitor genistein and phosphatidylinositol 3-kinase (PI3K) inhibitor wortmannin blocked insulin-mediated PKC activation and GRK2 membranous translocation. In addition to genistein and wortmannin, GRK2 membranous tranlocation was also blocked by PKC inhibitor chelerythrine chloride and GRK2-specific siRNA. Genistein, wortmannin, chelerythrine chloride, and GRK2 siRNA abrogated D1R serine phosphorylation and normalized D1R expression and affinity in insulin-treated cells. Furthermore, these inhibitors and siRNA restored D1R G protein coupling and ability of SKF38393 to inhibit Na-K-ATPase activity. In conclusion, insulin-induced D1R desensitization involves PI3K, PKC, and GRK2. Insulin activates PI3K-PKC-GRK2 cascade, causing D1R serine phosphorylation, which leads to D1R downregulation and uncoupling from G proteins, and results in the failure of SKF38393 to stimulate G proteins and inhibit Na-K-ATPase activity.

Hypertension in people with diabetes and the metabolic syndrome: pathophysiologic insights and therapeutic update

Hypertension (HTN) and type 2 diabetes mellitus (T2DM) are emerging as epidemics of the 21st century and are important components of the metabolic syndrome (MS). Evidence demonstrates a relationship between HTN, T2DM, and several vascular and metabolic abnormalities that are components of the MS. HTN affects nearly 70 million Americans and over one billion worldwide; likewise, the MS affects 44% of the US population above the age of 60 years and is rapidly increasing. HTN associated with the MS has certain pathophysiologic characteristics that provide clinical challenges. There is growing evidence that tissue activation of the renin-angiotensin system contributes to endothelial dysfunction, microalbuminuria, insulin resistance, and subsequent increased risk for cardiovascular and chronic kidney disease. The notion that HTN is a metabolic as well as a vascular disease provides a new treatment paradigm.

The burden of new-onset diabetes mellitus after transplantation

The clinical impact of new-onset diabetes mellitus (NODM) is frequently underestimated by clinicians. NODM occurs in approximately 15-20% of renal transplant patients and 15% of liver transplant recipients. Diabetes after transplantation is a leading risk factor for cardiovascular events, with a higher prognostic value than in the non-transplant population. NODM also appears to have a negative influence on graft function, and graft survival rates after renal transplantation are significantly lower in patients who develop diabetes than in controls. Patient mortality following renal transplantation is generally found to be higher in patients with NODM, due to increased cardiovascular and peripheral vascular disease, accelerated graft deterioration and diabetes-related complications, notably infection. A renal registry analysis has reported an increase of 87% in risk of death following onset of NODM. There is also limited evidence that NODM is associated with increased risk of death in liver transplant patients. The relative incidence and severity of diabetic complications in transplant recipients have not been assessed rigorously in a clinical trial but registry data indicate that 20% of renal transplant patients with NODM experience at least one clinically significant diabetic complication within three years. Financially, the additional healthcare costs incurred over the first two years following onset of NODM amount to 21,500 dollars. Routine pre-transplant assessment of diabetic risk, with requisite modification of lifestyle, glycaemic monitoring and immunosuppressive regimens, and coupled with standardized, aggressive hypoglycaemic management as necessary, offers an important opportunity to alleviate the burden of NODM for transplant patients.

Prevalence and associated risk factors of undiagnosed diabetes among adult Moroccan Sahraoui women

OBJECTIVE

The goal of the present work was to examine the prevalence and associated risk factors of undiagnosed diabetes among urban Moroccan Sahraoui women.

DESIGN AND SETTING

Randomised sample of adult women living in the city of Laayoune in south Morocco who visited public health centres during an immunisation campaign. Body weight, height, waist and hip circumferences, blood pressure, fasting plasma glucose (FPG), triglycerides, dietary intake and physical activity were collected.

SUBJECTS

Data were obtained on 249 urban women aged 15 years and older, who were not pregnant. Only subjects identified as of Sahraoui origin were eligible for this investigation.

RESULTS

The prevalence of impaired fasting glucose (IFG) was 5.5% and that of undiagnosed diabetes 6.4%. Diabetes and IFG were more common among older and obese women as well as among women with hypertension or a family history of diabetes. In addition, sucrose intakes were higher in women with diabetes than in those with normal FPG. Also, physical activity estimated as the time spent in walking was negatively associated with FPG. Regression analyses showed an independent association of age, obesity, family history of diabetes and triglycerides with diabetes.

CONCLUSION

The high proportion of unknown diabetes suggests the need for increased diabetes awareness in this population. The data suggest also the involvement of obesity in diabetes and the potential importance of intervention strategies to reduce population adiposity for the prevention and management of cardiovascular risk factors.

Sodium intake and hypertension

In current diets, the level of sodium is very high, whereas that of potassium, calcium, and magnesium is low compared with the level in diets composed of unprocessed, natural foods. We present the biologic rationale and scientific evidence that show that the current salt intake levels largely explain the high prevalence of hypertension. Comprehensive reduction of salt intake, both alone and particularly in combination with increases in intakes of potassium, calcium, and magnesium, is able to lower average blood pressure levels substantially. During the past 30 years, the one-third decrease in the average salt intake has been accompanied by a more than 10-mm Hg fall in the population average of both systolic and diastolic blood pressure, and a 75% to 80% decrease in both stroke and coronary heart disease mortality in Finland. There is no evidence of any harmful effects of salt reduction. Salt-reduction recommendations alone have a very small, if any, population impact. In the United States, for example, the per capita use of salt increased by approximately 55% from the mid-1980s to the late 1990s. We deal with factors that contribute toward increasing salt intakes and present examples of the methods that have contributed to the successful salt reduction in Finland.

Stroke prevention in diabetes and obesity

Stroke is an important cause of morbidity and mortality, and is an economic burden. Diabetes and obesity are two important modifiable risk factors for stroke. Patients with diabetes have a higher incidence of stroke and a poorer prognosis after stroke. Risk-factor modification is the most important aspect of prevention of stroke in diabetes and obesity. This includes lifestyle modifications and different therapeutic modalities to control conditions, such as diabetes, hypertension, dyslipidemia and arrhythmia. Recent landmark studies have shown the beneficial effects of statins in diabetic patients even with close to normal or normal low-density lipoprotein cholesterol. Obesity, which is a risk factor for diabetes, hypertension and hyperlipidemia has been shown to be an independent risk factor for stroke. Increased leptin, dysregulation of adipocyte proteins, increased insulin resistance and C-reactive protein may be factors involved in the increased incidence of cardiovascular morbidity and mortality directly related to obesity. Visceral fat is a much bigger health risk than subcutaneous fat. Lifestyle interventions and pharmacotherapeutic agents have been used to manage obesity. In morbidly obese patients, surgical intervention seems to be the best method of treatment with a long-lasting favorable metabolic outcome. In the 21st Century, with the advanced medical knowledge and the therapeutic modalities available, it should be possible to reduce the incidence of stroke associated with diabetes and obesity.

Managing hypertension in patients with type 2 diabetes mellitus

PURPOSE

Current guideline recommendations for effective strategies to optimize the treatment of patients with concomitant hypertension and type 2 diabetes mellitus are reviewed.

SUMMARY

Current estimates indicate that 20 million people in the United States have diabetes, 90-95% of whom have type 2 diabetes mellitus. Type 2 diabetes mellitus is associated with an increased risk of premature death from cardiovascular disease (CVD), stroke, and end-stage renal disease. Hypertension is an extremely common comorbidity in patients with type 2 diabetes mellitus. The coexistence of hypertension in patients with type 2 diabetes is particularly destructive because of the strong linkage of the two conditions with CVD, stroke, progression of renal disease, and diabetic nephropathy. Current guidelines, including those issued by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, the National Kidney Foundation, and the American Diabetes Association, provide evidence-based recommendations for the treatment of hypertension in patients with type 2 diabetes mellitus. However, studies indicate that guidelines are not widely followed. Therefore, the beneficial effects of appropriate hypertension treatment observed in clinical trials are often not recognized in clinical practice. Pharmacists are ideally positioned to help improve guideline implementation and patient outcome.

CONCLUSION

Pharmacists must become more vigilant about following current guidelines for the treatment of patients with concomitant hypertension and type 2 diabetes mellitus. Strategies such as patient education and medication assessment can help to optimize care for these patients and slow the progression to diabetic nephropathy.