Insulin resistance and impaired glucose metabolism in a predominantly Maori community

Manipal lifestyle modification score to predict major adverse cardiac events in postcoronary angioplasty patients

BACKGROUND

Lifestyle modification (LSM) such as prudent diet, physical activity, avoidance of smoking, and maintaining a healthy weight may considerably decrease the risk for coronary artery disease.

OBJECTIVE

The primary objective of this study was to develop a new LSM scoring system and investigate the correlation between adherence to LSM and incidence of major adverse cardiac events (MACEs) at 12-month follow-up.

METHOD

A total of 1000 consecutive patients who underwent percutaneous transluminal coronary angioplasty (PTCA) were included in this prospective single-center study. Manipal lifestyle modification score (MLSMS) was developed by using five lifestyle-related factors. Adherence to LSM at the baseline and subsequent follow-ups was determined by using MLSMS. The MACE at 1-, 6-, and 12-month follow-up were analyzed.

RESULTS

There was a significant reduction in overall adherence to LSM (p < 0.001) at 12-month follow-up. Nonadherence to LSM [hazard ratio (HR) 0.575; 95% confidence interval (CI) 0.334-0.990; p < 0.046] and noncompliance to medication (HR 2.09; 95% CI 1.425-3.072; p < 0.001) were independent predictors of MACEs after PTCA. The cumulative MACE was 15.4%, which includes 4.9% of all-cause death, 5.2% of nonfatal myocardial infarction, 2.0% of target lesion revascularization, 1.8% of target vessel revascularization, and 1.3% of stroke at 12 months. The incidence of MACEs at 12 months was significantly (p = 0.03) higher in LSM nonadherent compared with LSM adherent patients.

CONCLUSION

There is an overall reduction in adherence to LSM on successive follow-ups and a significant association between the incidence of MACEs and the lack of adherence to LSM. MLSMS is a simple and effective evaluation tool in predicting MACEs in this group of patients.

Association of nocturnal melatonin secretion with insulin resistance in nondiabetic young women

Exogenous melatonin ameliorates insulin resistance in animals, while among humans, polymorphisms in the melatonin receptor gene are associated with insulin resistance. We aimed to investigate the association of endogenous nocturnal melatonin secretion with insulin resistance in humans. We analyzed the association between endogenous nocturnal melatonin secretion, estimated by measuring the main melatonin metabolite, 6-sulfatoxymelatonin, from the first morning urinary void, and the prevalence of insulin resistance based on fasting blood samples collected in a cross-sectional study of 1,075 US women (1997-1999) without diabetes, hypertension, or malignancy. Urinary 6-sulfatoxymelatonin level was standardized to urinary creatinine level; insulin resistance was defined as an insulin sensitivity index value (using the McAuley formula) less than 7.85. Logistic regression models included adjustment for age, body mass index, smoking, physical activity, alcohol intake, dietary glycemic index, family history of diabetes mellitus, blood pressure, plasma total cholesterol, uric acid, and estimated glomerular filtration rate. Higher nocturnal melatonin secretion was inversely associated with insulin levels and insulin resistance. In fully adjusted models, the odds ratio for insulin resistance was 0.45 (95% confidence interval: 0.28, 0.74) among women in the highest quartile of urinary 6-sulfatoxymelatonin:creatinine ratio compared with women in the lowest quartile. Nocturnal melatonin secretion is independently and inversely associated with insulin resistance.

Ngāti and healthy: translating diabetes prevention evidence into community action

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a major health issue in New Zealand Māori. Clinical trials have demonstrated potential for the prevention of T2DM, but whether community public health programmes aiming to prevent diabetes are effective is untested.

OBJECTIVE

To describe the planning and design of an intervention aiming to translate T2DM prevention clinical trial evidence into a community-wide population health intervention in a high risk predominantly Māori community.

APPROACH

Community concerns about the diabetes burden were heard by the local diabetes nurse, herself a tribal member, and discussed with a locally raised academic. Project planning ensued. The intervention and its evaluation were designed using a participatory community development model. The planned intervention had three components: community-wide health promotion initiatives conveying healthy lifestyle messages, community education and monitoring for identified high-risk individuals and their extended families, and a structural strategy aimed at adapting local environments to support lifestyle changes. The evaluation plan involved interrupted time series surveys coupled with formative and process evaluations rather than a randomised control trial design.

DISCUSSION

Consulting communities, validating community concerns and prioritising cultural and ethical issues were key steps. Time spent developing good relationships amongst the health provider and academic research team members at the outset proved invaluable, as the team were united in addressing the project planning and implementation challenges, such as funding obstacles that arose because of our ethically and culturally appropriate non-randomised control trial evaluation design. The pre-intervention survey demonstrated high rates of diabetes (13%), insulin resistance (33%) and risk factors, and provided evidence for positive, as opposed to negative, lifestyle intervention messages.

CONCLUSION

Community-wide lifestyle interventions have the potential to reduce rates of type 2 diabetes and other chronic diseases in high-risk communities, but require a high level of commitment from the health sector and buy-in from the community. Adequate commitment, leadership, planning and resources are essential.

Effects of macronutrient composition of the diet on body fat in indigenous people at high risk of type 2 diabetes

AIMS

We compared, in New Zealand Māori at risk of type 2 diabetes, advice emphasizing fiber rich carbohydrate and fat reduction (HCHF) and a high protein (HP) diet incorporating food preferences of indigenous people, with a control group (CONT).

METHODS

Eighty-four participants were randomized to three groups. Consecutive 8 week periods of supervised weight loss, supervised weight maintenance and unsupervised adherence to the prescribed diet using culturally sensitive methods were employed in intervention groups. Dietary compliance, body composition, blood pressure and metabolic variables were measured.

RESULTS

Body weight was reduced throughout on HP -2.6 (95% confidence interval: -4.4, -0.8)kg and HCHF (-1.6 (-3.0, -0.3)kg) compared with CONT. Total body fat (-1.6 (-3.0, -0.3)kg) and waist circumference (-3.0 (-5.7, -0.2)cm) showed sustained decreases on HP compared with CONT. Diet records suggested reasonable compliance with dietary advice on HP. Carbohydrate intake, but not dietary fiber, increased at the expense of fat on HCHF.

CONCLUSIONS

While moderate weight loss occurred on both HP and HCHF, HP was associated with some further favorable differences compared with the control group.

Two-year results from a community-wide diabetes prevention intervention in a high risk indigenous community: the Ngati and Healthy project

We describe changes in markers and prevalence of glucose metabolism disorders following a 2-year community-wide intervention aimed at reducing insulin resistance (IR) prevalence in a high risk community. Surveys were undertaken before and 2 years after implementation of a community developed and led diabetes prevention program. Proportions and means were calculated and compared by sex and age groups: 25-49 years and 50+ years. A process evaluation contributed to interpretation of results. Response rates were around 50% and demographic characteristics similar in both surveys. Overall, IR prevalence decreased markedly from 35.5% to 25.4% (p=0.003). Most changes were observed amongst 25-49 years old women for whom there was a significant change in prevalences of IR and glucose metabolism disorders (p=0.015), largely due to reduced IR prevalence (38.2-25.6%). In 2006, 60.3% achieved minimum recommended exercise levels and 65.4% ate wholegrain bread compared with 45.1% (p=0.002) and 42.2% (p=0.044), respectively, in 2003. Participation in a community diabetes prevention intervention appeared to reduce IR prevalence after 2 years in those with the highest level of participation and most marked lifestyle changes.

Ethnic differences in extreme obesity

A nationwide representative survey of New Zealand schoolchildren showed a 2.7% incidence of extreme obesity (versus 4% in the United States) but revealed worrying ethnic differences in prevalence. Prevalence percentages (95% CI) were 0.8 (0.4 to 1.9), 5.1 (3.6 to 7.1), and 10.9 (8.9 to 13.3) in New Zealand European, Māori, and Pacific Island groups, respectively. These findings warrant remedial action.