How are we diagnosing cardiometabolic risk in primary care settings?

Perceptions and Proficiencies of Primary Care Physicians Treating Metabolic Syndrome: A Descriptive Survey-Based Study

INTRODUCTION

Metabolic syndrome (MetS) is a chronic condition that has been implicated in adverse public health outcomes worldwide, including in the United States. It has been linked to diseases such as type 2 diabetes and heart disease. Little is known about the perceptions and practices of primary care physicians (PCPs) regarding MetS. The only studies examining this research topic were conducted outside the United States. The aim of this study was to evaluate the MetS knowledge, proficiency, training, and practices of American PCPs, for the purpose of informing future physician education initiatives directed at MetS.

METHODS

This was a descriptive correlational design using a Likert-scale questionnaire. The survey was distributed to more than 4000 PCPs. The first 100 completed surveys were evaluated using descriptive statistical analyses.

RESULTS

Cumulative survey results revealed that most PCPs perceived themselves as knowledgeable on MetS, but only a minority demonstrated an understanding of leading-edge MetS protocols. Ninety-seven percent agreed that MetS is a condition of concern, but only 22% reported possessing sufficient time and resources to fully address MetS. Only half indicated that they had received training in MetS.

DISCUSSION

Overall results suggested that a lack of time, training, and resources may pose the greatest obstacles to optimal MetS care. Future studies should aim to identify the specific reasons why these barriers exist.

The intersection of physician wellbeing and clinical application of diabetes guidelines

OBJECTIVES

Prediabetes (preDM) and diabetes are complex conditions that place significant strain on medical providers. This can have a negative impact on providers' wellbeing and could impact clinical decisions. We investigated the interplay of caring for patients with prediabetes, physician mental wellbeing, and clinical care.

METHODS

Using the theory of planned behavior, we conducted a secondary analysis to evaluate physicians' self-reported provision of care to patients with preDM. We evaluated the effect of mental wellbeing and perceived barriers to caring for patients with preDM.

RESULTS

Among 1015 academic physicians, a greater perception of barriers to care and a higher percentage of patients seen with preDM were both significantly associated with a less positive physician state of mind. Physician state of mind was not associated with self-reported clinical behavior. Physician perception of patient barriers has a positive correlation with their likelihood of prescribing metformin for preDM.

CONCLUSIONS

Caring for a larger proportion of patients with preDM is associated with worse mental wellbeing. Physician attitudes and subjective norms may predict adherence to guidelines, while physician attitudes and wellbeing affect self-reported prescribing behavior.

PRACTICE IMPLICATIONS

Future research should evaluate ways to lessen the psychological burden of caring for patients with diabetes and preDM.

Current knowledge and perception of bariatric surgery among Greek doctors living in Thessaly

INTRODUCTION

The purpose of this study was to assess doctors' knowledge, current conceptions, and clinical practice regarding obesity and bariatric surgery.

METHODS

A self-administered survey was administered to 500 doctors with varying medical specialties in public and private practice.

RESULTS

The response rate was 60%. Most participants (77.3%) were in private practice. Although almost half of the participants could define morbid obesity and obesity-related comorbidities, only 8.7% felt educated about bariatric surgery. Participants had little knowledge of various types of bariatric procedures. A minority of doctors (24.7%) knew of the existence of a bariatric center in their area. Only 21.3% of doctors had referred a patient to a bariatric center. Reasons for non-referral included lack of interest in bariatric surgery (37.3%), patient refusal (35.3%), increased operative fees (17.3%), lack of confidence in bariatric surgery (6.3%), and lack of access to a nearby bariatric center (3.7%). The majority of doctors were interested in learning more about bariatric surgery and related guidelines, but they remained reluctant to conduct patients' postoperative follow-ups.

CONCLUSION

The penetration of bariatric surgery in the medical community remains limited, despite its proven effectiveness in facilitating sustained weight loss and resolving several obesity-related comorbidities. A great effort should be made to inform health-care providers about the evolution of bariatric procedures, the potential benefits they offer, and the existence of certified bariatric centers. This will allow doctors to provide optimum health care to patients who could benefit from bariatric surgery.

An elevated 1-h post- load glucose level during the oral glucose tolerance test detects prediabetes

AIM

The objective of the study was to compare the diagnosis of dysglycemic states by conventional oral glucose tolerance test (OGTT) criteria (fasting and 2-h plasma glucose) with the 1-h post-load plasma glucose level.

MATERIAL AND METHODS

34 individuals (mean age: 55±13years; BMI: 27.7±6.3kg/m²) at risk for prediabetes were administered a 75g OGTT. Individuals with normal glucose tolerance (NGT) or prediabetes were identified according to fasting and/or 2-h plasma glucose (PG) concentrations. Subsequently, subjects were divided in 2 groups: group 1 (n=21) with a 1-h PG<155mg/dl and group 2 (n=13) with a 1-h PG≥155mg/dl. HOMA was performed to assess β-cell function and insulin sensitivity.

RESULTS

NGT or prediabetes based on conventional criteria correlated with the 1-h PG<or≥155mg/dl (p<0.001). Moreover, the 1-h PG≥155mg/dl was associated with higher HbA_1c levels (6.1±0.5 vs. 5.5±0.3%, p<0.001) and significantly impaired insulin secretion and hyperbolic product (BxS) on HOMA test vs. 1-h PG<155mg/dl.

CONCLUSION

The 1-h post-load plasma glucose value ≥155mg/dl is strongly associated with conventional criteria for (pre)diabetes and alterations of β-cell function.

Study of the Use of Lipid Panels as a Marker of Insulin Resistance to Determine Cardiovascular Risk

CONTEXT

When assessing the lipid panel, practical physicians tend to focus on the low-density lipoprotein cholesterol (LDL-c). However, an elevated triglyceride/high-density lipoprotein cholesterol (HDL-c) ratio, suggesting insulin resistance, also effectively predicts cardiovascular outcomes but requires different treatments than an elevated LDL-c. We tested whether high triglyceride/HDL-c ratios are associated with more risk than high LDL-c concentrations or other lipid markers of atherogenicity.

METHODS

We followed 103,646 members aged 50 to 75 years without cardiovascular disease or diabetes in a community health plan. Subjects were categorized as insulin sensitive or insulin resistant on the basis of triglyceride and HDL-c in the index year. The primary outcome was ischemic heart disease. The percentage of subjects with a primary outcome after 8 years was stratified by insulin category, lipid measures, and blood pressure. Hazard ratios (HR) for insulin resistance, LDL-c, age, sex, and the presence of hypertension were determined in a multivariate analysis.

RESULTS

Subjects with insulin resistance but lipid measures healthier than the median had worse outcomes than those who were insulin sensitive but had unhealthier lipid measures such as non-HDL-c and the ratios of total cholesterol/HDL-c and LDL-c/HDL-c. The HR for a 60 mg/dL increase in LDL-c was 1.14 (95% confidence interval [CI], 1.10-1.18); the HR for an LDL-c greater than 160 mg/dL was 1.19 (95% CI, 1.12-1.28). In contrast, the hazard ratio for having an insulin-resistant triglyceride/HDL-c ratio was 1.68 (95% CI, 1.57-1.80), compared with an insulin-sensitive ratio. There was no difference in outcomes between insulin-resistant but normotensive patients and insulin-sensitive but hypertensive patients.

CONCLUSION

Insulin resistance, as manifested by a high triglyceride/HDL-c ratio, was associated with adverse cardiovascular outcomes more than other lipid metrics, including LDL-c, which had little concordance. Physicians and patients should not overlook the triglyceride/HDL-c ratio.

The 1-hour post-load glucose level is more effective than HbA1c for screening dysglycemia

AIM

To assess the performance of HbA1c and the 1-h plasma glucose (PG ≥ 155 mg/dl; 8.6 mmol/l) in identifying dysglycemia based on the oral glucose tolerance test (OGTT) from a real-world clinical care setting.

METHODS

This was a diagnostic test accuracy study. For this analysis, we tested the HbA1c diagnostic criteria advocated by the American Diabetes Association (ADA 5.7-6.4 %) and International Expert Committee (IEC 6.0-6.4 %) against conventional OGTT criteria. We also tested the utility of 1-h PG ≥ mg/dl; 8.6 mmol/l. Prediabetes was defined according to ADA-OGTT guidelines. Spearman correlation tests were used to determine the relationships between HbA1c, 1-h PG with fasting, 2-h PG and indices of insulin sensitivity and β-cell function. The levels of agreement between diagnostic methods were ascertained using Cohen's kappa coefficient (Κ). Receiver operating characteristic (ROC) curve was used to analyze the performance of the HbA1c and 1-h PG test in identifying prediabetes considering OGTT as reference diagnostic criteria. The diagnostic properties of different HbA1c thresholds were contrasted by determining sensitivity, specificity and likelihood ratios (LR).

RESULTS

Of the 212 high-risk individuals, 70 (33 %) were identified with prediabetes, and 1-h PG showed a stronger association with 2-h PG, insulin sensitivity index, and β-cell function than HbA1c (P < 0.05). Furthermore, the level of agreement between 1-h PG ≥ 155 mg/dl (8.6 mmol/l) and the OGTT (Κ[95 % CI]: 0.40[0.28-0.53]) diagnostic test was stronger than that of ADA-HbA1c criteria 0.1[0.03-0.16] and IEC criteria (0.17[0.04-0.30]). The ROC (AUC[95 % CI]) for HbA1c and 1-h PG were 0.65[0.57-0.73] and 0.79[0.72-0.85], respectively. Importantly, 1-h PG ≥ 155 mg/dl (8.6 mmol/l) showed good sensitivity (74.3 % [62.4-84.0]) and specificity 69.7 % [61.5-77.1]) with a LR of 2.45. The ability of 1-h PG to discriminate prediabetes was better than that of HbA1c (∆AUC: -0.14; Z value: 2.5683; P = 0.01022).

CONCLUSION

In a real-world clinical practice setting, the 1-h PG ≥ 155 mg/dl (8.6 mmol/l) is superior for detecting high-risk individuals compared with HbA1c. Furthermore, HbA1c is a less precise correlate of insulin sensitivity and β-cell function than the 1-h PG and correlates poorly with the 2-h PG during the OGTT.

Physician knowledge about and perceptions of obesity management

OBJECTIVE

Approximately 35% of US adults are obese. The purpose of this study was to assess the knowledge and practice patterns of primary care physicians (PCPs), endocrinologists (ENDOs), cardiologists (CARDs) and bariatricians (BARIs) regarding obesity.

METHODS

A case vignette survey was distributed to 1625 US-based PCPs, ENDOs, CARDs, and BARIs via email and fax in February 2013. Results were analysed with PASW Statistics 18.

RESULTS

Respondents included 100 PCPs, 100 ENDOs, 70 CARDs, and 30 BARIs. The majority agreed obesity is a disease as defined by the AMA, however, half of PCPs, ENDOs, and CARDs also agreed obesity results from a lack of self-control. Familiarity with select obesity guidelines was low. Nearly all respondents used body mass index for obesity screening. No consensus as to when to initiate weight-loss medication was observed. Many physicians expected a larger weight loss with pharmacotherapy than is realistic (∼ 30%) or were unsure (∼ 22%). A majority of PCPs, ENDOs and CARDs expected less excess weight loss with gastric bypass surgery than is realistic, BARIs had a more reasonable expectation.

CONCLUSIONS

Overall, respondents demonstrated knowledge gaps for obesity guidelines and pathophysiology and generally lacked understanding of obesity medication efficacy, safety and MOA.

Expression of proteins associated with adipocyte lipolysis was significantly changed in the adipose tissues of the obese spontaneously hypertensive/NDmcr-cp rat

BACKGROUND

The etiology of the metabolic syndrome is complex, and is determined by the interplay of both genetic and environmental factors. The present study was designed to identify genes and proteins in the adipose tissues with altered expression in the spontaneously hypertensive/NIH -corpulent rat, SHR/NDmcr-cp (CP) and to find possible molecular targets associated with the pathogenesis or progression of obesity related to the metabolic syndrome.

METHODS

We extracted RNAs and proteins from the epididymal adipose tissues in CP, SHR/Lean (Lean), and Wistar Kyoto (WKY) rats and performed microarray analysis and two-dimensional difference in gel electrophoresis (2D-DIGE) linked to a matrix-assisted laser desorption ionization time-of-flight tandem mass spectrometry (MALDI-TOF/TOF MS).

RESULTS

The results showed different mRNA and protein expression levels in the adipose tissue: oligo DNA microarray identified 33 genes that were significantly (P < 0.01) up-regulated and 17 genes significantly down-regulated in CP compared with WKY and Lean rats at both 6 and 25 weeks of age. The affected genes-proteins were associated with lipolytic enzymes stimulated by peroxisome proliferator-activated receptor (PPAR) signaling. Further analysis using the 2D-DIGE connected with MALDI-TOF/TOF analysis, the expression of monoglyceride lipase (MGLL) was significantly up-regulated and that of carboxylesterase 3 (CES3) was significantly down-regulated in 6- and 25-week-old CP compared with age-matched control (WKY and Lean rats).

CONCLUSIONS

Our results suggest the possible involvement of proteins associated with adipocyte lipolysis in obesity related to the metabolic syndrome.

A comparison of the assessment and management of cardiometabolic risk in patients with and without type 2 diabetes mellitus in Canadian primary care

AIM

To investigate the cardiometabolic risk (CMR) assessment and management patterns for individuals with and without type 2 diabetes mellitus (T2DM) in Canadian primary care practices.

METHODS

Between April 2011 and March 2012, physicians from 9 primary care teams and 88 traditional non-team practices completed a practice assessment on the management of 2461 patients >40 years old with no clinical evidence of cardiovascular disease and diagnosed with at least one of the following risk factor-T2DM, dyslipidaemia or hypertension.

RESULTS

There were 1304 individuals with T2DM and 1157 without. Pharmacotherapy to manage hyperglycaemia, dyslipidaemia and hypertension was widely prescribed. Fifty-eight percent of individuals with T2DM had a glycated haemoglobin (HbA1c) ≤7.0%. Amongst individuals with dyslipidaemia, median low-density lipoprotein cholesterol (LDL-C) was 1.8 mmol/l for those with T2DM and 2.8 mmol/l for those without. Amongst individuals with hypertension, 30% of those with T2DM achieved the <130/80 mmHg target, whereas 60% of those without met the <140/90 mmHg target. The composite glycaemic, LDL-C and blood pressure (BP) target outcome was achieved by 12% of individuals with T2DM. Only 17% of individuals with T2DM and 11% without were advised to increase their physical activity. Dietary modifications were recommended to 32 and 10% of those with and without T2DM, respectively.

CONCLUSIONS

Patients at elevated CMR were suboptimally managed in the primary care practices surveyed. There was low attainment of recommended therapeutic glycaemic, lipid and BP targets. Advice on healthy lifestyle changes was infrequently dispensed, representing a missed opportunity to educate patients on the long-term benefits of lifestyle modification.