[Undiagnosed diabetes and impaired glucose metabolism on high risk Spanish population. The IGT study]

[Patient and health professional perceptions on the quality of care provided to diabetic patients]

OBJECTIVE

To describe the knowledge and perceptions of patients and health professionals on the factors that influence the quality and continuity of care of diabetic patients provided in Primary Care.

MATERIAL AND METHODS

A qualitative study using a phenomenological perspective.

PARTICIPANTS

Medical and nursing professionals working in Primary Care Centres in the city of Zaragoza, and patients with diabetes mellitus attended in the same centres. Two group (focus group) and 6 individual interviews were carried out in February and March 2010. A predetermined script, with the variables to explore, was used.

RESULTS

The patients and health professionals interviewed identified problems in assuming diabetes as a chronic disease. Among the factors related to success in changing habits and lifestyles, were gender (women showed greater difficulties to change), type of job and work situation. Health professionals identified the availability of guidelines and protocols, and personal motivation as factors that work in favour; and lack of time and current information systems as factors that hamper the provision of good quality care. There were discrepancies among health professionals as regards the role played by patient groups and associations.

CONCLUSIONS

It is important to take into account the factors that make changes in habits and lifestyles difficult, such as gender and the employment situation, when designing actions aimed at modifying risk factors in diabetic patients.

[Glucose metabolism alterations and follow-up study of a non-diabetic adult population]

OBJECTIVE

To determine the appearance of type 2 diabetes mellitus (DM2) and impaired fasting glucose (IFG) at five years of follow-up in a known non-diabetic population.

PATIENTS AND METHODS

DESIGN

nested case control studies (case s-control into a cohort) developed in two stages: 1) identification and characterization of the cohort and 2) follow-up.

STUDY POPULATION

representative sample of a non-diabetic population between 40 and 75 years old attended in a Primary Health Center.

RESULTS

IDENTIFICATION

326 persons, 2.1% of whom were diagnosed of previously unknown DM2 and 7.3% of IFG. Insulin resistance (IR) was higher in patients with IFG and pancreatic function of beta cells (PFBC) was higher in the population without glucose metabolism alteration.

FOLLOW-UP

121 persons, 9.7 % of whom evolved to DM2 (all with IFG). IFG proportion at the end of the follow-up was 23.96%.

CONCLUSIONS

At 5 years of follow-up, more than 1/3 of the population studied developed DM2 or IFG. These diagnoses were related with IR and PFBC.

Five-year predictive factors of type 2 diabetes in men with impaired fasting glucose

AIM

The outcome of 743 French men (age 20-60) with impaired fasting glucose (IFG) [blood glucose 6.1-6.9 mmol/l] at T1 was evaluated 5 years later, at T2.

METHODS

Personal and family medical history, smoking, nutritional habits, physical activity, blood pressure, body mass index (BMI) and waist girth, fasting biological data were collected at T1 and T2. Predictive factors for developing diabetes were compared between those who returned to normal fasting glucose and those who had diabetes, before and after adjustment for age, BMI, glucose and triglyceride (TG) levels.

RESULTS

At T2, 44%, 39%, 17% were classified as normal fasting plasma glucose (FPG), IFG or diabetic, respectively. Odd ratios for diabetes were 4.2 for men with a family history of diabetes (FHD), 3.4 if BMI > or = 25 kg/m(2), 2.9 if waist girth > or = 90 cm, 2.8 if TG > or = 2 mmol/l and 1.9 if no daily dairy products were eaten. Still significant after adjustment for age, BMI, glucose and TG levels were: FHD (P=0.001), no daily dairy products (P=0.001), high alcohol intake (P=0.02) and low physical activity (P = 0.02).

CONCLUSION

No daily dairy products, high alcohol intake and low physical activity were independent predictive factors of a 5-year onset of diabetes after adjusting for BMI, FHD, triglyceride and glucose levels at baseline. For a better prevention of diabetes, these findings give clues for behaviour modifications as soon as IFG is detected.

[The RECORD project. continuous blood glucose monitoring among high risk subjects for developing diabetes in Spanish primary health care]

OBJECTIVE

To evaluate the accuracy of continuous blood glucose monitoring (CBGM) in order to asses diagnostic procedures and predict glycaemic status in type 2 prediabetes.

DESIGN

Observational, multicenter, cross-sectional (phase 1) plus longitudinal, cohort follow-up study (phase 2).

SETTING

Five primary health-care centers.

INTERVENTIONS

A total of 84 high-risk subjects will be included after a non-diabetic oral glucose tolerance test (OGTT). A first CBGM using a subcutaneous microdialysis glucose sensor technique in order to obtain a continuous profile will be carried out. Two different cohorts, subjects with normal OGTT (n = 42) and individuals with prediabetic hyperglycemia (n = 42) will be established. Diagnoses will be revised at 12 and 24 month follow-up by means of an OGTT together with a new monitoring.

MAIN MEASUREMENT

Demographical, clinical (including metabolic syndrome items), basic, and advanced analyses (inflammation emergent markers, insulinemia, C-peptide). CBGM computerized analysis comparing fasting, preprandial, postprandial, nocturnal period, and area under the curve of continuous profile with regular diagnoses, taking into account temporary concordance. Relationship of CBGM parameters with normal glucose tolerance or diabetes incidence. Evaluation of day-to-day quality of life of CBGM users by means of an standardized Likert questionnaire.

DISCUSSION

This study seeks to demonstrate the effectiveness and feasibility of CBGM, more physiological than OGTT and based on an underestimated random blood glucose diagnostic criterion. This innovative system may provide interesting scientific data in the field of type 2 prediabetes.

[Prognosis of diabetic patients with ischemic cardiopathy]

The prevalence of diabetes in Spain is about 6% and increases with age and obesity. Diabetes is present in approximately 25% of patients with coronary heart disease (CHD). Pre-diabetic and diabetic patients have a higher incidence of CHD and poorer prognosis, with high short- and long-term mortality. The protective effect of pre-menopause status is suppressed by diabetes. Diabetes has a synergic effect with other cardiovascular risk factors. Primary prevention in diabetic patients should be approached as in non-diabetic post-infarction patients. In diabetes, a healthy life-style and strict control of blood sugar and the other cardiovascular risk factors, particularly hypertension, is mandatory.

[Significant incidence of type 2 diabetes on high-risk Spanish population. The IGT Study (2)]

BACKGROUND

Our purpose was to estimate the incidence of type 2 diabetes among a high risk population with or without impaired glucose tolerance (IGT), analysing the progression to diabetes.

PATIENTS AND METHOD

Multicenter cohort study on high risk individuals without diabetes (WHO-85 criteria) in primary health care. Subjects underwent an oral glucose tolerance test measuring fasting plasma glucose (FPG) and plasma glucose at 2 hours (2hPG). Mean follow-up was 37.2 months (4.3-69.7). Phenotypic features, diagnostic variation, diabetes incidence and predictive factors (multivariate analysis and Cox proportional hazards model) were assessed.

RESULTS

We included 243 individuals (148 females), aged 59.7 (10) years, with FPG < 7.8 mM and 2hPG < 11.1 mM. 137 IGT subjects (56.4%) and 106 (43.6%) normal glucose tolerance (NGT) subjects with a similar risk factor impact were evaluated. After the study was closed, 63 (25.9%) subjects developed diabetes: 43 (31.4%) with baseline IGT and 20 (18.9%) with NGT. Overall diabetes incidence increased over time but not proportionally. Mean annual incidence was 9.2% and it dropped to 4.6% when FPG was used as the unique diagnosis criterion (ADA-97). Male under 65 years with both overweight and IGT reported the highest incidence. HbA1c, FPG and 2hPG were independent predictors. Increased HDL cholesterol showed a protective effect on diabetes incidence. The IGT diagnosis interval was a much better predictor [OR = 2.06 (1.56-2.72)] of diabetes development than the impaired FPG diagnosis interval [OR = 1.37 (0.93-2.04)].

CONCLUSIONS

FPG predicted but undervalued diabetes incidence in high risk population. The IGT (2hPG) diagnosis interval predicted diabetes development better than the impaired fasting plasma glucose diagnosis interval. Increased diabetes incidence in high risk Spanish population, particularly with regard to IGT, means that primary preventive resources should be increased.

[Early carbohydrate metabolism dysfunction in chronic pancreatitis. Relation with the exocrine pancreatic function]

BACKGROUND

The relationship between endocrine and exocrine dysfunction in chronic pancreatitis (CP) is controversial. Our goals were to evaluate the disturbances of carbohydrate metabolism in relation to the degree of exocrine insufficiency, to compare the usefulness of oral glucose tolerance test (OGTT) versus fasting blood glucose and to investigate the degree of exocrine and endocrine dysfunction according to the duration of CP.

PATIENTS AND METHOD

73 patients with CP were studied. Pancreas exocrine and endocrine status was evaluated by secretin-CCK test (SCT), fecal fat analysis and OGTT.

RESULTS

Out of 8 patients with normal SCT, 4 had an abnormal glucose metabolism with diabetes in 2 of them. Out of 50 patients with moderate exocrine insufficiency, there was an abnormal fecal fat excretion in 20%, an endocrine dysfunction in 54% and diabetes in 40%. All patients with severe dysfunction of the exocrine pancreas were diabetics. The OGTT test demonstrated that 42% of patients with normal fasting blood glucose had an abnormal glucose metabolism. Mean evolution time of CP was shorter in patients with endocrine dysfunction than in those with steatorrhea.

CONCLUSIONS

As far as functional exocrine status is concerned, in chronic pancreatitis there is a higher proportion of patients with glucose metabolism dysfunction than with abnormal fecal fat excretion. Carbohydrate metabolism dysfunction can be demonstrated by OGTT in a large proportion of patients with normal fasting blood glucose. In patients with CP, hydrocarbonate dysfunction seems to develop earlier than abnormal fecal fat excretion.

[Cardiovascular risk and the new diagnostic categories for diabetes mellitus proposed by the American Diabetes Association]

OBJECTIVE

To study the cardiovascular risk (CVR) associated with the diagnostic criteria for diabetes proposed by the American Diabetes Association.

DESIGN

Cross-sectional, descriptive study.

SETTING

Urban health district.

PATIENTS

1840 patients > 14 years old, selected by simple randomised sampling from the clinical records (CR) archive, were studied.

METHOD

Through review of the CR, the patients were classified as having: normal glycaemia, disturbed basal glycaemia (DBG) and type-2 diabetes mellitus (DM2). CVR was studied through the simplified Framingham method and the CVR factors of obesity, tobacco dependency, hypertension, hypercholesterolaemia and hypertriglyceridaemia. The likelihood of having high or very high CVR and the CVR factors described in the patients with DBG or DM2 were compared with the same in those with normal glycaemia, through logistical regression with the odds ratio adjusted for age and sex.

RESULTS

1351 patients were classified: 995 with normal glycaemia, 146 with DBG and 210 with DM2. Patients with DBG or DM2 had greater likelihood of high or very high CVR, with some OR at 2.26 (95% CI, 1.39-3.69) and 2.74 (95% CI, 1.81-4.15), respectively. They also had differences (p < 0.05) for obesity (OR, 1.76 and 1.58), hypertension (OR, 1.75 and 2.15) and hypertriglyceridaemia (OR, 1.73 and 2.70), respectively. There were no differences (p > 0.05) for tobacco dependency and hypercholesterolaemia. No differences were found (p > 0.05) between DBG and DM2 for CVR and the CVR factors studied.

CONCLUSIONS

Patients with DBG and DM2 are at high CVR.

[Insulin secretion and insulin sensitivity in relation to glucose tolerance in a group of subjects at a high risk for type 2 diabetes mellitus]

BACKGROUND

Oral glucose tolerance test was evaluated, as well as, insulin sensitivity/secretion in a group of subjects at risk for type 2 diabetes mellitus.

METHOD

Metabolic profile of subjects included in the new category, impaired fasting glucose (IFG), was also evaluated.

RESULTS

IFG and impaired glucose tolerance identify different alterations in glucose homeostasis.

CONCLUSIONS

Those subjects with IFG are heterogeneous in their oral glucose tolerance. They display defects not only in insulin sensitivity but also in their capacity to compensate for it.

[ADA criteria undervalues the impact of diabetes in a high-risk Spanish population]

OBJECTIVE

The main aim was to investigate the prevalence of abnormal glucose homeostasis (impaired fasting glucose, impaired glucose tolerance and undiagnosed diabetes) on high-risk Spanish population. The second, to determine the prevalence and usefulness of classical risk factors for diabetes screening according WHO and ADA criteria and to evaluate the potential effect of different stepwise strategies.

DESIGN AND SETTING

Cross-sectional, multicentric, selective screening study carried out in primary health care which involved 9 health care centres and 1 diabetes unit (230,000 inhabitants).

PATIENTS

Individuals aged > 40 years, non pregnant with at least one major risk factor for diabetes: BMI > or = 30 kg/m2, a first degree relative with diabetes, previous abnormality of glucose tolerance or the use of oral hyperglycaemic drugs for a long time.

MEASUREMENTS

Database including sex, age and risk factors. Diagnoses were based on measurement of fasting plasma glucose (FPG) followed by a 2h-plasma glucose (2hPG) using a 75 gr. oral glucose tolerance test (OGTT). Positive predictive value (PPV) and odds ratio were calculated for each risk factor. The FPG concentration which maximised the sensitivity and specificity with respect to the 2hPG was established by means of the ROC-curves (receiver operator characteristics).

MAIN RESULTS

580 individuals were evaluated, 250 males (43.1%), mean age 58.1 +/- 10.7 years and BMI 31.2 +/- 5.2 kg/m2. A total of 132 (22.7%) individuals presented diabetes according the WHO criteria, 79 (13.6%) according ADA and only 53 (9.1%) according both sets of criteria. FPG > or = 126 mg/dl (7 mM) predicted a diabetic 2hPG with high specificity (94.2%) but a very low sensitivity (40.2%). If that cut-point was used alone for early screening half the diabetics with normal FPG but with a diabetic 2hPG would not have been diagnosed. According the WHO criteria PPV for classical risk factors oscillated between 23.4-29.1% and were significantly higher than those obtained according ADA criteria (11.6-18.3%; p < 0.01).

CONCLUSIONS

The OGTT is still the cornerstone for diabetes screening thus the FPG predictive value greatly decreases the 2hPG predictive value. ADA criteria undervalues the diabetes impact mainly on high-risk population.