Increased risk of cardiovascular disease in newly diagnosed type 2 diabetic patients in a primary health care center in Trinidad

Cardiovascular Disease in the Caribbean: Risk Factor Trends, Care and Outcomes Still Far From Expectations

Cardiovascular diseases (CVD) are a major public health concern in the Caribbean. Cardiovascular care in the Caribbean revealed encouraging improvements but still less than expectations. This study aims to gain insight into CVD and identify gaps in cardiovascular care in the Caribbean compared to high-income countries. More specifically, this review reports on the epidemiology, CVD risk factors, management practices, and patient outcomes (quality of life (QOL) and mortality). A systematic review of peer-reviewed articles was conducted to assess the CVD of individuals in the Caribbean from 1959 to 2022.Using multiple search engines and keywords, a systematic review of relevant peer-reviewed CVD articles was conducted using the necessary inclusion and exclusion criteria. Relevant data of studies were classified by title, publication year, location, type and size of samples, and results. Further analysis grouped patients by epidemiological profile, CVD risk, management, and selected outcomes (quality of life and inpatient mortality).  From the initial review of 1,553 articles, 36 were analyzed from Trinidad and Tobago (20), Barbados (4), Jamaica (7), along with the Bahamas (2), British Virgin Islands (1), Bonaire (1), and one article from a Caribbean study. The social environment of fast food, sedentary jobs, and stress determinants are postulated to be precursors for an increase in CV risks. CVD in the Caribbean reveals a high prevalence of CV risks, suboptimal care, poor compliance, and high inpatient mortality compared with high-income countries. Greater efforts are required to improve CVD care at all stages, including in the social environment.

Alterations of voltage-dependent K(+) channels in the mesenteric artery during the early and chronic phases of diabetes

This study investigated the alteration of voltage-dependent K(+) (Kv) channels in mesenteric arterial smooth muscle cells from control (Long-Evans Tokushima Otsuka [LETO]) and diabetic (Otsuka Long-Evans Tokushima Fatty [OLETF]) rats during the early and chronic phases of diabetes. We demonstrated alterations in the mesenteric Kv channels during the early and chronic phase of diabetes using the patch-clamp technique, the arterial tone measurement system, and RT-PCR in Long-Evans Tokushima (LETO; for control) and Otsuka Long-Evans Tokushima Fatty (OLETF; for diabetes) type 2 diabetic model rats. In the early phase of diabetes, the amplitude of mesenteric Kv currents induced by depolarizing pulses was greater in OLETF rats than in LETO rats. The contractile response of the mesenteric artery induced by the Kv inhibitor, 4-aminopyridine (4-AP), was also greater in OLETF rats. The expression of most Kv subtypes- including Kv1.1, Kv1.2, Kv1.4, Kv1.5, Kv1.6, Kv2.1, Kv3.2, Kv4.1, Kv4.3, Kv5.1, Kv6.2, Kv8.1, Kv9.3, and Kv10.1-were increased in mesenteric arterial smooth muscle from OLETF rats compared with LETO rats. However, in the chronic phase of diabetes, the Kv current amplitude did not differ between LETO and OLETF rats. In addition, the 4-AP-induced contractile response of the mesenteric artery and the expression of Kv subtypes did not differ between the two groups. The increased Kv current amplitude and Kv channel-related contractile response were attributable to the increase in Kv channel expression during the early phase of diabetes. The increased Kv current amplitude and Kv channel-related contractile response were reversed during the chronic phase of diabetes.

Perceptions of Caribbean type 2 diabetes patients on self-monitoring of blood glucose

CONTEXT

The views of type 2 diabetes (T2DM) patients have not been considered in the debate on the role of self-monitoring of blood glucose (SMBG) in the management of T2DM.

OBJECTIVE

To assess the views of T2DM patients on SMBG.

METHODS

Two previously trained research assistants used a structured pre-tested questionnaire to interview 416 T2DM patients practising SMBG in out-patient clinics in the privacy of the patients after they have consented to be interviewed.

RESULTS

79% of patients were unemployed with mean duration of diabetes of 11.8 ± 0.5 year. 94% of patients did not have health insurance policies while 86% did not belong to any diabetes support group. Although 70% of the patients identified SMBG as expensive, 94% believed it assists glycaemic control, while 89% thought it was worth the expense.

CONCLUSION

Caribbean T2DM patients believe SMBG was beneficial for the management of their diabetes and empowering them may reduce diabetes complications.

Prediction of 10-year coronary heart disease risk in Caribbean type 2 diabetic patients using the UKPDS risk engine

OBJECTIVE

Primary prevention of Coronary Heart Disease (CHD) in diabetic patients should be based on absolute CHD risk calculation. This study was aimed to determine the levels of 10-year CHD risk in Caribbean type 2 diabetic patients using the diabetes specific United Kingdom Prospective Diabetes Study (UKPDS) risk engine calculator.

SUBJECTS AND METHODS

Three hundred and twenty-five (106 males, 219 females) type 2 diabetic patients resident in two Caribbean Islands of Tobago and Trinidad met the UKPDS risk engine inclusion criteria. Records of their sex, age, ethnicity, smoking habit, diabetes duration, systolic blood pressure, total cholesterol, HDL-cholesterol and glycated haemoglobin were entered into the UKPDS risk engine calculator programme and the absolute 10-year CHD and stroke risk levels were computed. The 10-year CHD and stroke risks were statistically stratified into <15%, 15-30% and >30% CHD risk levels and differences between patients of African and Asian-Indian origin were compared.

RESULTS

In comparison with patients in Tobago, type 2 diabetic patients in Trinidad, irrespective of gender, had higher proportion of 10-year CHD risk (10.4 vs. 23.6%, P<0.001) whereas the overall 10-year stroke risk prediction was higher in patients resident in Tobago (16.9 vs. 11.4%, P<0.001). Ethnicity-based analysis revealed that irrespective of gender, higher proportion of patients of Indian origin scored >30% of absolute 10-year CHD risk compared with patients of African descent (3.2 vs. 28.2%, P<0.001).

CONCLUSIONS

The results of the study identified diabetic patients resident in Trinidad and patients of Indian origin as the most vulnerable groups for CHD. These groups of diabetic patients should have priority in primary or secondary prevention of coronary heart disease.

A comparative study of the prevalence of the metabolic syndrome and its components in type 2 diabetic patients in two Caribbean islands using the new International Diabetes Federation definition

BACKGROUND AND AIM

Tobago and Trinidad are two Caribbean islands with distinct genetic background and lifestyles; while Tobago is serene and a tourist centre, Trinidad is characterized by a hustling and bustling lifestyle. The study was aimed at determining and comparing the prevalence of the metabolic syndrome (MetS) and its critical components in type 2 diabetic patients using the new International Diabetes Federation (IDF) definition.

METHODS

Four hundred and thirteen (166 Tobago, 247 Trinidad) type 2 diabetic patients visiting 10 lifestyle disease clinics were studied. Blood pressure, anthropometric parameters (height, weight, body mass index and waist circumference) and overnight fasting blood samples were taken. Plasma glucose and serum triglycerides, total cholesterol, LDL- and HDL-cholesterol, insulin, and adiponectin were determined. Insulin resistance (IR) was determined using the HOMA method.

RESULTS

The patients in Tobago were significantly older than patients in Trinidad (p < 0.001) but the duration of diabetes (9.4 +/- 0.5 vs. 11.1 +/- 0.7 yr), medications, generalized (31.7 vs. 38.8%) and central (78.5 vs. 83.7%) obesity were similar (p > 0.05). In comparison with patients in Tobago, diabetic patients in Trinidad, irrespective of gender, had significantly higher prevalence of IDF critical components such as raised BP, raised triglycerides and reduced HDL-cholesterol (all, p < 0.001). Thus, while more patients in Trinidad were diagnosed with MetS based on three or four components, more patients in Tobago were diagnosed based on two components (p < 0.001).

CONCLUSIONS

There were high prevalence rates of the components of the MetS in both the islands of Tobago and Trinidad. Quantitatively, the aggregation of the components is higher in patients in Trinidad, which constitute greater risk for adverse cardiovascular outcome. Controlling central obesity should be the target in preventing MetS in the two islands.

Predictive performance of anthropometric indexes of central obesity for the risk of type 2 diabetes

BACKGROUND

In spite of several available anthropometric indexes, the relative merit of these indexes for the prediction of type 2 diabetes remains unknown. Considering that obesity and diabetes commonly coexist as co-morbidities, our objective was to directly compare the performance of measures of central and general obesity to predict the risk of type 2 diabetes.

METHODS

We conducted a case-control study of type 2 diabetes on 150 cases and 150 age- and gender-matched controls. We directly compared the predictive performance of five anthropometric indexes: four related to central obesity--waist circumference (WC), waist/hip ratio (WHR), abdominal volume index (AVI) and conicity index (CI); and one related to general obesity--body mass index (BMI). We used various statistical approaches like area under (AUC) receiver-operating characteristic (ROC) curves, likelihood ratios, logistic regression and Shannon's entropy to compare the performance of the indexes in the study sample as well as bootstrapped samples.

RESULTS

WC had the highest overall predictive accuracy that was gender insensitive (AUC=0.77 in males and 0.74 in females); a comparable information content as that of AVI (Shannon's entropy=1.81 for WC and 1.84 for AVI) and was a better predictor of the risk of type 2 diabetes than all the remaining indexes. WC also correlated strongly with the biochemical markers of diabetes like blood sugar and lipid profile.

CONCLUSIONS

WC is a simple, non-invasive and accurate predictor of the risk of type 2 diabetes that can potentially be used in screening programs in developing countries.

Glycaemic responses after ingestion of 3 local carbohydrate-based foods in West Indian patients with type-2 diabetes mellitus

BACKGROUND & AIM

Previous studies suggest that inadequate glycaemic control in diabetic patients might be related to the type of carbohydrates the patients consume regularly. Thus, we aimed to assess glucose and insulin responses after diabetic and non-diabetic subjects ingested 3 commonly consumed carbohydrate-based foods.

METHODS

Thirty-eight type-2 diabetic and 27 non-diabetic subjects were studied in 3 different occasions of 7 days apart. On each day of the study, anthropometric indices were measured and after collecting fasting blood samples, subjects randomly consumed bread, roti or rice within 10 min. Subsequently 7 ml of venous blood samples were collected at 60, 90, 120 and 150 min for determination of glucose and insulin responses.

RESULTS

Although the diabetic patients were older than the healthy subjects (P < 0.05), both subjects had similar weight, body mass index and waist and hip circumferences (P > 0.05). The mean fasting and post meal plasma glucose concentrations for the 3 test foods were higher in diabetic patients than the corresponding values for the healthy subjects (all; P < 0.001). Generally, roti elicited the highest total incremental glucose responses in the diabetic patients irrespective of ethnic group (P < 0.05).

CONCLUSION

There were variations in glucose and insulin responses to the 3 test foods. However, roti elicited the highest postprandial hyperglycaemia and should therefore be discouraged in regular dietary plan of diabetic patients.

Indices of obesity, dyslipidemia, and insulin resistance in apparently healthy Caribbean subjects

Reports from developing countries indicate that a rise in the socioeconomic level is a risk factor for metabolic disorders. We aimed to assess the indices of obesity, dyslipidemia, and insulin resistance among fairly literate healthy adults in a multidisciplinary institution in Trinidad. The study included 156 volunteers (46 males and 110 females, 17-40 years old). The subjects provided information on age, ethnicity, educational attainment, and occupation in self-administered, closed-ended questionnaires. Waist and hip circumferences (cm), weight (kg), and height (m) were measured. Fasting blood samples were taken for glucose, insulin, and lipid determinations in 78 subjects who volunteered for laboratory measurements. Insulin resistance was determined with homeostasis model assessment (HOMA). Of the 156 subjects studied, 83% had received tertiary education, and had no previous record of body mass index (BMI); 8% were obese, 17% were overweight, and 27% were underweight. Laboratory measurements in 78 subjects revealed 28% hypercholesterolemia and 20% hyperinsulinemia. There were no significant gender-related differences in these prevalence rates (P>0.05). The identification of obesity, underweight, hyperinsulinemia, and hypercholesterolemia in this healthy population suggests that screening for the indices of metabolic disorders in a healthy population would be potentially useful for the early identification and treatment of metabolic-related disorders.

Survival in patients with type 2 diabetes in a Swedish community: skaraborg hypertension and diabetes project

OBJECTIVE

To explore risk factors for all-cause mortality in patients with type 2 diabetes treated in primary care.

RESEARCH DESIGN AND METHODS

A prospective population-based study of 400 patients with type 2 diabetes who consecutively completed an annual checkup in primary care in Skara, Sweden, during 1992-1993. Vital status was ascertained to year 2000. Baseline characteristics as predictors for mortality were analyzed by Cox regression and expressed as relative risks (RRs), with 95% CIs.

RESULTS

During a mean follow-up time of 5.9 years, 131 patients died (56 deaths per 1,000 patients per year). In both sexes, all-cause mortality was predicted by HbA(1c) (by 1%; RR 1.14, 95% CI 1.01-1.27), and by LDL-to-HDL cholesterol ratios (1.15, 1.00-1.32). Increased mortality was also seen with prevalent hypertension (1.72, 1.21-2.44), microalbuminuria (1.87, 1.27-2.76), and previous cardiovascular disease (1.70, 1.15-2.50). Subanalyses revealed that increased mortality related to HbA(1c) was restricted to hypertensive patients with type 2 diabetes (1.23, 1.04-1.47). Serum triglycerides (by 1 mmol/l) predicted all-cause mortality in women (1.25, 1.06-1.47).

CONCLUSIONS

Poor glucose and lipid control and hypertension predicted all-cause mortality. Survival was also predicted by prevalent microalbuminuria and by previous cardiovascular disease. Confirming results from clinical trials, this population-based study has implications for primary and secondary prevention.

Cardiovascular risk in obese and nonobese patients with type 2 diabetes in the West Indies

OBJECTIVE

To evaluate the impact of obesity on glycemic control and the risk of progressing to cardiovascular disease (CVD) in obese and nonobese type 2 diabetic patients in primary care settings.

METHODS

One hundred and ninety patients (64 men, 126 women) with type 2 diabetes (mean duration 9.2 years) were studied after an overnight fast. Weight, height, waist and hip circumferences and blood pressure were measured and blood samples were taken for glucose, glycated hemoglobin (HbA(1c)), total cholesterol, triglyceride, high-density lipoprotein (HDL)-cholesterol, low-density lipoprotein (LDL)-cholesterol and creatinine determinations.

RESULTS

About 85% of the patients had HbA(1c) levels > 7.0%, and 48% had a diastolic blood pressure (BP) >83 mm Hg, while 40% had a total cholesterol/HDL-cholesterol ratio greater than 6. The prevalence rates of hypercholesterolemia, hypertriglyceridemia, high BP and ratios of total cholesterol to HDL-cholesterol between the obese and nonobese patients were similar irrespective of sex (p > 0.05). Multiple linear regression analysis confirmed that ethnicity, sex, age and duration of diabetes had significant impact on the cardiovascular risk in this population.

CONCLUSION

Both obese and nonobese diabetic patients had poor glycemic control and their risk of CVD was not independent of age, sex, ethnicity and duration of diabetes. We suggest strict metabolic control and improved diabetes health education at the primary care level.