Prevalence of latent autoimmune diabetes of adults (LADA) in Southern Spain

The worldwide prevalence of latent autoimmune diabetes of adults among adult-onset diabetic individuals: a systematic review and meta-analysis

PURPOSE

The actual global burden of Latent Autoimmune Diabetes of Adults (LADA) remains unknown even though its prevalence is almost equal to the type 1 form of diabetes. Hence the present systematic review and meta-analysis were performed to estimate the prevalence of LADA among diabetic individuals using the studies published at global levels.

METHODS

A comprehensive literature revival was performed to identify articles on the prevalence of LADA published till 2023. The prevalence estimates were calculated using DerSimonian and Laird random-effects models with a heterogeneity measure by Cochrane Q and I2 statistics. Publication bias was assessed by the Doi plot and Luis Furuya-Kanamori asymmetry index (LFKindex). P < 0.05 was considered statistically significant.

RESULTS

The overall pooled prevalence of LADA obtained from a total of 51,725 diabetic individuals was found to be 8.9% (95%CI 7.5-10.4, P < 0.001) with a prevalence range of 2.3% in to 18.9% in United Arab Emirates and Bahrain respectively. Subgroup analysis of LADA in the context of the IDF geographic regions showed a higher prevalence in North America (13.5%), 9.5% in Middle East and North Africa, 9.4% in Africa, 9.2% in South East Asia, 8.3% in Western Pacific and the lowest prevalence of 7.0% in Europe.

CONCLUSION

The Meta-analysis revealed a worldwide prevalence of LADA as 8.9%, with the highest prevalence in Bahrain and the lowest in United Arab Emirates. Further, the higher prevalence in some IDF regions and the inconsistent association between socioeconomic status and LADA recommend more research in the future.

Development and validation of a clinical score for identifying patients with high risk of latent autoimmune adult diabetes (LADA): The LADA primary care-protocol study

BACKGROUND

Latent autoimmune diabetes in adults (LADA) is a type of diabetes mellitus showing overlapping characteristics between type 1 Diabetes Mellitus and type 2 Diabetes Mellitus (T2DM), and autoimmunity against insulin-producing pancreatic cells. For its diagnosis, at least one type of anti-pancreatic islet antibody (GADAb is the most common) is required. Many authors recommend performing this measure in all newly diagnosed patients with DM, but it is not possible in Primary Health Care (PHC) due to its high cost. Currently, a relevant proportion of patients diagnosed as T2DM could be LADA. Confusing LADA with T2DM has clinical and safety implications, given its different therapeutic approach. The main objective of the study is to develop and validate a clinical score for identifying adult patients with DM at high risk of LADA in PHC.

METHODS

This is an observational, descriptive, cross-sectional study carried out in Primary Care Health Centers with a centralized laboratory. All people over 30 years of age diagnosed with diabetes within a minimum of 6 months and a maximum of 4 years before the start of the study will be recruited. Individuals will be recruited by consecutive sampling. The study variables will be obtained through clinical interviews, physical examinations, and electronic medical records. The following variables will be recorded: those related to Diabetes Mellitus, sociodemographic, anthropometric, lifestyle habits, laboratory parameters, presence of comorbidities, additional treatments, personal or family autoimmune disorders, self-perceived health status, Fourlanos criteria, and LADA diagnosis (as main variable) according to current criteria.

DISCUSSION

The study will provide an effective method for identifying patients at increased risk of LADA and, therefore, candidates for antibody testing. However, a slight participation bias is to be expected. Differences between participants and non-participants will be studied to quantify this potential bias.

Low rate of latent autoimmune diabetes in adults (LADA) in patients followed for type 2 diabetes: A single center's experience in Turkey

Objective

In this study, we aimed to determine the frequency of and the clinical and metabolic features of patients with latent autoimmune diabetes in adults (LADA) at a single center in Turkey.

Methods

Patients over 30 years of age diagnosed with type 2 diabetes who did not require insulin for a minimum of 6 months following diagnosis were included. Data from 324 patients (163 women; 161 men), with a mean age of 54.97 ± 7.53 years, were analyzed in the study. Levels of antibodies to glutamate decarboxylase (anti-GAD) were measured in all patients, and LADA was diagnosed in patients testing positive for anti-GAD antibodies.

Results

Anti-GAD positivity was identified in 5 patients (1.5%). Family history of diabetes, body mass index (BMI), age, sex distribution, insulin resistance, serum triglycerides, high-density lipoprotein, and low-density lipoprotein were similar in the LADA and type 2 diabetes patients. Median HbA1c was significantly higher (10.8% vs. 7.38%, p = 0.002) and fasting C-peptide was lower (0.75 ng/mL vs. 2.82 ng/mL, p = 0.009) in patients with LADA compared to in those with type 2 diabetes. Among the 5 patients with LADA, 4 were positive for antithyroid peroxidase antibodies. The median disease duration was relatively shorter among patients with LADA (4 years vs. 7 years, p = 0.105).

Conclusion

We observed a LADA frequency of 1.5% among Turkish patients followed for type 2 diabetes. The presence of obesity and metabolic syndrome did not exclude LADA, and patients with LADA had worse glycemic control than patients with type 2 diabetes did.

Latent Autoimmune Diabetes in Adults (LADA) and its Metabolic Characteristics among Yemeni Type 2 Diabetes Mellitus Patients

PURPOSE

Although there is ample data about the prevalence of diabetes in the Middle East, little is known about the prevalence and features of autoimmune diabetes in this region. The aim of this study was to investigate the prevalence and metabolic characteristics of latent autoimmune diabetes in adults (LADA) amongst Yemeni Type 2 DM patients.

PATIENTS AND METHODS

In this cross-section study, 270 Type 2 DM patients aged 30-70 years were recruited from the National Diabetes Center, Al-Thowra Hospital, Sana'a city, during the period November 2015 to August 2016. All Type 2 DM patients were diagnosed within 5 years and who did not require insulin for a minimum of 6 months following diagnosis. Levels of glutamic acid decarboxylase autoantibodies (GADA) were measured in all patients, and LADA was diagnosed in patients testing positive for anti-GAD antibodies. Further, biochemical analysis was carried out including fasting blood glucose (FBG), glycated haemoglobin (HbA1c), insulin, and lipid profile. Insulin resistance (HOMA-IR) and β-cell function (HOMA-β) were calculated.

RESULTS

The prevalence of LADA, as defined by GADA-positive, amongst patient with Type 2 DM was 4.4%; with no significant difference in the prevalence between male (5.8%) and female (3.4%). LADA patients were younger than GADA-negative Type 2 DM. Body mass index, waist circumference, insulin and HOMA-β were significantly lower in LADA patients, whereas triglyceride, cholesterol, HDL-c and HOMA-IR were non-significantly lower with respect to Type 2 DM. In contrast, FBG and HbA1c were significantly higher in LADA patients. Moreover, the prevalence of metabolic syndrome was significantly lower in LADA as compared with Type 2 DM. Only 2 out of the 12 GADA-positive (16.7%) were on insulin treatment at the time of the study.

CONCLUSION

The prevalence of LADA in Yemeni Type 2 DM is lower than many of those reported in the literature, with no gender preference. Metabolic syndrome was significantly lower in LADA patients. Patients with LADA share insulin resistance with Type 2 DM but display a more severe defect in β-cell function, thus highlighting the importance of an early diagnosis of LADA, to correctly treat LADA patients, allowing safe and effective therapies.

Respiratory chain polymorphisms and obesity in the Spanish population, a cross-sectional study

OBJECTIVE

To study the association of genes involved in the mitochondrial respiratory chain (MRC) pathway with body mass index (BMI) and obesity risk.

DESIGN

This work studies three cross-sectional populations from Spain, representing three provinces: HORTEGA (Valladolid, Northwest/Centre), SEGOVIA (Segovia, Northwest/centre) and PIZARRA (Malaga,South).

SETTING

Forty-eight single nucleotide polymorphisms (SNPs) from MRC genes were selected and genotyped by SNPlex method. Association studies with BMI and obesity risk were performed for each population. These associations were then verified by analysis of the studied population as a whole (3731 samples).

PARTICIPANTS

A total of 3731 Caucasian individuals: 1502 samples from HORTEGA, 988 from PIZARRA and 1241 from SEGOVIA.

RESULTS

rs4600063 (SDHC), rs11205591 (NDUFS5) and rs10891319 (SDHD) SNPs were associated with BMI and obesity risk (p values for BMI were 0.04, 0.0011 and 0.0004, respectively, and for obesity risk, 0.0072, 0.039 and 0.0038). However, associations between rs4600063 and BMI and between these three SNPs and obesity risk are not significant if Bonferroni correction is considered. In addition, rs11205591 and rs10891319 polymorphisms showed an additive interaction with BMI and obesity risk.

CONCLUSIONS

Several polymorphisms from genes coding MRC proteins may be involved in BMI variability and could be related to the risk to become obese in the Spanish general population.

Development of type 2 diabetes mellitus in people with intermediate hyperglycaemia

BACKGROUND

Intermediate hyperglycaemia (IH) is characterised by one or more measurements of elevated blood glucose concentrations, such as impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and elevated glycosylated haemoglobin A1c (HbA1c). These levels are higher than normal but below the diagnostic threshold for type 2 diabetes mellitus (T2DM). The reduced threshold of 5.6 mmol/L (100 mg/dL) fasting plasma glucose (FPG) for defining IFG, introduced by the American Diabetes Association (ADA) in 2003, substantially increased the prevalence of IFG. Likewise, the lowering of the HbA1c threshold from 6.0% to 5.7% by the ADA in 2010 could potentially have significant medical, public health and socioeconomic impacts.

OBJECTIVES

To assess the overall prognosis of people with IH for developing T2DM, regression from IH to normoglycaemia and the difference in T2DM incidence in people with IH versus people with normoglycaemia.

SEARCH METHODS

We searched MEDLINE, Embase, ClincialTrials.gov and the International Clinical Trials Registry Platform (ICTRP) Search Portal up to December 2016 and updated the MEDLINE search in February 2018. We used several complementary search methods in addition to a Boolean search based on analytical text mining.

SELECTION CRITERIA

We included prospective cohort studies investigating the development of T2DM in people with IH. We used standard definitions of IH as described by the ADA or World Health Organization (WHO). We excluded intervention trials and studies on cohorts with additional comorbidities at baseline, studies with missing data on the transition from IH to T2DM, and studies where T2DM incidence was evaluated by documents or self-report only.

DATA COLLECTION AND ANALYSIS

One review author extracted study characteristics, and a second author checked the extracted data. We used a tailored version of the Quality In Prognosis Studies (QUIPS) tool for assessing risk of bias. We pooled incidence and incidence rate ratios (IRR) using a random-effects model to account for between-study heterogeneity. To meta-analyse incidence data, we used a method for pooling proportions. For hazard ratios (HR) and odds ratios (OR) of IH versus normoglycaemia, reported with 95% confidence intervals (CI), we obtained standard errors from these CIs and performed random-effects meta-analyses using the generic inverse-variance method. We used multivariable HRs and the model with the greatest number of covariates. We evaluated the certainty of the evidence with an adapted version of the GRADE framework.

MAIN RESULTS

We included 103 prospective cohort studies. The studies mainly defined IH by IFG5.6 (FPG mmol/L 5.6 to 6.9 mmol/L or 100 mg/dL to 125 mg/dL), IFG6.1 (FPG 6.1 mmol/L to 6.9 mmol/L or 110 mg/dL to 125 mg/dL), IGT (plasma glucose 7.8 mmol/L to 11.1 mmol/L or 140 mg/dL to 199 mg/dL two hours after a 75 g glucose load on the oral glucose tolerance test, combined IFG and IGT (IFG/IGT), and elevated HbA1c (HbA1c5.7: HbA1c 5.7% to 6.4% or 39 mmol/mol to 46 mmol/mol; HbA1c6.0: HbA1c 6.0% to 6.4% or 42 mmol/mol to 46 mmol/mol). The follow-up period ranged from 1 to 24 years. Ninety-three studies evaluated the overall prognosis of people with IH measured by cumulative T2DM incidence, and 52 studies evaluated glycaemic status as a prognostic factor for T2DM by comparing a cohort with IH to a cohort with normoglycaemia. Participants were of Australian, European or North American origin in 41 studies; Latin American in 7; Asian or Middle Eastern in 50; and Islanders or American Indians in 5. Six studies included children and/or adolescents.Cumulative incidence of T2DM associated with IFG5.6, IFG6.1, IGT and the combination of IFG/IGT increased with length of follow-up. Cumulative incidence was highest with IFG/IGT, followed by IGT, IFG6.1 and IFG5.6. Limited data showed a higher T2DM incidence associated with HbA1c6.0 compared to HbA1c5.7. We rated the evidence for overall prognosis as of moderate certainty because of imprecision (wide CIs in most studies). In the 47 studies reporting restitution of normoglycaemia, regression ranged from 33% to 59% within one to five years follow-up, and from 17% to 42% for 6 to 11 years of follow-up (moderate-certainty evidence).Studies evaluating the prognostic effect of IH versus normoglycaemia reported different effect measures (HRs, IRRs and ORs). Overall, the effect measures all indicated an elevated risk of T2DM at 1 to 24 years of follow-up. Taking into account the long-term follow-up of cohort studies, estimation of HRs for time-dependent events like T2DM incidence appeared most reliable. The pooled HR and the number of studies and participants for different IH definitions as compared to normoglycaemia were: IFG5.6: HR 4.32 (95% CI 2.61 to 7.12), 8 studies, 9017 participants; IFG6.1: HR 5.47 (95% CI 3.50 to 8.54), 9 studies, 2818 participants; IGT: HR 3.61 (95% CI 2.31 to 5.64), 5 studies, 4010 participants; IFG and IGT: HR 6.90 (95% CI 4.15 to 11.45), 5 studies, 1038 participants; HbA1c5.7: HR 5.55 (95% CI 2.77 to 11.12), 4 studies, 5223 participants; HbA1c6.0: HR 10.10 (95% CI 3.59 to 28.43), 6 studies, 4532 participants. In subgroup analyses, there was no clear pattern of differences between geographic regions. We downgraded the evidence for the prognostic effect of IH versus normoglycaemia to low-certainty evidence due to study limitations because many studies did not adequately adjust for confounders. Imprecision and inconsistency required further downgrading due to wide 95% CIs and wide 95% prediction intervals (sometimes ranging from negative to positive prognostic factor to outcome associations), respectively.This evidence is up to date as of 26 February 2018.

AUTHORS' CONCLUSIONS

Overall prognosis of people with IH worsened over time. T2DM cumulative incidence generally increased over the course of follow-up but varied with IH definition. Regression from IH to normoglycaemia decreased over time but was observed even after 11 years of follow-up. The risk of developing T2DM when comparing IH with normoglycaemia at baseline varied by IH definition. Taking into consideration the uncertainty of the available evidence, as well as the fluctuating stages of normoglycaemia, IH and T2DM, which may transition from one stage to another in both directions even after years of follow-up, practitioners should be careful about the potential implications of any active intervention for people 'diagnosed' with IH.

A Global Perspective of Latent Autoimmune Diabetes in Adults

Latent autoimmune diabetes in adults (LADA) is characterized by the presence of islet autoantibodies and initial insulin independence, which can lead to misdiagnosis of type 2 diabetes (T2D). As such, understanding the genetic etiology of LADA could aid in more accurate diagnosis. However, there is ongoing debate regarding the exact definition of LADA, so understanding its impact in different populations when contrasted with type 1 diabetes (T1D) and T2D is one potential strategy to gain insight into its etiology. Unfortunately, the lack of consistent and thorough autoantibody screening around the world has hampered well-powered genetic studies of LADA. This review highlights recent genetic and epidemiological studies of LADA in diverse populations as well as the importance of autoantibody screening in facilitating future research.

Demographic associations for autoantibodies in disease-free individuals of a European population

The presence of autoantibodies usually precedes autoimmune disease, but is sometimes considered an incidental finding with no clinical relevance. The prevalence of immune-mediated diseases was studied in a group of individuals from the Estonian Genome Project (n = 51,862), and 6 clinically significant autoantibodies were detected in a subgroup of 994 (auto)immune-mediated disease-free individuals. The overall prevalence of individuals with immune-mediated diseases in the primary cohort was 30.1%. Similarly, 23.6% of the participants in the disease-free subgroup were seropositive for at least one autoantibody. Several phenotypic parameters were associated with autoantibodies. The results suggest that (i) immune-mediated diseases are diagnosed in nearly one-third of a random European population, (ii) 6 common autoantibodies are detectable in almost one-third of individuals without diagnosed autoimmune diseases, (iii) tissue non-specific autoantibodies, especially at high levels, may reflect preclinical disease in symptom-free individuals, and (iv) the incidental positivity of anti-TPO in men with positive familial anamnesis of maternal autoimmune disease deserves further medical attention. These results encourage physicians to evaluate autoantibodies in addition to treating a variety of patient health complaints to detect autoimmune-mediated disease early.

Latent autoimmune diabetes amongst adults with type 2 diabetes in a Nigerian tertiary hospital

AIMS

The aim was to investigate the frequency and characteristics of persons with latent autoimmune diabetes in adults (LADA) amongst patients who had been clinically diagnosed as type 2 diabetes mellitus (CT2DM) in a tertiary care centre.

METHODOLOGY

One hundred and sixty patients with CT2DM participated in this cross-sectional study following selection by systematic random sampling. Demographic data, relevant clinical history and anthropometric measurements (weight, height, waist circumference and hip circumference) were taken and blood samples were obtained for analysis of fasting blood glucose, glycated haemoglobin (HbA1c) and glutamic acid decarboxylase antibodies (GADA). The results were analysed using SPSS version 16.

RESULTS

Nineteen (11.9%) out of 160 persons with CT2DM were positive for GADA. 95(59.4%) of the total study population were females. The mean (SD) age, BMI, waist circumference, were 60.49 (10.37) years, 26.47 (4.80) kg/m2, 92.16 (11.50)cm respectively. Subjects with CT2DM who were GADA positive had trend towards lower mean BMI (25.64 kg/m2 vs. 26.59 kg/m2) and waist circumference (89.80 kg/m2 vs. 92.47 kg/m2) than GADA negative subjects. GADA positive subjects also had a trend showing higher mean fasting blood glucose (144 mg/dl vs. 125 mg/dl, t=2.20, p=0.14), higher mean HbA1c (7% vs. 6.1%, t=3.19, p=0.077) and a higher proportion on insulin (31.6% vs. 22%, χ2=0.07, p=0.25) when compared with GADA negative patients.

CONCLUSION

The prevalence of LADA amongst a subset of Nigerians with CT2DM was 11.9%. There were no distinguishing clinical features to help characterize persons with LADA. The above finding emphasizes the importance of GADA testing for appropriate classification of persons with CT2DM. Early diagnosis of LADA would help direct appropriate therapy to optimize glycaemic control.

The prevalence of latent autoimmune diabetes in adults and its correlates in patients with type 2 diabetes in Kerman, Iran [2011]

INTRODUCTION

Latent autoimmune diabetes in adults [LADA] is a type of autoimmune diabetes in adults that is usually identified by positive GAD-antibody [glutamic acid decarboxylase]. Epidemiological studies show that this disease has no identified prevalence and incidence in Asia due to the various criteria in diagnosing the disease.

METHODS

500 patients with type 2 diabetes based on American Diabetes Association [ADA] criteria and age of diabetes onset above 35 years old who needed no insulin until at least 6 months after the diagnosis of diabetes were selected from KERCADR Study and their anti-GAD serum level was determined.

RESULTS

From 500 patients, 429 ones [85%] were negative and 71 ones [14.2%] were positive for GAD antibody. The prevalence of latent autoimmune diabetes was higher in the age group of 50-59 years compared to the other age groups. There was no significant correlation between LADA and hypertension, family history of diabetes, cigarette smoking and tobacco use.

CONCLUSION

The prevalence rate of latent autoimmune diabetes in adults in patients with type 2 diabetes was 14.2% and we could not find any relationship.

Risk factors associated with retinal vein occlusion

AIMS

Retinal vein occlusion (RVO) is the most frequent retinal vascular disease after diabetic retinopathy in which arterial risk factors are much more relevant than venous factors. The objective was to evaluate the role of risk factors in the development of the first episode of RVO.

SUBJECTS AND METHODS

One hundred patients with RVO [mean age 56 years, 42% females and mean body mass index (BMI) 27.5 kg/m(2)] were recruited consecutively from the outpatient clinic of a tertiary hospital in Valencia (Spain). All subjects underwent clinical assessment including anthropometric and blood pressure measurements and laboratory test including homocysteine, antiphospholipid antibodies (aPLAs) and thrombophilia studies. In half of the subjects, a carotid ultrasonography was performed. Three control populations matched by age, sex and BMI from different population-based studies were used to compare the levels and prevalence of arterial risk factors. One cohort of young patients with venous thromboembolic disease was used to compare the venous risk factors.

RESULTS

Blood pressure levels and the prevalence of hypertension were significantly higher in the RVO population when compared with those for the general populations. There was also a large proportion of undiagnosed hypertension within the RVO group. Moreover, carotid evaluation revealed that a large proportion of patients with RVO had evidence of subclinical organ damage. In addition, homocysteine levels and prevalence of aPLAs were similar to the results obtained in our cohort of venous thromboembolic disease.

CONCLUSIONS

The results indicate that hypertension is the key factor in the development of RVO, and that RVO can be the first manifestation of an undiagnosed hypertension. Furthermore, the majority of these patients had evidence of atherosclerotic disease. Among the venous factors, a thrombophilia study does not seem to be useful and only the prevalence of hyperhomocysteinaemia and aPLAs is higher than in the general population.

Impact of obesity-related genes in Spanish population

Background

The objective was to investigate the association between BMI and single nucleotide polymorphisms previously identified of obesity-related genes in two Spanish populations. Forty SNPs in 23 obesity-related genes were evaluated in a rural population characterized by a high prevalence of obesity (869 subjects, mean age 46 yr, 62% women, 36% obese) and in an urban population (1425 subjects, mean age 54 yr, 50% women, 19% obese). Genotyping was assessed by using SNPlex and PLINK for the association analysis.

Results

Polymorphisms of the FTO were significantly associated with BMI, in the rural population (beta 0.87, p-value <0.001). None of the other SNPs showed significant association after Bonferroni correction in the two populations or in the pooled analysis. A weighted genetic risk score (wGRS) was constructed using the risk alleles of the Tag-SNPs with a positive Beta parameter in both populations. From the first to the fifth quintile of the score, the BMI increased 0.45 kg/m² in Hortega and 2.0 kg/m² in Pizarra. Overall, the obesity predictive value was low (less than 1%).

Conclusion

The risk associated with polymorphisms is low and the overall effect on BMI or obesity prediction is minimal. A weighted genetic risk score based on genes mainly acting through central nervous system mechanisms was associated with BMI but it yields minimal clinical prediction for the obesity risk in the general population.

Metabolically healthy but obese, a matter of time? Findings from the prospective Pizarra study

BACKGROUND

Prospective longitudinal studies evaluating the relevance of "Metabolically Healthy but Obese" (MHO) phenotype at risk for type 2 diabetes mellitus (T2D) and cardiovascular diseases are few and results are contradictory.

METHODS

As a representative of the general population, 1051 individuals were evaluated in 1997-1998 and re-evaluated after 6 years and 11 years. Subjects without known T2D were given an oral glucose tolerance test. Anthropometric and biochemical variables were measured. Four sets of criteria were considered to define MHO subjects besides body mass index ≥30 kg/m(2): A: Homeostatic Model of Assessment-Insulin Resistance Index (HOMA-IR) <90th percentile; B: HOMA-IR <90th percentile, high-density lipoprotein cholesterol >40 mg/dL in men and high-density lipoprotein cholesterol >50 mg/dL in women, triglycerides <150 mg/dL, fasting glucose <110 mg/dL, and blood pressure ≤140/90 mm Hg; C: HOMA-IR <90th percentile, triglycerides <150 mg/dL, fasting glucose <110 mg/dL, and blood pressure ≤140/90 mm Hg; D: HOMA-IR <90th percentile, triglycerides <150 mg/dL, and fasting glucose <110 mg/dL. Subjects with T2D at baseline were excluded from the calculations of incidence of T2D.

RESULTS

The baseline prevalence of MHO phenotype varied between 3.0% and 16.9%, depending on the set of criteria chosen. Metabolically nonhealthy obese subjects were at highest risk for becoming diabetic after 11 years of follow-up (odds ratio = 8.20; 95% confidence interval = 2.72-24.72; P < .0001). In MHO subjects the risk for becoming diabetic was lower than in metabolically nonhealthy obese subjects, but this risk remained significant (odds ratio = 3.13; 95% confidence interval = 1.07-9.17; P = .02). In subjects who lost weight during the study, the association between MHO phenotype and T2D incidence disappeared, even after adjusting for HOMA-IR.

CONCLUSIONS

The results suggest that MHO is a dynamic concept that should be taken into account over time. As a clinical entity, it may be questionable.

Quality of care of patients with type-2 diabetes in Galicia (NW Spain) [OBTEDIGA project]

AIMS

The aim of this study was to describe the degree of compliance of agreed practices with reference to primary care patients with Type 2 diabetes of 40 years old and older in Galicia (NW Spain).

METHODS

A total of 108 primary care physicians were selected at random from the totality of doctors. Each physician selected 30 patients at random from their patients suffering from diabetes of 40 years old or older. External observers gathered information from each patient's medical record regarding their characteristics, condition and degree of compliance of selected indicators of good practice.

RESULTS

Group of physicians participated in this study had a mean age of 50 years (standard deviation = 3.9); 48% of them were females; and 17.5% involved in medical residents training. A total of 3078 diabetic patients were included in the study: mean age = 69 years (SD = 10.9), 47.6% women, presence of high blood pressure (72%), hypercholesterolaemia (56%), and regular smokers (10.3%). Compliance with selected indicators such as foot examination (14%), ophthalmological examination (30.6%), abdominal circumference measurement (6.1%), measurement of total or LDL-cholesterol (78.1), blood pressure measurement (84.8), glycosylated haemoglobin measurement < 7% (54.3%) was observed. Adequate monitoring in cases of high blood pressure and hypercholesterolaemia were 34.2% and 27.4%, respectively. Variability between physicians differs according to the different indicators, with interquartile range for compliance of between 16.4 and 66%.

CONCLUSIONS

There is a wide margin for improvement in the adaptation of clinical practice to recommendations for diabetic patients. The large variation existing in certain indicators would suggest that certain control objectives are less demanding than advisable in those that comply least, while low compliance and low variability in other indicators point to structural problems or unsatisfactory training of doctors.

Dietary polyunsaturated fatty acids may increase plasma LDL-cholesterol and plasma cholesterol concentrations in carriers of an ABCG1 gene single nucleotide polymorphism: study in two Spanish populations

BACKGROUND

ABCG1 mediates cellular cholesterol transport, but there is very little known about the influence of ABCG1 polymorphisms on human plasma lipoprotein cholesterol concentrations or on the interactions of these polymorphisms with diet.

OBJECTIVE

Our objective was to investigate whether interactions between PUFA intake and ABCG1 polymorphisms modulate associations with plasma total cholesterol (TC), LDL- and HDL-cholesterol in two Spanish populations.

METHODS

We grounded our investigation on two general population-based studies: the Hortega study (population A) and the Pizarra study (population B). Participants included 1178 individuals (50.0% women, age range 21-85 years) and 763 individuals (66% women, age range 23-73 years) from populations A and B, respectively, without lipid lowering drugs. Subjects were genotyped for ABCG1 variants. Biochemical measurements were taken by standard procedures. Dietary intakes were estimated with a validated questionnaire.

RESULTS

In population A, the A allele homozygotes of SNP rs4148102 had higher TC and LDLc concentrations in subjects on a high PUFA diet than did the carriers of the G allele (242.1 ± 38.9 vs. 198.0 ± 36.0mg/dL, p = 0.003, and 149.8 ± 37.9 vs. 111.4 ± 32.1mg/dL, p = 0.005, respectively), and significant gene-diet interactions were observed (p=0.020 and p = 0.013, respectively). In population B, similar differences in TC and LDLc concentrations were also found in association with this SNP under a high PUFA diet (253.2±24.9 vs. 197.7 ± 39.9 mg/dL, p = 0.009, and 171.8 ± 20.5 vs. 120.4 ± 34.2mg/dL, p = 0.004, respectively), but the gene-diet interactions observed were not significant (p = 0.379 and p = 0.422, respectively). In the pooled populations, differences in the TC and LDLc concentrations increased (246.8 ± 32.9 vs. 198.0 ± 37.5, p = 6 × 10(-5), and 159.0±32.6 vs. 114.3 ± 33.1, p = 3 × 10(-5), respectively), and significant gene-diet interactions were maintained (p = 0.006 and p = 0.003, respectively).

CONCLUSION

In two Spanish populations, the ABCG1 polymorphism rs4148102 was associated with variations in plasma lipoprotein cholesterol concentrations in subjects with high PUFA intakes. Carriers of the AA genotype consuming high PUFA diet showed higher plasma LDLc concentrations.

Prevalence and correlates of latent autoimmune diabetes in adults in Tianjin, China: a population-based cross-sectional study

OBJECTIVE

Data on latent autoimmune diabetes in adults (LADA) from population-based studies are sparse. We sought to investigate the prevalence and correlates of LADA.

RESEARCH DESIGN AND METHODS

A total of 8,109 participants, who were aged ≥15 years and living in Tianjin, China, were assessed to identify individuals with type 2 diabetes (American Diabetes Association Criteria, 1997) and further to detect patients with LADA. LADA was ascertained by 1) the presence of type 2 diabetes and age ≥35 years, 2) the lack of a requirement for insulin at least 6 months after the diagnosis of type 2 diabetes, and 3) serum GAD antibody positivity. Data were analyzed using multinomial logistic regression with adjustment for potential confounders.

RESULTS

Of all participants, 498 (6.1%) were patients with type 2 diabetes. Of them, 46 (9.2%) were found to have LADA. The prevalence of LADA was 0.6% (46 of 8,109), and tended to increase with age up to 50-59 years in all participants. The odds ratios (95% CI) of LADA related to hypertension, family history of diabetes, waist-to-hip ratio ≥0.85, and major stressful events were 1.93 (1.02-3.65), 17.59 (9.08-34.06), 5.37 (2.31-12.49), and 4.09 (1.75-9.52), respectively.

CONCLUSIONS

The prevalence of LADA is ∼9% in patients with type 2 diabetes. Hypertension, family history of diabetes, central obesity, and major stressful events may be associated with the occurrence of LADA.

Intake and home use of olive oil or mixed oils in relation to healthy lifestyles in a Mediterranean population. Findings from the prospective Pizarra study

Discordances exist in epidemiological studies regarding the association between the intake of nutrients and death and disease. We evaluated the social and health profile of persons who consumed olive oil in a prospective population cohort investigation (Pizarra study) with a 6-year follow-up. A food frequency questionnaire and a 7 d quantitative questionnaire were administered to 538 persons. The type of oil used in food preparation was determined by direct measurement of the fatty acids in samples obtained from the kitchens of the participants at baseline and after follow-up for 6 years. The fatty acid composition of the serum phospholipids was used as an endogenous marker of the type of oil consumed. Total fat intake accounted for a mean 40 % of the energy (at baseline and after follow-up). The concordance in intake of MUFA over the study period was high. The fatty acid composition of the serum phospholipids was significantly associated with the type of oil consumed and with fish intake. The concentration of polar compounds and polymers, indicative of degradation, was greater in oils from the kitchens where sunflower oil or refined olive oil was used, in oils used for deep frying and in oils that had been reused for frying five times or more. Consumption of olive oil was directly associated with educational level. Part of the discordance found in epidemiological studies between diet and health may be due to the handling of oils during food preparation. The intake of olive oil is associated with other healthy habits.

The -30G>A polymorphism of the glucokinase gene promoter is associated with obesity in a population from southern Spain

The aim of this study was to test the hypothesis of an association between the -30G>A polymorphism of the promoter of the glucokinase gene and the prevalence and incidence of obesity. We studied the -30G>A polymorphism of the glucokinase gene promoter in 981 persons, of whom 866 were seen again 6 years later. All the persons underwent an oral glucose-tolerance test and the BMI (weight/height(2)) was recorded. The -30G>A polymorphism of the glucokinase gene promoter was studied using RFLP-PCR. At the initial study, the probability of having a BMI > or =25 in carriers of the A allele was significantly lower than expected by chance (odds ratio (OR) = 0.63; 95% confidence interval (CI) = 0.456-0.885). In those persons with a BMI > or =30 at the first study, the probability at 6 years of losing weight (reaching a BMI < 30) was greater in carriers of the A allele (OR = 0.22; 95% CI = 0.087-0.576). The increase in weight over these 6 years, taken as a continuous variable, was significantly less only in those persons who were originally obese (P = 0.018). In conclusion, in a population from southern Spain, carriers of the A allele of the -30G>A polymorphism in the promoter of the glucokinase gene had a lower risk for obesity and the likelihood of losing weight was greater in those obese persons who had the A allele (GA or AA).

Incidence of type 2 diabetes in southern Spain (Pizarra Study)

BACKGROUND

Few European studies have used an oral glucose tolerance test (OGTT) to examine the incidence of type 2 diabetes. We determined the incidence of impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and type 2 diabetes in a population from southern Spain.

MATERIAL AND METHODS

A population-based cohort study was undertaken in Pizarra, Spain. Baseline data were recorded on age, sex, weight, height, waist and hip circumferences, and diabetes status for 1051 persons, of whom 910 were free of type 2 diabetes (at-risk sample). Of these, 714 completed the 6-year follow-up study. Body mass index, waist-to-hip ratio and weight increase since baseline were calculated. The homeostasis model assessment equations were used to estimate the indices of insulin resistance and beta-cell function. Each person received an OGTT at baseline and after 6 years.

RESULTS

Type 2 diabetes developed in 81 people for a total of 4253 person-years, representing an incidence of 19.1 cases per 1000 person-years (95% confidence interval, 15.3-23.6). Age and the presence of obesity, central obesity and carbohydrate metabolism disorders [IFG (cut off = 100 mg dL(-1), capillary blood glucose level), IGT or both] at baseline were significant markers for the onset of type 2 diabetes during follow-up. After adjusting for these variables, multivariate analysis showed weight increase, waist-to-hip ratio and the indices of insulin resistance and beta-cell function were significantly associated with the risk for type 2 diabetes.

CONCLUSIONS

The incidence of type 2 diabetes in a population from southern Spain is high. It is probably associated with the high prevalence of obesity and weight increase in this population.

Effect of the combination of the variants -75G/A APOA1 and Trp64Arg ADRB3 on the risk of type 2 diabetes (DM2)

OBJECTIVE

Numerous genes have been associated with the risk for type 2 diabetes mellitus (DM2). In an attempt to understand how specific variants of different genes interact and intervene in the molecular and physiological mechanisms of disorders such as diabetes or insulin resistance, the search for gene-gene interactions is constantly growing. We searched for a possible interaction between two polymorphisms (Trp64Arg of ADRB3 gene and -75G/A of APOA1gene) and the risk for DM2 in a population from southern Spain.

DESIGN AND METHODS

A cross-sectional study in southern Spain of 1020 people, aged 18-65 years. All persons underwent a clinical, anthropometrical and biochemical evaluation, including an oral glucose tolerance test (OGTT). Insulin resistance was measured by homeostasis model of assessment (HOMA). The polymorphisms -75G/A of APOA1 and Trp64Arg of ADRB3 were detected by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and real-time PCR, respectively.

RESULTS

The genotype frequencies of the -75G/A polymorphism of the APOA1 gene were 62.7% GG, 25.7% GA and 11.6% AA, whereas for the Trp64Arg polymorphism of the ADRB3 gene, they were 87.5% Trp/Trp, 11.7% Trp/Arg and 0.8% Arg/Arg. Subjects with both gene variants had a greater odds ratio (OR) of having DM2 [OR = 5.5; 95% confidence interval (CI) = 1.2-23.5] than persons with one or none of the variants, after adjusting for age, sex, body mass index (BMI) and homeostasis model assessment of insulin resistance (HOMA-IR).

CONCLUSIONS

Joint association of allele -75A (APOA1) and allele Arg64 (ADRB3) increase the risk of DM2 in a population from southern Spain.

Evolución de la prevalencia de la diabetes tipo 2 en población adulta española

Type 2 diabetes has been catalogued as the epidemic of the 21st Century, both because of its increasing magnitude and its impact on cardiovascular disease, the leading cause of death in developed countries. This review analyses the evolution of the prevalence of diabetes in Spain over recent years, based on various cross-sectional studies. This study shows that previous estimates have been surpassed, with 10-15% of Spanish adults estimated to have diabetes. Factors influencing this phenomenon include the change in diagnostic criteria, population aging, a lower mortality among persons with diabetes or a true increase in the incidence.

Population-based incidence of type 2 diabetes in northern Spain: the Asturias Study

OBJECTIVE

The aim of this study was to define the incidence of type 2 diabetes in a low-risk Caucasian population in northern Spain and its association with various risk factors.

RESEARCH DESIGN AND METHODS

The Asturias Study is a prospective, population-based survey of diabetes and cardiovascular risk factors. The baseline examination was carried out during 1998-1999 when 1,034 individuals, aged 30-75 years, were randomly selected to determine the prevalence of type 2 diabetes and pre-diabetes in the Principality of Asturias (northern Spain). In 2004-2005, these same subjects were invited for a follow-up examination; 700 participated. This study includes only those individuals who did not have diabetes at baseline. We used the World Health Organization 1999 criteria to classify glucose metabolism at both baseline and follow-up.

RESULTS

The incidence of diabetes adjusted for the age and sex structure of Asturias was 10.8 cases/1,000 person-years (95% CI 8.1-14.8). The incidence rates were 5 cases/1,000 person-years in individuals with normoglycemia, 21 cases/1,000 person-years in individuals with isolated impaired glucose tolerance (IGT), 34.7 cases/1,000 person-years in individuals with isolated impaired fasting glucose (IFG), and 95.2 cases/1,000 person-years in individuals with combined IFG-IGT. Stepwise multiple logistic regression analysis showed that, together with fasting plasma glucose (FPG) and 2-h plasma glucose, which were the strongest predictors of diabetes, triglycerides and BMI were also independently associated with progression to diabetes.

CONCLUSIONS

In this 6-year prospective population-based study, we found an incidence of type 2 diabetes of 10.8 cases/1,000 person-years. Both FPG and 2-h plasma glucose were strongly predictive of diabetes, and their effect was additive.

Serum phospholipid fatty acid profile and dietary intake in an adult Mediterranean population with cystic fibrosis

The relative importance of the usual diet in serum phospholipids in subjects with cystic fibrosis (CF) has been poorly studied. To compare the fatty acid profile in serum phospholipids from adult CF subjects with that of healthy subjects, and determine the role of the normal diet in this profile, we studied thirty-seven adult CF subjects with stable pulmonary disease and thirty-seven healthy controls matched for age, sex and nutritional status. A dietary questionnaire was obtained, anthropometric data were recorded, and the fatty acid profile measured by GLC. Compared with the controls, the percentages of myristic, palmitoleic and stearic acids and total MUFA were significantly higher in the CF group, and DHA, linoleic acid, total PUFA and n−6 fatty acids were significantly lower in the CF group. The CF subjects with worse pulmonary function and with pancreatic insufficiency had significantly lower levels of linoleic and n−6 fatty acids. The total energy intake was significantly higher in the CF subjects, although the energy distribution in the CF subjects and the controls was not different for the carbohydrates, lipids and proteins. No differences were detected in fat intake for MUFA (51 (sd 4) v. 52 (sd 4) %) or saturated fatty acids (33·5 (sd 5) v. 31·2 (sd 3·8) %), but the PUFA were slightly lower in the CF subjects (15·4 (sd 4·5) v. 17·4 (sd 4·2) %; P=0·02). The usual dietary intake of fatty acids by adult CF subjects does not appear to explain the difference in the fatty acid profile compared with controls. This suggests an abnormal fatty acid metabolism in CF subjects.

[Detection of LADA-type diabetes in overweight diabetic patients. Is treatment with metformin suitable?]

OBJECTIVES

To detect type-1 LADA (latent auto-immune diabetes in adults) in adults with overweight. To describe the metabolic variations in these patients after metformin treatment.

DESIGN

Observational, multi-centre study based on a series of cases.

SETTING

Health centres in Barcelona province, Spain.

PARTICIPANTS

Diabetic patients with overweight or obesity, diagnosed with diabetes for <2 years, aged between 35 and 65, and without clinical micro-macrovascular complications and without initial glycaemia-lowering drug treatment.

INTERVENTION

Metformin administration (1700 mg/day).

MEASUREMENTS

The metabolic control variable was HbA1c. Other variables measured were: body mass index (BMI), glucose in fast, insulinaemia, C-peptide, and insulin resistance (HOMA-IR). We determined ICA, GADAb and IA2Ab antibodies to diagnose LADA-type diabetes.

RESULTS

In our sample of diabetics (N=103), we detected 3 type-1 LADA cases. These patients had higher levels of HbA1c, insulin and, especially, HOMA-IR. Metformin treatment for one year improved HbA1c in both groups (with and without type-1 LADA). However, the decrease in insulin one year afterwards was greater in type-1 LADA patients.

CONCLUSIONS

The percentage of type-1 LADA in our sample made us wonder whether we should search for pancreatic antibodies more often in primary care. More studies on the prevalence of type-1 LADA in our country are needed, especially in diabetic patients with overweight. Type-1 LADA patients improved their metabolic control after metformin treatment and showed a drastic decrease in insulin levels. Further studies are needed to evaluate whether metformin improves metabolic control, even though it may not protect insulin reserves, and to contrast metformin with other drugs.

Evolución de las hospitalizaciones por insuficiencia cardíaca en Andalucía en la última década

BACKGROUND AND OBJECTIVES

The cost of hospitalization represents the greatest proportion of total expenditure due to heart failure. Our objective was to analyze the trends of morbidity of chronic heart failure in Andalusia between 1990-2000.

MATERIAL AND METHODS

The data on hospitalizations in Andalusia (title 428 of the ninth revision of the International Disease Classification) were obtained from the National Survey of Hospital Morbidity of the National Institute of Statistics. The rates, standardized by age and gender, of admission due to heart failure were calculated by the direct standardization method.

RESULTS

The absolute number of hospitalizations due to hear failure in people over 45 years was 4,345 in 1990 and 10,153 in 2000 (a relative increase of 230%) and it represents 14.2% hospitalizations in Spain. The increase was focused on those over 65 years and the standardized rates were slightly greater in women than in men.

CONCLUSIONS

Hospitalization discharge rates increased mostly in the population older than 65 and women showed hospitalization rates slightly greater than men.

Pro12Ala polymorphism of the PPARG2 gene is associated with type 2 diabetes mellitus and peripheral insulin sensitivity in a population with a high intake of oleic acid

Activation of the PPAR gamma 2 gene (PPARG2) improves the action of insulin and its lipid metabolism. We examined the association between Pro12Ala polymorphism of PPARG2, type 2 diabetes mellitus (DM2), and peripheral insulin sensitivity in a population with a high intake of oleic acid. A cross-sectional, population-based study was undertaken in Pizarra, a small town in the province of Malaga in southern Spain. A total of 538 subjects, aged 18-65 y, were selected randomly from the municipal census. All subjects underwent a clinical, anthropometrical, and biochemical evaluation, including an oral glucose tolerance test and Pro12Ala polymorphism of PPARG2. Insulin resistance was measured by homeostasis model assessment. Those subjects with the Ala-12 allele had an odds ratio for impaired fasting glucose of 0.55, for impaired glucose tolerance of 0.59, and for DM2 of 0.30. The intake of monounsaturated fatty acids (MUFA) contributed to the variance of the homeostasis model assessment insulin resistance index (HOMA IR) (P = 0.04), with a 2-way interaction between the Ala-12 allele of PPARG2 and the intake of MUFA (P = 0.005). The results suggest the existence of an interaction between Pro12Ala polymorphism of PPARG2 and dietary MUFA, such that obese people with the Ala-12 allele have higher HOMA IR values, especially if their intake of MUFA is low.

Clinical phenotype and beta-cell autoimmunity in Italian patients with adult-onset diabetes

OBJECTIVE

To characterize the phenotype of a large population of Italian patients with adult onset (> or =40 years) diabetes who were attending outpatient clinics and who were screened for glutamic acid decarboxylase 65 autoantibodies (GADA), protein tyrosine phosphatase IA-2 (IA-2A) and IA-2beta/phogrin (IA-2betaA).

DESIGN AND METHODS

This was a cross-sectional study comprising a total of 881 patients, aged < or = 70 years, diagnosed with type 2 diabetes after the age of 40 years, and consecutively recruited in five clinics located in different geographic areas of Italy (Milan, Florence, Rome, Naples and Catania). Their mean disease duration was 8.1 (6.9; s.d.) years. GADA, IA-2A and IA-2betaA were measured with radiobinding assays with in vitro translated S-methionine-labelled glutamic acid decarboxylase 65 (GAD65) or IA-2 or IA-2beta. Anthropometric and clinical data were collected and compared amongst patients with or without autoantibodies.

RESULTS

Sixty-three (7.1%) patients had one or more autoantibodies, 58 (6.6%) had GADA, 22 (2.5%) had IA-2A, six (0.7%) had IA-2betaA and 19 (2.15%) had two or more autoantibodies. IA-2A or IA-2betaA, in the absence of GADA, were found in only five patients. Autoantibody-positive patients were more often female (63.5 vs 36.5%; P < 0.009), had higher glycated haemoglobin (Hb A1c) (P < 0.001), lower body mass index (BMI; P < 0.0005) and waist/hip ratio (WHR; P < 0.01); female gender being the main contributor to BMI and WHR. We did not observe any differences in age at diagnosis or duration of disease with respect to the presence or absence of islet autoantibodies. The proportion of patients on insulin therapy was higher in patients with two or more antibodies, compared with those with one antibody only, and no antibodies (P for trend < 0.001), and among patients with GADA, in those with higher antibody titre (73.9% in those with > 10 units vs 42.0% in those with < or = 10 units; P < 0.007).

CONCLUSIONS

Patients with adult onset diabetes characterized by autoimmunity to beta-cells showed a clinical phenotype with anthropometric features that differed from those classically observed in patients with type 2 diabetes. The number and titre of autoantibodies, which reflect the severity of autoimmunity and beta-cell impairment, amplified this difference. The usefulness of autoantibody screening in adult-onset diabetes is further emphasized by these findings.

La diabetes mellitus en España: mortalidad, prevalencia, incidencia, costes económicos y desigualdades

OBJECTIVE

Describing the situation of diabetes mellitus (DM) in Spain from a public health perspective.

MATERIAL AND METHOD

manual review of books and other documents on diabetes mellitus in Spain was conducted. In addition, a specific research of articles published using MeSH terms diabetes mortality, prevalence, incidence, cost, inequalities and Spain was conducted in Medline through Internet (PubMed). Minimun Basic Data Set was utilized as source for complication description by Communities Autonomus.

RESULTS

DM is one of the leading cause of mortality and the third one in women. With regard to Autonomous Communities, Canary Islands, Ceuta y Melilla and Andalusia show the greatest mortality with a downward trend. Diabetics present greater mortality than non diabetic patients, being complications the main cause of the over-mortality, especially ischemic heart disease. Estimations of prevalence for DM2 range from 4.8% to 18.7% and for DM1, from .08% to .2%. In pregnancy, it has been noted a prevalence ranging from 4.5% to 16.1%. With respect to incidence per year, it is estimated a range from 146 to 820 per 100,000 inhabitants for DM2 and a range from 10 to 17 new cases annually per 100,000 inhabitants for DM1. Costs for DM1 show very different results, averaging between 1,262 and 3,311 euro per people and year. There are differences for DM2 costs as well, averaging between 381 and 2,560 euro per patient and year. Total costs estimated range from 758 to 4,348 euro per person and year. Relationship between a low socioeconomic level (LSL) and DM2 risk has been proved. Moreover, it has been noted that the less LSL the worse is the disease control, coupled with a greater frequency and more frequent factors of DM2 risk.

CONCLUSIONS

The knowledge about the situation of the DM as a Public Health problem in Spain is limited. Mortality data available does not gather its real magnitude, and prevalence, incidence, costs and inequalities research are very poor and hardly comparable. In spite of this degree of incertitude, we can state that DM is an important public health problem with a continuous increase, especially DM2, if the appropriate prevention and control measures are not taken.

Diabetes mellitus and impaired glucose regulation in the Canary Islands (Spain): prevalence and associated factors in the adult population of Telde, Gran Canaria

AIMS

To estimate the prevalence and the determinants of diabetes mellitus and impaired glucose regulation (IGR) in an adult Canarian population.

METHODS

Cross-sectional study. One thousand and thirty subjects aged 30-82 years were randomly selected. Participants completed a survey questionnaire and underwent blood pressure measurements, anthropometry, blood samples, and a 75-g standardized oral glucose tolerance test.

RESULTS

The age-standardized prevalence of diabetes was 15.8% (95% confidence interval: 11.8-19.8) in men and 10.6% (7.1-14.1) in women. Total prevalence was 13.2% (11.1-15.2). Among individuals with diabetes, 55.4% of men and 38.2% of women were not previously diagnosed. The age-standardized prevalences of impaired glucose tolerance and impaired fasting glycaemia were 11.4% (9.5-13.4) and 2.8% (1.8-3.8), respectively. In multivariate analyses, age, waist circumference, serum triglycerides, and familial history of diabetes were independently associated with diabetes in both sexes, while a value of C-reactive protein (CRP) >/= 1 mg/l showed an association with diabetes, but only in men. Age and triglycerides were related to impaired glucose regulation (IGR) in both sexes, waist circumference was related to IGR exclusively in men, and familial diabetes exclusively in women. Statistically significant interactions between gender and both CRP and triglycerides were found with respect to diabetes, and between gender and both waist circumference and triglycerides for IGR.

CONCLUSIONS

Compared with the rest of Spain, the prevalence of diabetes is moderately increased in this area of the Canary Islands. Along with other well-established risk factors, CRP was independently associated with diabetes, but only in the male population.

Tratamiento de los pacientes con diabetes mellitus tipo 2 en atención primaria en España

BACKGROUND AND OBJECTIVE

We assess the metabolic control, complications, quality of life related to health (QLRH) and the type and amount of medical resource consumption (MRC) in type 2 diabetic patients (2DMp) followed by primary care physicians (PCP) in Spain.

PATIENTS AND METHOD

We studied 628 2DMp divided in 4 cohorts: 1. Either newly diagnosed 2DMp who required pharmacological treatment or failed to non-pharmacological measures; 2. Patients pharmacologically treated for less than 1 year; 3. Patients with pharmacological treatment for more than 1 year; 4. Patients with impaired fasting glucose (control group).

RESULTS

Eighty percent of the subjects were overweight. At baseline, 27.9, 23.5 and 36.9% of patients from cohorts 1, 2 and 3, respectively, had HbA1C < 8%. After 6 months of follow-up, 14.6, 21.3 and 22.8% of patients from cohorts 1, 2 and 3, respectively, still had "bad control". At baseline, 38.0%, 21.2% and 20.7% of patients from cohorts 1, 2, and 3, respectively, had "bad lipid profile". After 6 months, 57.4%, 54.2% and 45.3% of cohorts 1, 2 and 3, respectively, still had plasma cLDL levels > 130 mg/dl. Complications were more frequent in cohort 3. During the 6-month period, MRC was higher among 2DMp than controls (p < 0.05) and higher among patients from cohort 3 (p < 0.05) compared with all the other patients. More diabetic than control patients and more patients from cohort 3 than patients from cohort 1 and 2 reported that their expected quality of life would be better without diabetes.

CONCLUSIONS

One out of four of diabetic patients studied had HbA1C and lipids higher than the limits suggested by guidelines. Type 2 diabetes is associated with higher MRC and worse QLRH. This situation is worse among long-term diabetic patients.

Association between MspI polymorphism of the APO AI gene and Type 2 diabetes mellitus

AIMS

Genes of the Apo AI/CIII/AIV cluster on chromosome 11 have been related to plasma lipid patterns. The close relationship between carbohydrate metabolism and lipid metabolism warrants investigation of the association between this cluster and Type 2 diabetes mellitus. We therefore examined the possible association between polymorphisms of this cluster and Type 2 diabetes mellitus as part of a study of the prevalence of diabetes and the metabolic syndrome in southern Spain.

METHODS

A total of 1224 persons were selected randomly from the town of Pizarra in the province of Malaga, southern Spain. The sample errors for the prevalence of Type 2 diabetes mellitus and the three polymorphisms studied were all < or = 4%. All subjects underwent phenotyping after an oral glucose tolerance test (75 g) (WHO 1998 criteria) and the XmnI and MspI polymorphisms of Apo AI and the SstI polymorphism of Apo CIII were genotyped.

RESULTS

Those subjects with the mutated AA genotype of the MspI polymorphism (-75 G-->A) of Apo AI had a greater risk of impaired glucose tolerance [odds ratio (OR) = 1.95, CI = 1.02-3.8, P = 0.05], Type 2 diabetes mellitus, both known (OR = 7.38, CI = 1.3-39.7, P = 0.02) and unknown (OR = 3.7, CI = 1.4-9.9, P = 0.009). This risk was independent of age, sex, obesity, triglyceride level, HDL cholesterol and pattern of insulin resistance.

CONCLUSIONS

Pending confirmation in prospective studies, the AA genotype of the MspI polymorphism of the Apo AI gene, within the Apo A-I/C-III/A-IV cluster, seems to be a risk factor for Type 2 diabetes mellitus.

Factores de riesgo cardiovascular en la población española: metaanálisis de estudios transversales

BACKGROUND AND OBJECTIVE

To review published studies on the prevalence of the main vascular risk factors -hypertension, hypercholesterolemia, diabetes mellitus, obesity and tobacco smoking- in Spain, and to combine their results in an estimate for the Spanish population.

MATERIAL AND METHOD

After a bibliographic search, the studies fulfilling the following inclusion criteria were selected: cross-sectional design, sampling on Spanish population, results including prevalence data of at least one of the above mentioned risk factors, and objective [corrected] (not self-referred) determination of arterial blood pressure, total serum cholesterol, basal glucose, weight, size and body mass index. The combined prevalence was obtained by means of the random effects model, including weight for the proportion that the studied population supposes on the total Spanish population.

RESULTS

Forty-eight studies were identified including a total of 130.945 subjects. According to these studies, the most frequent vascular risk factors were hypertension in the elderly (66.7%, CI 59-74%), overweight/obesity in adult women (48,3%, CI 41-55%) and smoking among men (41.1%, CI 38-44%). In the Spanish population as a whole, 23% showed total cholesterol levels above 250 mg/dl; 33% were smokers (41,1% in men and 24% in women); 34% suffered hypertension; 20% were obese (18% in men and 23% in women); and diabetes affected 8% women and 12% men.

CONCLUSION

Cardiovascular risk in Spain is high. Monitoring the vascular risk factors at a population level is basic for preventive and health care measures.

Diabetes-related antibodies in adult diabetic patients

Islet autoimmunity is made evident by the appearance of islet-cell antibodies directed against insulin (IAA), glutamic acid decarboxylase (GADA), protein tyrosine phosphatase IA-2 (IA-2Ab) and other autoantigens. IAA and IA-2Ab are predominantly detected in childhood type 1 diabetes mellitus (T1DM), while frequency of GADA is not affected by age. In adult-onset T1DM patients, GADA is the immune marker of higher diagnostic sensitivity. In adult diabetic patients not requiring insulin treatment for at least 6 months after diagnosis, GADA identifies the so-called latent autoimmune diabetes in adults (LADA). In over 80% of cases, LADA patients develop insulin dependency within a few years after the diagnosis and have an increased risk for the development of other organ-specific autoimmune diseases. High GADA titers identify a subgroup of LADA patients with low body mass index (BMI), low C-peptide levels and increased frequency of T1DM-related HLA class II haplotypes. GADA assay should be offered to every diabetic patient, and in cases of positivity screening for other autoimmune diseases should be carried out.

Patterns of insulin resistance in the general population of southeast Spain

The aim of this study was to evaluate patterns of insulin resistance in the general population. The study was cross sectional. Clinical, anthropometric, and lipid measurements were made in 1226 persons aged 18-65 years. An oral glucose tolerance test (OGTT) was performed in 1020 subjects, with insulin levels determined at baseline and after 2 h. The homeostasis model assessment insulin resistance index (HOMA IR) and HOMA beta-cell function were calculated. Compared with subjects with normal glucose tolerance, the groups with abnormal OGTT had different baseline insulinemia, 2 h post OGTT insulinemia, HOMA IR and HOMA beta-cell indices. Serum insulin levels at baseline and 2 h after OGTT showed a characteristic pattern for each category of glucose tolerance, resulting from the different insulin responses. In the subjects with normal glucose tolerance, the pattern of the relationships between both types of serum insulin levels was exactly the same, so that it was possible to determine risk groups according to the ratio of baseline serum insulin/2 h insulin. HOMA IR and HOMA beta-cell were significantly associated with the risk of impaired fasting glucose, previously unknown diabetes mellitus, and known diabetes mellitus. These results support the rationale for introducing preventive measures against insulin resistance in the general population.

Excess hospitalizations, hospital days, and inpatient costs among people with diabetes in Andalusia, Spain

OBJECTIVE

The goal of this study was to estimate the excess hospitalizations, hospital days, and inpatient costs attributable to diabetes in Andalusia, Spain (37 hospitals, 7,236,459 inhabitants), during 1999 compared with those without diabetes.

RESEARCH DESIGN AND METHODS

This study was an analysis of all hospital discharges. Those with an ICD-9-CM code of 250 as either the main or secondary diagnosis were considered to have been admissions of individuals with diabetes. An estimate of costs was applied to each inpatient admission by assigning a cost weight based on the diagnostic-related group (DRG) related to each admission.

RESULTS

A total of 538,580 admissions generated 4,310,654 hospital bed-days and total costs of 940,026,949 euro. People with diabetes accounted for 9.7% of all hospital discharges, 13.8% of total stays, and 14.1% of the total cost. Of the total cost for individuals with diabetes (132,509,217 euro), 58.3% were excess costs, of which 47% was attributable to cardiovascular complications and 43% to admissions for comorbid diseases. Individuals 45-75 years of age accounted for 75% of the excess costs. The rate of admissions during the study year was 145 per 1,000 inhabitants for individuals with diabetes compared with 70 admissions per 1,000 inhabitants for individuals without diabetes.

CONCLUSIONS

The costs arising from hospitalization of individuals with diabetes are disproportionate in relation to their prevalence. For those aged >or=45 years, cardiovascular complications were clearly the most important factor determining increased costs from diabetes.

Islet cell autoimmunity in a triethnic adult population of the Third National Health and Nutrition Examination Survey

Markers of humoral islet cell autoimmunity, such as autoantibodies (AAs) against the 65-kDa isoform of GAD (GAD65), serve as determinants of risk for autoimmune diabetes. Despite the high prevalence of diabetes in U.S. racial and ethnic minority adult populations, little is known concerning the prevalence of GAD65 AA in these groups. We estimated the prevalence of GAD65 AA in 1,064 diabetic and 1,036 nondiabetic participants who were 40-90 years of age from the Third National Health and Nutrition Examination Survey (NHANES III), which provides a representative ethnic sample of the U.S. diabetic population. The prevalence of GAD65 AA was higher in diabetic participants compared with nondiabetic participants in non-Hispanic whites (n = 920; 6.3% vs. 2.0%; P = 0.001) and non-Hispanic blacks (n = 534; 3.7% vs. 1.3%; P = 0.08) but not in Mexican Americans (n = 646; 1.2% vs. 2.6%; P = 0.18). Among diabetic non-Hispanic whites and non-Hispanic blacks, being GAD65 AA positive was associated with lower BMI and C-peptide (P < 0.05). These results may reflect the outcome of an autoimmune process leading to beta-cell destruction/dysfunction in non-Hispanic white and non-Hispanic black adult diabetic patients as it occurs in a similar manner in type 1 diabetes. Among diabetic Mexican Americans, the lower prevalence of GAD65 AA suggests a lower frequency of autoimmune-related diabetes.

A clinically orientated approach increases the efficiency of screening for latent autoimmune diabetes in adults (LADA) in a large clinic-based cohort of patients with diabetes onset over 50 years

AIMS

To assess if a clinically orientated approach improves screening for latent autoimmune diabetes in adults (LADA) in patients developing diabetes over age 50.

METHODS

From a clinic-based cohort of 3327 patients with Type 2 DM diagnosed over age 50 we recruited those with at least one feature suggestive of insulin deficiency: (i) fasting blood glucose > or = 15 mmol/l and/or HbA(1c) > or = 10% in spite of adequate compliance to diet and treatment; (ii) decreasing body weight > or = 10% in the previous 3 months in spite of constant diet; (iii) BMI < 25 mg/kg(2). A control group of 240 patients not presenting any of the previous criteria was randomly selected from the out-patient clinic.

RESULTS

We identified 220 (6.6%) patients, of whom 70 were positive for glutamic acid decarboxylase antibodies (GADA) and/or islet cell antibodies (ICA), giving a prevalence of LADA of 31.8% (95% CI 25.7-38.4). In contrast, no patient randomly selected from the remaining cohort had marker positivities. With respect to patients negative for both ICA and GADA, those who were positive had lower C-peptide values (0.53 +/- 0.51 vs. 0.88 +/- 0.42 nmol/l, P < 0.001); the lowest levels were found in patients in whom both antibodies were positive. In linear regression analysis, variables independently associated with fasting C-peptide were GADA (beta = -0.25, P < 0.001), ICA (beta = -0.15, P = 0.04), BMI (beta = 0.03, P < 0.001) and duration of diabetes (beta = -0.02, P < 0.001).

CONCLUSION

This study shows that: (i) a clinically orientated approach increases the efficiency of a screening programme for LADA, so that one in three screened patients are classified correctly; (ii) ICA and GADA positivity were negatively associated with residual beta-cell function, independent of BMI and duration of the disease; (iii) positivity for both ICA and GADA identifies patients with the lowest residual beta-cell function.

Contribution of polymorphisms in the apolipoprotein AI-CIII-AIV cluster to hyperlipidaemia in patients with gout

BACKGROUND

Studies have shown that hyperuricaemia is independently related to the insulin resistance syndrome and that polymorphisms of the apolipoprotein AI-CIII-AIV cluster are also related to insulin resistance.

OBJECTIVE

To study the prevalence of polymorphisms of the apolipoprotein AI-CIII-AIV cluster in persons with gout and to determine whether these polymorphisms contribute to the pathophysiology of gout or to altered lipid concentrations.

METHODS

Plasma cholesterol, triglycerides, uric acid, VLDL, LDL, IDL, and HDL triglycerides, cholesterol, and the renal excretion of uric acid were measured in 68 patients with gout with gout and 165 healthy subjects. Polymorphisms were studied by amplification and RFLP in all subjects, using XmnI and MspI in the apolipoprotein AI gene and SstI in the apolipoprotein CIII gene.

RESULTS

The A allele at position -75 bp in the apolipoprotein AI gene was more common in patients with gout than in controls (p = 0.01). Levels of cholesterol, triglycerides, uric acid, basal glycaemia, and HDL cholesterol were higher in the patients (p<0.001). In the patients there was also an interaction between mutations at the two polymorphic loci studied in the apolipoprotein AI gene (p = 0.04). An absence of the mutation at position -75 bp of the apolipoprotein AI gene resulted in increased plasma triglyceride levels.

CONCLUSIONS

Gouty patients have an altered allelic distribution in the apolipoprotein AI-CIII-AIV cluster, which could lead to changes in levels of lipoproteins. This is not caused by a single mutation but rather by a combination of different mutations.