The prevention of type 2 diabetes--lifestyle change or pharmacotherapy? A challenge for the 21st century

Comparison of long-term effects of metformin on longevity between people with type 2 diabetes and matched non-diabetic controls

BACKGROUND

Metformin, a medication for type 2 diabetes, has been linked to many non-diabetes health benefits including increasing healthy lifespan. Previous work has only examined the benefits of metformin over periods of less than ten years, which may not be long enough to capture the true effect of this medication on longevity.

METHODS

We searched medical records for Wales, UK, using the Secure Anonymised Information Linkage dataset for type 2 diabetes patients treated with metformin (N = 129,140) and sulphonylurea (N = 68,563). Non-diabetic controls were matched on sex, age, smoking, and history of cancer and cardiovascular disease. Survival analysis was performed to examine survival time after first treatment, using a range of simulated study periods.

FINDINGS

Using the full twenty-year period, we found that type 2 diabetes patients treated with metformin had shorter survival time than matched controls, as did sulphonylurea patients. Metformin patients had better survival than sulphonylurea patients, controlling for age. Within the first three years, metformin therapy showed a benefit over matched controls, but this reversed after five years of treatment.

INTERPRETATION

While metformin does appear to confer benefits to longevity in the short term, these initial benefits are outweighed by the effects of type 2 diabetes when patients are observed over a period of up to twenty years. Longer study periods are therefore recommended for studying longevity and healthy lifespan.

EVIDENCE BEFORE THIS STUDY

Work examining the non-diabetes outcomes of metformin therapy has suggested that there metformin has a beneficial effect on longevity and healthy lifespan. Both clinical trials and observational studies broadly support this hypothesis, but tend to be limited in the length of time over which they can study patients or participants.

ADDED VALUE OF THIS STUDY

By using medical records we are able to study individuals with Type 2 diabetes over a period of two decades. We are also able to account for the effects of cancer, cardiovascular disease, hypertension, deprivation, and smoking on longevity and survival time following treatment.

IMPLICATIONS OF ALL THE AVAILABLE EVIDENCE

We confirm that there is an initial benefit to longevity of metformin therapy, but this benefit does not outweigh the negative effect on longevity of diabetes. Therefore, we suggest that longer study periods are required for inference to be made about longevity in future research.

Self-care practice and its associated factors among diabetic patients attending public hospitals in Gurage zone southwest, Ethiopia

Background

Diabetes is a chronic disease that requires lifelong medical treatment and lifestyle modifications. Even though patients often neglect their own needs, self-care is an important factor in preventing and delaying complications related to diabetes. There are limited studies about self-care practice, and most of the studies conducted in Ethiopia focused on some parts of the recommended self-care practice. Therefore, this study aimed to assess the self-care practice and associated factors among diabetic patients in Gurage zone, south Ethiopia.

Methods

An institution-based cross-sectional study was conducted from February 6 to March 29, 2021. A systematic sampling method was employed to select 420 study participants. The data were collected using a pretested interviewer-administered questionnaire. All variables with P < 0.25 in the bi-variable logistic regression analysis were entered into multivariable logistic regression analysis. The statistical significance was declared at a p-value < 0.05.

Results

A total of 384 diabetes patients participated with a response rate of 91.4%. This study showed that more than half (60.4%) of the study participants had poor self-care practices. Being female (AOR: 2.40; 95% CI:1.31–4.40), rural residence (AOR:7.16;95% CI: 3.31–15.46), duration of diabetes treatment 5–10 years (AOR: 0.03; 95% CI: 0.1–0.11), duration of diabetes treatment ≥ 10 years (AOR:0.8; 95% CI: 0.03–0.21), haven’t social support (AOR: 0.10; 95% CI: 0.05–0.23), haven’t got health education (AOR: 0.17,95%CI 0.09–0.32) were factors significantly associated with self-care practice.

Conclusions

Despite, the importance of diabetes self-care practice for the management of diabetes and preventing its complications, a high number of diabetes patients had poor self-care practices. Female, rural residence, duration of diabetes mellitus, lack of social support, and not get of health education were significantly associated with poor self-care practice. Therefore, health care providers should give attention to diabetic patients with the aforementioned factors that affect diabetic patients’ self-care practices.

Protective effects of calorie restriction on insulin resistance and islet function in STZ-induced type 2 diabetes rats

Background

Caloric restriction (CR) has become increasingly attractive in the treatment of type 2 diabetes mellitus (T2DM) because of the increasingly common high-calorie diet and sedentary lifestyle. This study aimed to evaluate the role of CR in T2DM treatment and further explore its potential molecular mechanisms.

Methods

Sixty male Sprague–Dawley rats were used in this study. The diabetes model was induced by 8 weeks of high-fat diet (HFD) followed by a single dose of streptozotocin injection (30 mg/kg). Subsequently, the diabetic rats were fed HFD at 28 g/day (diabetic control) or 20 g/day (30% CR regimen) for 20 weeks. Meanwhile, normal rats fed a free standard chow diet served as the vehicle control. Body mass, plasma glucose levels, and lipid profiles were monitored. After diabetes-related functional tests were performed, the rats were sacrificed at 10 and 20 weeks, and glucose uptake in fresh muscle was determined. In addition, western blotting and immunofluorescence were used to detect alterations in AKT/AS160/GLUT4 signaling.

Results

We found that 30% CR significantly attenuated hyperglycemia and dyslipidemia, leading to alleviation of glucolipotoxicity and thus protection of islet function. Insulin resistance was also markedly ameliorated, as indicated by notably improved insulin tolerance and homeostatic model assessment for insulin resistance (HOMA-IR). However, the improvement in glucose uptake in skeletal muscle was not significant. The upregulation of AKT/AS160/GLUT4 signaling in muscle induced by 30% CR also attenuated gradually over time. Interestingly, the consecutive decrease in AKT/AS160/GLUT4 signaling in white adipose tissue was significantly reversed by 30% CR.

Conclusion

CR (30%) could protect islet function from hyperglycemia and dyslipidemia, and improve insulin resistance. The mechanism by which these effects occurred is likely related to the upregulation of AKT/AS160/GLUT4 signaling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12986-021-00575-y.

Network pharmacology combined with metabolomics to study the mechanism of Shenyan Kangfu Tablets in the treatment of diabetic nephropathy

ETHNOPHARMACOLOGICAL RELEVANCE

Shenyan Kangfu Tablets (SYKFT) is a traditional prescription evolved from Shenqi Pills. It has been included in the Synopsis of the Golden Chamber for more than 2000 years. SYKFT was listed as a national Chinese medicine protected class by the China Food and Drug Administration. Diabetic nephropathy (DN) is one of the serious microvascular diseases caused by diabetes and is also one of the important factors leading to the death of patients. The pathogenesis of DN is diverse and complex, and there is no particularly effective drug treatment. There is clinical evidence that SYKFT has a good therapeutic effect on DN with no obvious adverse effects, but the mechanism of treatment is not clear.

AIM OF THE STUDY

In this study, network pharmacology was combined with metabolomics technology to explore the mechanism of SYKFT in the treatment of DN.

MATERIALS AND METHODS

First, the research team conducted a qualitative study of the chemical components contained in SYKFT, and carried out network pharmacology to search for potential targets based on the characterized chemical components. Second, we analysed the metabolic profile of db/db mouse urine based on UHPLC-QTOF-MS technology, and biomarkers were identified by multivariate statistical analysis. Then, we performed further pathway enrichment analysis. Finally, the results of metabolomics and network pharmacology were conjointly analysed.

RESULTS

Seventy-five chemical components of SYKFT were identified. According to the TCMSP database, the corresponding targets of the qualitatively identified components were searched, and a total of 36 potentially active components and 160 targets related to DN were obtained. A total of 38 biomarkers were found in metabolomics based on UHPLC-QTOF-MS technology. Biosynthesis of unsaturated fatty acids and starch and sucrose metabolism are the most related pathways, the former of which has been rarely reported concerning DN. Finally, the results of the joint analysis show that two targets, hexokinase 2 (HK2) and maltase glucoamylase (MGAM), are the overlapping targets. It means they are not only the related targets of pathways involved in potential biomarkers in metabolomics but also the intersection targets of diseases and drugs identified by network pharmacology.

CONCLUSIONS

The study reveals that the potential mechanism of SYKFT is most related to insulin resistance (IR) in the treatment of DN. It also proves that network pharmacology combined with metabolomics to find the mechanisms by which herbs treat complex diseases is a feasible tool.

The impact of urbanization on mood disorders: an update of recent evidence

PURPOSE OF REVIEW

Mood disorders are highly prevalent and represent a leading cause of global disability. Urbanization holds great public health implications spanning various environmental, lifestyle behavioural, economic and social domains. Underlying risk factors for mood disorders are heterogeneous but the psychiatric literature has extended beyond individual-level risk, to account for population-level environment and social-related precursors to mental ill health. This review summarizes recent studies published since 2017 examining the impact of urbanization and associated environmental, social and lifestyle risks for mood disorders, specifically depression.

RECENT FINDINGS

All identified studies examined depression or subclinical mood-related symptomatology. Recent evidence suggests individuals residing in urban areas experience increased risk of depression. Mechanistic pathways include increased exposure to noise, light and air pollution, poor quality housing, reduced diet quality, physical inactivity, economic strain and diminished social networks. The role of the gut microbiome in the development of mood disorders represents a novel research domain expected to hold potential for the psychiatric and environmental field. Further research is needed to extrapolate the relationship between increased sedentary lifestyles and technology use and depression in urban societies.

SUMMARY

Recent evidence highlights the complexity and reciprocity of underlying driving factors in the relationship between urbanization and mood disorders. Future epidemiological research should continue to untangle such complexity. There was a dearth of evidence relating to urbanization and mood disorders other than depression. Future research should identify the unique experiences of vulnerable subgroups who experience disproportionate increased risk of adverse health experiences associated with urbanization.

A Systematic Review and Meta-Analysis of the Effect of Lifestyle Modification on Metabolic Control in Overweight Children

Childhood obesity is associated with type 2 diabetes mellitus. We aimed to determine the effects of lifestyle modification programs on fasting plasma glucose (FPG) levels in overweight children. We queried six relevant electronic databases and manually searched for studies published before December 2016. Overweight/obese children who underwent a lifestyle modification for more than 6 months were included. A total of 3923 children from eight randomized controlled trials (RCTs) were included. Compared with the control group, the lifestyle modification group had significantly lower FPG levels by 1.3 mg/dL. The mean differences were significantly decreased for both secondary outcomes; BMI z-score decreased by 0.16 units and insulin levels decreased by 2.4 mU/L. The metaregression showed that the follow-up duration was associated with FPG levels and BMI and insulin levels and half year is a suitable follow-up duration for this population. This study showed that lifestyle modification programs may be effective in reducing the FPG levels of overweight/obese children. Further high-quality RCTs with longer follow-up periods are needed to evaluate the long-term effect of this complementary approach for diabetes mellitus prevention on overweight/obese children.

Dietary metabolites and the gut microbiota: an alternative approach to control inflammatory and autoimmune diseases

It is now convincingly clear that diet is one of the most influential lifestyle factors contributing to the rise of inflammatory diseases and autoimmunity in both developed and developing countries. In addition, the modern 'Western diet' has changed in recent years with increased caloric intake, and changes in the relative amounts of dietary components, including lower fibre and higher levels of fat and poor quality of carbohydrates. Diet shapes large-bowel microbial ecology, and this may be highly relevant to human diseases, as changes in the gut microbiota composition are associated with many inflammatory diseases. Recent studies have demonstrated a remarkable role for diet, the gut microbiota and their metabolites-the short-chain fatty acids (SCFAs)-in the pathogenesis of several inflammatory diseases, such as asthma, arthritis, inflammatory bowel disease, colon cancer and wound-healing. This review summarizes how diet, microbiota and gut microbial metabolites (particularly SCFAs) can modulate the progression of inflammatory diseases and autoimmunity, and reveal the molecular mechanisms (metabolite-sensing G protein-coupled receptor (GPCRs) and inhibition of histone deacetylases (HDACs)). Therefore, considerable benefit could be achieved simply through the use of diet, probiotics and metabolites for the prevention and treatment of inflammatory diseases and autoimmunity.

WITHDRAWN: Dietary advice for the prevention of type 2 diabetes mellitus in adults

Review status was set to withdrawn. The review is out of date and does not meet current Cochrane standards. It will be superseded by a new expanding Cochrane review on 'Diet, physical activity or both for the prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk'.

The editorial group responsible for this previously published document have withdrawn it from publication.

The use of a chronic disease and risk factor surveillance system to determine the age, period and cohort effects on the prevalence of obesity and diabetes in South Australian adults--2003-2013

Background

Age, period and cohort (APC) analyses, using representative, population-based descriptive data, provide additional understanding behind increased prevalence rates.

Methods

Data on obesity and diabetes from the South Australian (SA) monthly chronic disease and risk factor surveillance system from July 2002 to December 2013 (n = 59,025) were used. Age was the self-reported age of the respondent at the time of the interview. Period was the year of the interview and cohort was age subtracted from the survey year. Cohort years were 1905 to 1995. All variables were treated as continuous. The age-sex standardised prevalence for obesity and diabetes was calculated using the Australia 2011 census. The APC models were constructed with ‘‘apcfit’’ in Stata.

Results

The age-sex standardised prevalence of obesity and diabetes increased in 2002-2013 from 18.6% to 24.1% and from 6.2% to 7.9%. The peak age for obesity was approximately 70 years with a steady increasing rate from 20 to 70 years of age. The peak age for diabetes was approximately 80 years. There were strong cohort effects and no period effects for both obesity and diabetes. The magnitude of the cohort effect is much more pronounced for obesity than for diabetes.

Conclusion

The APC analyses showed a higher than expected peak age for both obesity and diabetes, strong cohort effects with an acceleration of risk after 1960s for obesity and after 1940s for diabetes, and no period effects. By simultaneously considering the effects of age, period and cohort we have provided additional evidence for effective public health interventions.

Variability between self-reported diabetes and measured glucose among health screening participants in South Central Kentucky

AIMS

To assess self-reported diabetes and random glucose among health screening participants and examine factors associated with these two diabetes outcomes.

METHODS

Study subjects were adults aged ≥18 years who participated in diabetes screenings via a mobile health clinic operated by the Institute for Rural Health at Western Kentucky University from 2006 to 2011. Data on self-reported diabetes were based on physicians' past diagnosis. Random plasma glucose was obtained during the screenings. Non-fasting plasma glucose levels of ≥180mg/dl and ≥140mg/dl were used as cutoffs to determine diabetes and diabetes or pre-diabetes, respectively. Logistic regression was used to examine factors associated with self-reported diabetes and elevated non-fasting glucose levels controlling for comorbidities and sociodemographic factors.

RESULTS

The proportion of self-reported diabetes was 9.6%. The proportion of participants with ≥180mg/dl was 3.2% and that with ≥140mg/dl was 7.4%. Odds ratios indicated that self-reported diabetes was higher in older and obese groups and those who had hypertension and hypercholesterolemia and family history of diabetes, while elevated non-fasting glucose levels were higher among participants without health insurance and those who reported they had diabetes.

CONCLUSIONS

Variability in risks between self-reported diabetes and measured glucose should be incorporated in diabetes self-care.

Medication adherence in patients with type 2 diabetes mellitus treated at primary health clinics in Malaysia

PURPOSE

Diabetes mellitus is a growing global health problem that affects patients of all ages. Even though diabetes mellitus is recognized as a major chronic illness, adherence to antidiabetic medicines has often been found to be unsatisfactory. This study was conducted to assess adherence to medications and to identify factors that are associated with nonadherence in type 2 diabetes mellitus (T2DM) patients at Primary Health Clinics of the Ministry of Health in Malaysia.

MATERIALS AND METHODS

The cross-sectional survey was carried out among T2DM patients to assess adherence to medication in primary health clinics. Adherence was measured by using the Medication Compliance Questionnaire that consists of a total of seven questions. Other data, such as patient demographics, treatment, outcome, and comorbidities were also collected from patient medical records.

RESULTS

A total of 557 patients were recruited in the study. Approximately 53% of patients in the study population were nonadherent. Logistic regression analysis was performed to predict the factors associated with nonadherence. Variables associated with nonadherence were age, odds ratio 0.967 (95% confidence interval [CI]: 0.948-0.986); medication knowledge, odds ratio 0.965 (95% CI: 0.946-0.984); and comorbidities, odds ratio 1.781 (95% CI: 1.064-2.981).

CONCLUSION

Adherence to medication in T2DM patients in the primary health clinics was found to be poor. This is a cause of concern, because nonadherence could lead to a worsening of disease. Improving medication knowledge by paying particular attention to different age groups and patients with comorbidities could help improve adherence.

Glucan-rich polysaccharides from Pleurotus sajor-caju (Fr.) Singer prevents glucose intolerance, insulin resistance and inflammation in C57BL/6J mice fed a high-fat diet

Background

Pleurotus sajor-caju (P. sajor-caju) has been extremely useful in the prevention of diabetes mellitus due to its low fat and high soluble fiber content for thousands of years. Insulin resistance is a key component in the development of diabetes mellitus which is caused by inflammation. In this study, we aimed to investigate the in vivo efficacy of glucan-rich polysaccharide of P. sajor-caju (GE) against diabetes mellitus and inflammation in C57BL/6J mice fed a high-fat diet.

Methods

Diabetes was induced in C57BL/6J mice by feeding a high-fat diet. The mice were randomly assigned to 7 groups (n=6 per group). The control groups in this study were ND (for normal diet) and HFD (for high-fat diet). The treated groups were ND240 (for normal diet) (240 mg/kg b.w) and HFD60, HFD120 and HFD240 (for high-fat), where the mice were administrated with three dosages of GE (60, 120, 240 mg GE/kg b.w respectively). Metformin (2 mg/kg b.w) served as positive control. The glucose tolerance test, glucose and insulin levels were measured at the end of 16 weeks. Expressions of genes for inflammatory markers, GLUT-4 and adiponectin in the adipose tissue of the mice were assessed. One-way ANOVA and Duncan’s multiple range tests (DMRT) were used to determine the significant differences between groups.

Results

GE treated groups improved the glucose tolerance, attenuated hyperglycemia and hyperinsulinemia in the mice by up-regulating the adiponectin and GLUT-4 gene expressions. The mice in GE treated groups did not develop insulin resistance. GE also down-regulated the expression of inflammatory markers (IL-6, TNF-α, SAA2, CRP and MCP-1) via attenuation of nuclear transcription factors (NF-κB).

Conclusion

Glucan-rich polysaccharide of P. sajor-caju can serve as a potential agent for prevention of glucose intolerance, insulin resistance and inflammation.

Towards creating a superstimulus to normalise glucose metabolism in the prediabetic: a case-study in the feast-famine and activity-rest cycle

We live in a time of plenty. During evolution, periods of hunger and simultaneously high activity levels would combine giving a stimulus which is absent from modern lifestyles. This is potentially connected with abnormal glucose metabolism. It was hypothesised that simultaneous fasting and aggressive aerobic neuromuscular electrical stimulation (NMES) exercise, until metabolic exhaustion, may be an acceptable modern equivalent. A healthy subject fasted for 44 h (water allowed) during which he undertook three aerobic NMES sessions at >50%VO(2max); heart rate >160 bpm. Metabolic gas analysis of a comparable session in the non-fasting state showed 100% carbohydrate substrate utilisation. With fasting the NMES exercise consumed mostly fat-up to 100% fat utilisation at 42 h. This clear shift away from using carbohydrate as a substrate and hypoglycaemia may indicate that carbohydrate stores are nearly depleted. The authors postulate that this may constitute a metabolic super stimulus mimicking the famine-activity periods of our ancestors.

Treatment of diabetic vasculopathy with rosiglitazone and ramipril: Hype or hope?

Cardiovascular diseases are responsible for increased morbidity and mortality in people with diabetes. Diabetic macrovasculopathy is associated with structural and functional changes in large arteries, which causes endothelial dysfunction, increased arterial stiffness, or decreased arterial distensability. Diabetic complications can be controlled and avoided by strict glycemic control, maintaining normal lipid profiles, regular physical exercise, adopting a healthy lifestyle and pharmacological interventions. Treatment goals for patients with type 2 diabetes specify targets for glycemia and other cardiometabolic risk factors, for example, hypertension and dyslipidemia. In recent years, special attention has been devoted to both thiazolidindiones (TZDs) and angiotensin converting enzyme (ACE) inhibitors as clinical trials revealed that these drugs may reduce the rate of progression to diabetes or delay the onset of diabetes, regression of impaired glucose tolerance (IGT) to normoglycemia and reduces the composite of all-cause mortality, nonfatal myocardial infarction and stroke in patients with diabetes. This review focuses on the potential roles of rosiglitazone, a member of TZD class of antidiabetic agents, and ramipril, an ACE inhibitor, in preventing the preclinical macrovasculopathy in diabetes and IGT population.

Reduction of diabetes risk in routine clinical practice: are physical activity and nutrition interventions feasible and are the outcomes from reference trials replicable? A systematic review and meta-analysis

Background

The clinical effectiveness of intensive lifestyle interventions in preventing or delaying diabetes in people at high risk has been established from randomised trials of structured, intensive interventions conducted in several countries over the past two decades. The challenge is to translate them into routine clinical settings. The objective of this review is to determine whether lifestyle interventions delivered to high-risk adult patients in routine clinical care settings are feasible and effective in achieving reductions in risk factors for diabetes.

Methods

Data sources: MEDLINE (PubMed), EMBASE, CINAHL, The Cochrane Library, Google Scholar, and grey literature were searched for English-language articles published from January 1990 to August 2009. The reference lists of all articles collected were checked to ensure that no relevant suitable studies were missed. Study selection: We included RCTs, before/after evaluations, cohort studies with or without a control group and interrupted time series analyses of lifestyle interventions with the stated aim of diabetes risk reduction or diabetes prevention, conducted in routine clinical settings and delivered by healthcare providers such as family physicians, practice nurses, allied health personnel, or other healthcare staff associated with a health service. Outcomes of interest were weight loss, reduction in waist circumference, improvement of impaired fasting glucose or oral glucose tolerance test (OGTT) results, improvements in fat and fibre intakes, increased level of engagement in physical activity and reduction in diabetes incidence.

Results

Twelve from 41 potentially relevant studies were included in the review. Four studies were suitable for meta-analysis. A significant positive effect of the interventions on weight was reported by all study types. The meta-analysis showed that lifestyle interventions achieved weight and waist circumference reductions after one year. However, no clear effects on biochemical or clinical parameters were observed, possibly due to short follow-up periods or lack of power of the studies meta-analysed. Changes in dietary parameters or physical activity were generally not reported. Most studies assessing feasibility were supportive of implementation of lifestyle interventions in routine clinical care.

Conclusion

Lifestyle interventions for patients at high risk of diabetes, delivered by a variety of healthcare providers in routine clinical settings, are feasible but appear to be of limited clinical benefit one year after intervention. Despite convincing evidence from structured intensive trials, this systematic review showed that translation into routine practice has less effect on diabetes risk reduction.

Description of an academic community partnership lifestyle program for lower income minority adults at risk for diabetes

PURPOSE

Translating strategies and approaches from the successful clinically based Diabetes Prevention Program's lifestyle intervention to community settings is a key next step. This article describes a lifestyle program developed in partnership by researchers at a major university and public health professionals at a local health department.

METHODS

The Live Well, Be Well (LWBW) program was designed to meet the needs of lower income, minority, and low-literacy adults at risk for diabetes. It was adapted from interventions with demonstrated efficacy and delivered in Spanish and English by health department staff. The program consisted of a 6-month active phase and a 6-month maintenance phase and was primarily telephone based, with one in-person planning session and several group workshops. In-person and group sessions were held in convenient community-based settings. Counselors provided education and skills training to modify diet and increase physical activity. Self-selected and attainable goal-setting and action plans were emphasized to enhance self-efficacy. LWBW is the intervention component of a randomized trial with primary outcomes of fasting glucose, weight, and other clinical measures.

CONCLUSIONS

The program provides a unique translational model for implementing diabetes risk reduction programs for underserved populations. Individually tailored and nonprescriptive, it utilized existing health department infrastructure, focused on telephone counseling, used culturally appropriate, low-literacy materials, and was delivered in local, community-based facilities.

Metabolic network topology reveals transcriptional regulatory signatures of type 2 diabetes

Type 2 diabetes mellitus (T2DM) is a disorder characterized by both insulin resistance and impaired insulin secretion. Recent transcriptomics studies related to T2DM have revealed changes in expression of a large number of metabolic genes in a variety of tissues. Identification of the molecular mechanisms underlying these transcriptional changes and their impact on the cellular metabolic phenotype is a challenging task due to the complexity of transcriptional regulation and the highly interconnected nature of the metabolic network. In this study we integrate skeletal muscle gene expression datasets with human metabolic network reconstructions to identify key metabolic regulatory features of T2DM. These features include reporter metabolites—metabolites with significant collective transcriptional response in the associated enzyme-coding genes, and transcription factors with significant enrichment of binding sites in the promoter regions of these genes. In addition to metabolites from TCA cycle, oxidative phosphorylation, and lipid metabolism (known to be associated with T2DM), we identified several reporter metabolites representing novel biomarker candidates. For example, the highly connected metabolites NAD+/NADH and ATP/ADP were also identified as reporter metabolites that are potentially contributing to the widespread gene expression changes observed in T2DM. An algorithm based on the analysis of the promoter regions of the genes associated with reporter metabolites revealed a transcription factor regulatory network connecting several parts of metabolism. The identified transcription factors include members of the CREB, NRF1 and PPAR family, among others, and represent regulatory targets for further experimental analysis. Overall, our results provide a holistic picture of key metabolic and regulatory nodes potentially involved in the pathogenesis of T2DM.

Type 2 diabetes mellitus is a complex metabolic disease recognized as one of the main threats to human health in the 21^st century. Recent studies of gene expression levels in human tissue samples have indicated that multiple metabolic pathways are dysregulated in diabetes and in individuals at risk for diabetes; which of these are primary, or central to disease pathogenesis, remains a key question. Cellular metabolic networks are highly interconnected and often tightly regulated; any perturbations at a single node can thus rapidly diffuse to the rest of the network. Such complexity presents a considerable challenge in pinpointing key molecular mechanisms and biomarkers associated with insulin resistance and type 2 diabetes. In this study, we address this problem by using a methodology that integrates gene expression data with the human cellular metabolic network. We demonstrate our approach by analyzing gene expression patterns in skeletal muscle. The analysis identified transcription factors and metabolites that represent potential targets for therapeutic agents and future clinical diagnostics for type 2 diabetes and impaired glucose metabolism. In a broader perspective, the study provides a framework for analysis of gene expression datasets from complex diseases in the context of changes in cellular metabolism.

Nurse-led motivational interviewing to change the lifestyle of patients with type 2 diabetes (MILD-project): protocol for a cluster, randomized, controlled trial on implementing lifestyle recommendations

Background

The diabetes of many patients is managed in general practice; healthcare providers aim to promote healthful behaviors, such as healthful diet, adequate physical activity, and smoking cessation. These measures may decrease insulin resistance, improve glycemic control, lipid abnormalities, and hypertension. They may also prevent cardiovascular disease and complications of diabetes. However, professionals do not adhere optimally to guidelines for lifestyle counseling. Motivational interviewing to change the lifestyle of patients with type 2 diabetes is intended to improve diabetes care in accordance with the national guidelines for lifestyle counseling. Primary care nurses will be trained in motivational interviewing embedded in structured care in general practice. The aim of this paper is to describe the design and methods of a study evaluating the effects of the nurses' training on patient outcomes.

Methods/Design

A cluster, randomized, controlled trial involving 70 general practices (35 practices in the intervention arm and 35 in the control arm) starting in March 2007. A total of 700 patients with type 2 diabetes will be recruited. The patients in the intervention arm will receive care from the primary care nurse, who will receive training in an implementation strategy with motivational interviewing as the core component. Other components of this strategy will be adaptation of the diabetes protocol to local circumstances, introduction of a social map for lifestyle support, and educational and supportive tools for sustaining motivational interviewing. The control arm will be encouraged to maintain usual care. The effect measures will be the care process, metabolic parameters (glycosylated hemoglobin, blood pressure and lipids), lifestyle (diet, physical activity, smoking, and alcohol), health-related quality of life, and patients' willingness to change behaviors. The measurements will take place at baseline and after 14 months.

Discussion

Applying motivational interviewing for patients with diabetes in primary care has been studied, but to our knowledge, no other study has yet evaluated the implementation and sustainability of motivating and involving patients in day-to-day diabetes care in general practice. If this intervention proves to be effective and cost-effective, large-scale implementation of this nurse-oriented intervention will be considered and anticipated.

Trial registration

Current Controlled Trials ISRCTN68707773.

An integrative literature review of lifestyle interventions for the prevention of type II diabetes mellitus

AIMS AND OBJECTIVES

An integrative literature review was undertaken to determine what type II diabetes prevention programmes have been evaluated, what type of programme is the most effective and how adherent to lifestyle changes adults are after participating in a prevention programme.

BACKGROUND

Type II diabetes is important because the disease is affecting millions of people worldwide. Obesity and sedentary lifestyles are preventable risk factors for type II diabetes, leading many researchers from around the world to examine different programmes that are focussed on prevention of the disease.

DESIGN

Integrative literature review.

METHOD

Search of electronic databases.

RESULTS

Diet, exercise, counselling and diet plus exercise were the types of prevention programmes, with the diet plus exercise being the most efficacious. Although many studies demonstrated excellent results initially, maintaining the effects of the lifestyle behaviour change proved to be difficult for participants, with only one study demonstrating the persistence of results after six years.

CONCLUSION

Future research should focus on long-term maintenance programmes, rather than just short-term prevention programmes to determine the need for booster interventions or other means to ultimately decrease the incidence of type II diabetes.

RELEVANCE TO CLINICAL PRACTICE

As front-line healthcare providers working across a broad array of settings, nurses are particularly well-suited to play an integral part in future applications of diabetes prevention programmes. Lifestyle interventions are being delivered in a variety of settings and venues such as the workplace, the Internet and places of worship. In addition, at-risk populations also can be targeted, particularly overweight and obese persons, with at least one parent having type II diabetes or persons with gestational diabetes.

Dietary advice for the prevention of type 2 diabetes mellitus in adults

BACKGROUND

Prevention of type 2 diabetes in adults is a far better option than treatment, to alleviate pressure on health care providers and resources. However, there is no current review of the evidence regarding the efficacy of a diet-only intervention for prevention.

OBJECTIVES

To assess the effects of type and frequency of dietary advice for the prevention of type 2 diabetes mellitus.

SEARCH STRATEGY

We carried out a comprehensive search of The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, bibliographies and contacted relevant experts.

SELECTION CRITERIA

All randomised controlled trials, of twelve months or longer, in which dietary advice for the prevention of type 2 diabetes was the only intervention in adults.

DATA COLLECTION AND ANALYSIS

The lead investigator performed all data extraction and quality scoring with duplication being carried out by one of the other four investigators independently with discrepancies resolved by discussion and consensus. Authors were contacted for missing data. Change data are presented.

MAIN RESULTS

Two trials which randomised 358 people to dietary treatment and control groups were identified. Longest duration of follow-up was six years. In the 6-year Da Qing IGT & Diabetes study, the incidence of type 2 diabetes in the control group was 67.7% (95% confidence interval (CI) 59.8% to 75.2%) which was reduced to 43.8% (95% CI 35.5% to 54.7%) in the diet group. Overall, the dietary intervention group had a 33% reduction in the incidence of diabetes after six years (P < 0.03). The Oslo Diet & Exercise Study (ODES) found significant (P<0.05) reductions in insulin resistance, fasting insulin (pmol/L), fasting C-peptide (pmol/L), fasting proinsulin (pmol/L), fasting blood glucose (mmol/L), BMI (kg/m(2)), mBP (mmHg) and fasting triglycerides (mmol/L), and a significant increase in fasting HDL cholesterol (mmol/L) and PAI-1 (U/ml) after 12 months of dietary intervention. Data on mortality, morbidity, health-related quality of life, adverse effects, costs were not reported in either study.

AUTHORS' CONCLUSIONS

There are no high quality data on the efficacy of dietary intervention for the prevention of type 2 diabetes. More well-designed, long-term studies, providing well-reported, high-quality data are required before proper conclusions can be made into the best dietary advice for the prevention of diabetes mellitus in adults.

Pharmacological intervention in prediabetes: considering the risks and benefits

The impact of the diabetes epidemic will be staggering in terms of costs to individuals and society. Social educational initiatives are imperative to altering the lifestyle trends that drive the growth of the epidemic. Targeted lifestyle or drug interventions aimed at preventing progression from prediabetes to type 2 diabetes mellitus carry costs and risks that need to be considered in the context of expected benefits, which also need to be carefully defined. In terms of pharmacological intervention as part of a primary prevention programme, the risk/benefit assessment must include the potential for adverse effects in a large population of asymptomatic individuals, a significant proportion of whom would not progress to diabetes in the absence of treatment and in whom impaired glucose regulation may reflect different underlying pathogenetic mechanisms. Improving the balance of risks and benefits in drug interventions will require a greater ability to determine which treatments are likely to safely improve glucose regulation and prevent diabetes and its adverse cardiovascular outcomes in individual patients.

Soluble CD40 ligand levels in otherwise healthy subjects with impaired fasting glucose

Unlike diabetes mellitus and impaired glucose tolerance, it is not clear whether the subjects with impaired fasting glucose (IFG) are at increased risk of atherosclerosis and cardiovascular diseases. The CD40-CD40 ligand interaction is involved in the mechanism of atherosclerosis. We investigated whether soluble CD40L (sCD40L) as well as high sensitive C-reactive protein (hsCRP) levels are increased in subjects with IFG having no confounding factors for inflammation or atherosclerosis. Twenty four IFG subjects with no additional disorders and 40 appropriate healthy controls were studied. sCD40L and hsCRP levels in the IFG and control groups were similar. Blood pressures, total and LDL-cholesterol, and triglyceride levels were also similar, whereas HDL-cholesterol was lower and HOMA-IR indexes were higher in the IFG group. Though the sample size was small, the present data show that sCD40L seems not to alter in subjects with IFG suggesting that it might not be an independent risk factor for atherosclerosis.

Metformin-like effect of Salvia officinalis (common sage): is it useful in diabetes prevention?

Common sage (Salvia officinalis L.) is among the plants that are claimed to be beneficial to diabetic patients, and previous studies have suggested that some of its extracts have hypoglycaemic effects in normal and diabetic animals. In the present study, we aimed to verify the antidiabetic effects of an infusion (tea) of common sage, which is the most common form of this plant consumed. Replacing water with sage tea for 14d lowered the fasting plasma glucose level in normal mice but had no effect on glucose clearance in response to an intraperitoneal glucose tolerance test. This indicated effects on gluconeogenesis at the level of the liver. Primary cultures of hepatocytes from healthy, sage-tea-drinking rats showed, after stimulation, a high glucose uptake capacity and decreased gluconeogenesis in response to glucagon. Essential oil from sage further increased hepatocyte sensitivity to insulin and inhibited gluconeogenesis. Overall, these effects resemble those of the pharmaceutical drug metformin, a known inhibitor of gluconeogenesis used in the treatment and prevention of type 2 diabetes mellitus. In primary cultures of rat hepatocytes isolated from streptozotocin (STZ)-induced diabetic rats, none of these activities was observed. The present results seem to indicate that sage tea does not possess antidiabetic effects at this level. However, its effects on fasting glucose levels in normal animals and its metformin-like effects on rat hepatocytes suggest that sage may be useful as a food supplement in the prevention of type 2 diabetes mellitus by lowering the plasma glucose of individuals at risk.

Closing the gap between clinical research and clinical practice: can outcome studies with thiazolidinediones improve our understanding of type 2 diabetes?

Recent clinical research has provided a wealth of information to support optimal management strategies in type 2 diabetes mellitus (T2DM). In particular, outcome studies appropriately have had an increasingly important impact on clinical decision-making. Additional, new data are required, however, to close the current gaps in clinical knowledge and improve patient outcomes in T2DM. These outcome studies are particularly important in assessing the long-term benefit of newer agents for which data are available for short-term glycaemic control, effects on lipids and some data on non-traditional cardiovascular risk markers, but outcome data for harder end points relevant to the natural history of T2DM, particularly beta-cell function, are lacking. Outcome studies such as ADOPT and DREAM are investigating the impact of thiazolidinediones (TZDs) on beta-cell function and disease progression in T2DM and impaired glucose tolerance, respectively, the results of which are eagerly anticipated. The primary focus of this article is on TZD outcome studies evaluating beta-cell function and disease progression.

Inhibition of recombinant human maltase glucoamylase by salacinol and derivatives

Inhibitors targeting pancreatic alpha-amylase and intestinal alpha-glucosidases delay glucose production following digestion and are currently used in the treatment of Type II diabetes. Maltase-glucoamylase (MGA), a family 31 glycoside hydrolase, is an alpha-glucosidase anchored in the membrane of small intestinal epithelial cells responsible for the final step of mammalian starch digestion leading to the release of glucose. This paper reports the production and purification of active human recombinant MGA amino terminal catalytic domain (MGAnt) from two different eukaryotic cell culture systems. MGAnt overexpressed in Drosophila cells was of quality and quantity suitable for kinetic and inhibition studies as well as future structural studies. Inhibition of MGAnt was tested with a group of prospective alpha-glucosidase inhibitors modeled after salacinol, a naturally occurring alpha-glucosidase inhibitor, and acarbose, a currently prescribed antidiabetic agent. Four synthetic inhibitors that bind and inhibit MGAnt activity better than acarbose, and at comparable levels to salacinol, were found. The inhibitors are derivatives of salacinol that contain either a selenium atom in place of sulfur in the five-membered ring, or a longer polyhydroxylated, sulfated chain than salacinol. Six-membered ring derivatives of salacinol and compounds modeled after miglitol were much less effective as MGAnt inhibitors. These results provide information on the inhibitory profile of MGAnt that will guide the development of new compounds having antidiabetic activity.

Low rates of exercise in patients with metabolic syndrome after an acute coronary syndrome

BACKGROUND

Metabolic syndrome (MetSyn) has reached epidemic proportions; however, regular exercise can prevent its progression to type 2 diabetes.

HYPOTHESIS

The study was undertaken to determine both the rate and predictors of routine exercise 1 year after an acute coronary syndrome (ACS) in patients with MetSyn.

METHODS

In a registry of 1,199 patients presenting with ACS, those with MetSyn were identified using the modified NCEP-ATP III criteria. Baseline and 1-year exercise patterns were examined in these patients, and the characteristics of those who were exercising were then compared with those who were not. A multivariable logistic regression analysis was subsequently conducted to identify independent predictors of exercise at 1 year.

RESULTS

Of 273 patients with MetSyn, baseline and 1-year data about patients' exercise patterns were available for 170, of whom only 92 (54.2%) were exercising at 1 year. Characteristics that differed between those who were and those who were not exercising at 1 year included exercise at baseline (40 vs. 16.7%, p<0.001), Caucasian race (92.4 vs. 79.5%, p = 0.01), and body mass index (BMI) (30.4 +/- 4.3 vs. 32.1 +/- 5.0, p = 0.02). In a multivariable analysis, significant independent predictors of exercise were routine exercise at the time of admission for ACS (odds ratio [OR] = 2.6,95% confidence interval [CI] = 1.1-6.4), younger age (OR = 0.67 per 10-year increase [95% CI = 0.45-0.99]), and lower BMI (OR = 0.4 per 10-unit increase [95% CI = 0.17-0.911).

CONCLUSIONS

Almost half of patients with MetSyn did not participate in routine exercise 1 year after their admission for ACS. Innovative strategies are needed to increase exercise participation in such patients, particularly those not exercising at baseline as well as obese and older patients.

Nanoscale analysis of protein and peptide absorption: insulin absorption using complexation and pH-sensitive hydrogels as delivery vehicles

Recent advances in the discovery and delivery of drugs to cure chronic diseases are achieved by combination of intelligent material design with advances in nanotechnology. Since many drugs act as protagonists or antagonists to different chemicals in the body, a delivery system that can respond to the concentrations of certain molecules in the body is invaluable. For this purpose, intelligent therapeutics or "smart drug delivery" calls for the design of the newest generation of sensitive materials based on molecular recognition. Biomimetic polymeric networks can be prepared by designing interactions between the building blocks of biocompatible networks and the desired specific ligands and by stabilizing these interactions by a three-dimensional structure. These structures are at the same time flexible enough to allow for diffusion of solvent and ligand into and out of the networks. Synthetic networks that can be designed to recognize and bind biologically significant molecules are of great importance and influence a number of emerging technologies. These synthetic materials can be used as unique systems or incorporated into existing drug delivery technologies that can aid in the removal or delivery of biomolecules and restore the natural profiles of compounds in the body.

Risk constellations in patients with the metabolic syndrome: epidemiology, diagnosis, and treatment patterns

The prevalence of diabetes mellitus is increasing worldwide. Among other complications, diabetes is associated with the risk of coronary heart disease (CHD) that is thought to be equal to the risk of CHD in subjects without diabetes with previous myocardial infarction. Studies have shown that CHD risk factors start to increase long before the onset of clinical diabetes. Furthermore, the risk factors that are present in prediabetic individuals are also components of the highly prevalent metabolic syndrome. This suggests that treatment of CHD risk factors may effectively reduce the incidence of type 2 diabetes. Lifestyle interventions have proved effective in preventing the onset of type 2 diabetes in subjects with impaired glucose tolerance. A number of post hoc studies have reported consistent reductions in the incidence of type 2 diabetes in hypertensive patients treated with either angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). As a result of these positive data, ongoing prospective studies are investigating whether antihypertensive agents prevent or delay the onset of diabetes in patients at risk. Telmisartan, a selective oral ARB that is indicated for first-line therapy of essential hypertension, may provide improved tolerability compared with ACE inhibitors. Therefore, the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) program is investigating the effectiveness of telmisartan in the prevention or delay of type 2 diabetes. The program comprises ONTARGET and the Telmisartan Randomized Assessment Study in ACE-Intolerant Subjects with Cardiovascular Disease (TRANSCEND).

Antihyperglycaemic and Antioxidant Effect of Rutin, a Polyphenolic Flavonoid, in Streptozotocin-Induced Diabetic Wistar Rats

Flavonoids are non-nutritive dietary components that are widely distributed in plants. The present study investigated the antihyperglycaemic and antioxidant effect of rutin, a polyphenolic flavonoid in normal and streptozotocin-induced diabetic Wistar rats. Diabetes as induced in rats by an intraperitoneal injection of streptozotocin. Rutin was orally administered to normal and diabetic rats for a period of 45 days. Fasting plasma glucose, glycosylated haemoglobin, thiobarbituric acid reactive substances and lipid hydroperoxides were significantly (P<0.05) increased, whereas insulin, C-peptide, total haemoglobin, protein levels, non-enzymic antioxidants (glutathione, vitamin C, vitamin E and ceruloplasmin) were decreased significantly (P<0.05) in diabetic rats. Oral administration of rutin to diabetic rats significantly (P<0.05) decreased fasting plasma glucose, glycosylated haemoglobin and increased insulin, C-peptide, haemoglobin and protein levels. Administration of rutin also decreased thiobarbituric acid reactive substances and lipid hydroperoxides and increased the non-enzymic antioxidants significantly (P<0.05). Treatment of normal rats with rutin did not significantly (P<0.05) alter any of the parameters studied. These results show that rutin exhibits antihyperglycaemic and antioxidant activity in streptozotocin-induced diabetic rats.

Energy restriction prevents the development of type 2 diabetes in Zucker diabetic fatty rats: coordinated patterns of gene expression for energy metabolism in insulin-sensitive tissues and pancreatic islets determined by oligonucleotide microarray analysis

Energy restriction (ER) causes metabolic improvement in the prediabetic and diabetic state. Little information exists on the mechanism of action of ER, for example, on the changes at the transcriptional gene level in insulin-sensitive tissues. To gain further insight, we have investigated changes in gene expressions in skeletal muscle, liver, fat, and pancreatic islets after ER in male Zucker diabetic fatty rats. Eighteen Zucker diabetic fatty rats were divided at the age of 7 weeks into a control group (ad libitum diet) and an ER group (30% ER compared with the control group). Blood glucose, weight, and food intake were measured weekly. After 5 weeks, blood samples, and skeletal muscle, liver, visceral fat (epididymal fat pads), and islets tissue were collected. Gene expression was quantified with high-density oligonucleotide, microarray GeneChip technology. ER ameliorated the development of hyperglycemia, increased the levels of plasma insulin, and reduced plasma total cholesterol and the glucagon-insulin ratio (P < .05). In skeletal muscle, the expression of 55 genes increased and 245 decreased involving genes related to glucose metabolism (eg, phosphorylase kinase, pyruvate dehydrogenase kinase 4), lipid metabolism (eg, carnitine palmitoyltransferase 1, fatty acid transporter), and signaling pathways (eg, mitogen-activated protein kinases, protein kinase C). In the liver, the expression of 123 genes increased and 103 decreased involving genes related primarily to lipid metabolism. In pancreatic islets, the expression of 110 genes increased and that of 127 decreased, whereas in visceral fat, the expression of 279 genes increased and that of 528 decreased. ER counteracts the development of diabetes and causes changes in the expression of multiple genes involved in glucose and lipid metabolism in skeletal muscle, liver, and pancreatic islets, which may play an important role for the prevention of diabetes.

The prevention of type 2 diabetes mellitus

With a worldwide pandemic of type 2 diabetes upon us, it is imperative that effective and practical preventive strategies be developed for this disease which, once established, carries with it excess morbidity and mortality. This article reviews recently published data on the prevention of type 2 diabetes and compares the demonstrated effectiveness of each strategy, including lifestyle modification and several pharmacologic agents. Although much new information is available, many translational questions remain that chiefly concern the generalizability and applicability of these programs to clinical practice. Recent diabetes prevention guidelines are discussed, and a practical framework for their implementation is presented.

Ambulatory blood pressure reduction after rosiglitazone treatment in patients with type 2 diabetes and hypertension correlates with insulin sensitivity increase

BACKGROUND

Within the metabolic syndrome, insulin resistance and compensatory hyperinsulinemia are associated with blood pressure (BP) elevation through various potential mechanisms. Thiazolidinediones are antihyperglycemic agents that decrease insulin resistance.

OBJECTIVE

To determine the effect of the thiazolidinedione rosiglitazone on BP and insulin resistance in patients with type 2 diabetes and hypertension.

METHODS

In 20 subjects (nine men and 11 women) with type 2 diabetes but with a poor glycemic control, and with poorly controlled or newly diagnosed hypertension, rosiglitazone 4 mg daily was added-on therapy for 26 weeks. At baseline and at the end of the treatment period patients underwent ambulatory blood pressure monitoring, a hyperinsulinemic euglycemic clamp, and blood tests for glucose, insulin, HbA1c, lipids, and routine laboratory parameters.

RESULTS

Insulin sensitivity estimated with the clamp significantly increased (Mbw/I index changed from 33.9 +/- 2.6 to 41.9 +/- 3.2 micromol/min per kg per nmol/l, P < 0.001) and the HOMA-IR index significantly decreased (6.34 +/- 0.39 versus 4.40 +/- 0.33, P < 0.001) during rosiglitazone treatment. Ambulatory BP presented small but significant reductions for the total 24-h period (135.3 +/- 1.8 versus 129.9 +/- 1.7 mmHg, P < 0.001 for systolic BP and 76.0 +/- 1.6 versus 71.9 +/- 1.6 mmHg, P < 0.001 for diastolic BP), daytime and night-time. The changes in systolic and diastolic BP correlated with the change in insulin sensitivity (r = -0.78, P < 0.01 and r = -0.68, P < 0.01, respectively). There were also significant reductions in fasting plasma glucose (9.39 +/- 0.41 versus 7.55 +/- 0.31 mmol/l, P < 0.001), insulin (94.0 +/- 0.41 versus 79.5 +/- 5.6 pmol/l, P < 0.01) and HbA1c (8.15 +/- 0.24 versus 7.24 +/- 0.19%, P < 0.001).

CONCLUSIONS

Treatment of type 2 diabetic hypertensive patients with rosiglitazone significantly increased insulin sensitivity and lowered ambulatory BP. These changes were strongly correlated. Thiazolidinediones may thus possess a BP-lowering effect beyond their antihyperglycemic properties.

Latin American consensus on diabetes mellitus and hypertension

Diabetes mellitus and hypertension, responsible of a major burden of cardiovascular complications, are increasing their incidence in Latin America in similar proportions to the rest of the world. The metabolic syndrome, a strong predictor of both diabetes and hypertension deserves more attention from the primary care physicians. Evidence based and updated guidelines on detection, prevention and treatment of diabetes and hypertension, issued by local experts, are willing to inform and translate these recommendations to the clinical practice of physicians assisting these patients throughout Latin America.

Postprandial hyperglycaemia in type 2 diabetes: pathophysiological aspects, teleological notions and flags for clinical practice

Type 2 diabetes subjects carry an excess risk for micro- and macrovascular disease and a higher cardiovascular morbidity and mortality rate. The beneficial impact of tight glycaemic control-evidenced by the integrated marker of fasting glucose and postprandial glucose values, the HbA1c-for the prevention of microvascular complications is definitely confirmed. Over the past few years, several studies have identified postprandial hyperglycaemia as a better predictor of cardiovascular or even of all-cause mortality, as well as an independent risk factor for atherosclerosis. The continuous glucose monitoring could offer a rationale means for the detection of postprandial hyperglycaemia and ultimately for its effective management. Advances in technology keep a promise for a reliable, convenient and closer to the idea of the artificial endocrine pancreas glucose sensor. Subcutaneous glucose levels charted by one of the new sensors were found to be well correlated with venous glucose measurements. Intervention for a healthy lifestyle is frequently hampered by patients' poor compliance. The availability of diverse antidiabetic agents provides options for targeting the glycaemic goal and a choice more fitted to the particularized pathophysiology of each individual subject. Drugs targeting postprandial glycaemia may prove to represent the 'sine qua non' for the 'return' of postprandial glucose values at a 'non-deleterious' threshold, either as monotherapy for the early stages of the disease or as combination therapy later in the progression of diabetes.

The effects of dietary caloric restriction on antioxidant status and lipid peroxidation in mild and severe streptozotocin-induced diabetic rats

BACKGROUND

Dietary caloric restriction (CR) without malnutrition is effective in the control of diabetes mellitus by stabilizing glucose homeostasis and enhancing glycemic control. Mild and severe streptozotocin-induced diabetic and non-diabetic rats were subjected to caloric restriction and ad libitum feeding to evaluate their effects on oxidative stress and lipid profile in the plasma of experimental animals.

METHODS

Mild and severe diabetes were induced in Male Wistar rats by intraperitoneal injection of 35 and 65 mg/kg streptozotocin respectively. The experimental animals were subjected to 40% caloric restriction and ad libitum feeding for 9 weeks.

RESULTS

CR was effective in significantly reducing body weight, blood glucose, HbA IC and TG concentrations (all p < 0.001) in mild diabetic rats and non-significantly improving the plasma HDL-cholesterol concentrations. However, CR did not produce any significant effect on the antioxidant enzyme activities and MDA concentrations in all the groups nor in any of the parameters measured in non-diabetic rats except their overall weight change. There were significant (p < 0.001) decreases in body weight and non-significant fluctuating results in HbA IC and HDL-cholesterol in severe diabetic animals.

CONCLUSIONS

These results demonstrate that caloric restriction is most effective in mild than in non-diabetic or severe diabetic animals.

Thiazolidinedione therapy in the prevention/delay of type 2 diabetes in patients with impaired glucose tolerance and insulin resistance

AIM

The second-generation thiazolidinediones (TZDs), rosiglitazone and pioglitazone, significantly decrease fasting plasma glucose and glycosylated haemoglobin (HbA(1c)) levels in patients with diabetes. Recent studies suggest that early treatment with TZDs may prevent the progression from insulin resistance (IR) to type 2 diabetes mellitus (T2DM). This prospective analysis examined the effect of early TZD treatment in the prevention or delay of T2DM in a multiethnic population with impaired glucose tolerance (IGT) and IR.

METHODS

The analysis included 172 patients (aged 29-86 years) with IGT and IR (normal or borderline HbA(1c), C-peptide levels > 2 mg/ml, fasting blood sugar 100-125 mg/dl, and 2-h postprandial blood glucose levels 140-200 mg/dl). Patients in the active treatment group (n = 101) had received troglitazone for an average of 10 months before being randomly switched to rosiglitazone (4 mg/day) or pioglitazone (30 mg/day). Patients were switched when troglitazone was withdrawn from the US market because of liver toxicity concerns. Patients with IGT and IR who received no antidiabetic medication served as a control group (n = 71). HbA(1c) and C-peptide levels were measured at baseline (2 years) and study end point (3 years). Kaplan-Meier testing, using time to outcome as the main outcome variable, determined risk reduction in the TZD group relative to the control group.

RESULTS

Mean HbA(1c) and C-peptide levels decreased for patients receiving either TZD at the 2-year assessment, and reductions were maintained at study end point. After 2 years, none of the patients receiving TZD therapy progressed to T2DM; three patients progressed to T2DM by study end point. In the control group, 11 patients became diabetic after 2 years and 19 patients became diabetic by the end of the study. The incidence (risk reduction) of diabetes after 3 years was 88.9% lower in the TZD group compared with the control group (p < 0.001).

CONCLUSIONS

The TZDs, rosiglitazone and pioglitazone, were effective in reducing HbA(1c) and C-peptide levels in patients with IGT/IR. Progression of IR/IGT to T2DM appears to be significantly delayed or prevented with early TZD treatment.

The prevention of type 2 diabetes mellitus: recent advances

Diabetes is a major public health problem that is approaching epidemic proportions globally. There is an urgent need for strategies to curb the rising prevalence of this disease, and prevention appears a logical approach. Lifestyle modifications with weight loss and moderate exercise can reduce the incidence of diabetes by >50% in patients with impaired glucose tolerance (IGT). The use of metformin, acarbose and other agents have been shown in randomized prospective trials to prevent type 2 diabetes in high-risk subjects with IGT. Other pharmacological interventions are currently being examined in large prospective studies. It is likely that one or a combination of these approaches could make diabetes prevention a reality in the near future.

Schizophrenia and weight management: a systematic review of interventions to control weight

OBJECTIVE

Weight gain is a frequent side effect of antipsychotic medication which has serious implications for a patient's health and well being. This study systematically reviews the literature on the effectiveness of interventions designed to control weight gain in schizophrenia.

METHOD

A systematic search strategy was conducted of major databases in addition to citation searches. Study quality was rated.

RESULTS

Sixteen studies met the inclusion criteria. Five of eight pharmacological intervention studies reported small reductions in weight (<5% baseline body weight). All behavioural (including diet and/or exercise) interventions reported small reductions in, or maintenance of, weight.

CONCLUSION

Weight loss may be difficult but it is not impossible. Given the inconsistent results, the widespread use of pharmacological interventions cannot be recommended. Both dietary and exercise counselling set within a behavioural modification programme is necessary for sustained weight control.

What is important in treating osteoarthritis? Whom should we treat and how should we treat them?

Most of the treatments used today for OA have a relatively weak evidence base to support their use, and their effect size is small. Many key questions about OA management remain unanswered, in part because of the strong bias toward research on single pharmaceutical agents rather than nonpharmacologic interventions and a comprehensive package of care involving pharmacologic and nonpharmacologic measures. Good management of OA involves the coordination of several different types of interventions provided by health care professionals; however, while a great deal of research is available on the use of individual treatments, there is a lack of information on how health services for patients who have OA should be organized. The problem is compounded by the fact that many people who have OA use complementary therapy as well as, or instead of, allopathic treatments despite the fact that most of the evidence suggests that many such interventions are no better than placebo [123], which might be because of the relatively small effects of most conventional nonsurgical treatment for OA and to the need for a more holistic, individualized approach to treatment than most conventional health professionals usually provide. For many people who have OA, the fear of side effects is a major barrier to the use of pharmacologic interventions [11]. The authors believe that future research in OA therapeutics should concentrate more on behavioral and physical interventions than on drugs, should examine packages of care involving combinations of treatment modalities, and should include a consideration of patient preferences. The authors also believe that the academic community striving to provide help for people who have OA should bear in mind the concept that there is "too much medicine" [37].

Is there a role for alpha-glucosidase inhibitors in the prevention of type 2 diabetes mellitus?

Type 2 diabetes mellitus is a major health problem associated with excess morbidity and mortality. As the prevalence of this metabolic disorder is rapidly increasing and current treatment fails to stabilise the disease in most patients, prevention should be considered as a key objective in the near future. People who develop type 2 diabetes pass through a phase of impaired glucose tolerance (IGT). Defects in the action and/or secretion of insulin are the two major abnormalities leading to development of glucose intolerance. Any intervention in the impaired glucose tolerance phase that reduces resistance to insulin or protects the beta-cells, or both, should prevent or delay progression to diabetes.Acarbose, miglitol and voglibose act by competitively inhibiting the alpha-glucosidases, a group of key intestinal enzymes involved in the digestion of carbohydrates. They decrease both postprandial hyperglycaemia and hyperinsulinaemia, and thereby may improve sensitivity to insulin and release the stress on beta-cells. These compounds do not induce hypoglycaemia and have a good safety profile, although gastrointestinal adverse effects may limit long-term compliance to therapy. The recent placebo-controlled prospective STOP-noninsulin-dependent diabetes mellitus (STOP-NIDDM) trial demonstrated that acarbose 100mg three times daily reduces the risk of developing type 2 diabetes in patients with IGT (relative risk reduction of 25% after a mean follow-up of 3.3 years). The 6-year Early Diabetes Intervention Trial (EDIT), comparing the effect of acarbose 50mg three times daily to that of metformin, showed a trend to a positive effect of acarbose compared with placebo, in a mid-term 3-year analysis, which should be confirmed in the final analysis. To our knowledge, no such prevention intervention trials have been or are currently being performed with miglitol or voglibose. In conclusion, because of its absence of toxicity and its particular mechanism of action on gastrointestinal tract and indirect consequences on both insulin action and beta-cell function, acarbose may be used to prevent type 2 diabetes. If the ongoing EDIT trial confirms the positive results of the recent STOP-NIDDM trial, acarbose could be used, either as an alternative or in addition to changes in lifestyle, to delay development of diabetes in patients with IGT. However, the best dosage of acarbose for this specific indication remains to be specified, especially when all three important parameters, efficacy, tolerance and cost, are taken into consideration.