FINDRISK questionnaire combined with HbA1c testing as a potential screening strategy for undiagnosed diabetes in a healthy population

NMR derived changes of lipoprotein particle concentrations related to impaired fasting glucose, impaired glucose tolerance, or manifest type 2 diabetes mellitus

Background

Type 2 diabetes mellitus (T2D) and corresponding borderline states, impaired fasting glucose (IFG) and/or glucose tolerance (IGT), are associated with dyslipoproteinemia. It is important to distinguish between factors that cause T2D and that are the direct result of T2D.

Methods

The lipoprotein subclass patterns of blood donors with IFG, IGT, with IFG combined with IGT, and T2D are analyzed by nuclear magnetic resonance (NMR) spectroscopy. The development of lipoprotein patterns with time is investigated by using samples retained for an average period of 6 years. In total 595 blood donors are classified by oral glucose tolerance test (oGTT) and their glycosylated hemoglobin (HbA1c) concentrations. Concentrations of lipoprotein particles of 15 different subclasses are analyzed in the 10,921 NMR spectra recorded under fasting and non-fasting conditions. The subjects are assumed healthy according to the strict regulations for blood donors before performing the oGTT.

Results

Under fasting conditions manifest T2D exhibits a significant concentration increase of the smallest HDL particles (HDL A) combined with a decrease in all other HDL subclasses. In contrast to other studies reviewed in this paper, a general concentration decrease of all LDL particles is observed that is most prominent for the smallest LDL particles (LDL A). Under normal nutritional conditions a large, significant increase of the concentrations of VLDL and chylomicrons is observed for all groups with IFG and/or IGT and most prominently for manifest T2D. As we show it is possible to obtain an estimate of the concentrations of the apolipoproteins Apo-A1, Apo-B100, and Apo-B48 from the NMR data. In the actual study cohort, under fasting conditions the concentrations of the lipoproteins are not increased significantly in T2D, under non-fasting conditions only Apo-B48 increases significantly.

Conclusion

In contrast to other studies, in our cohort of “healthy” blood donors the T2D associated dyslipoproteinemia does not change the total concentrations of the lipoprotein particles produced in the liver under fasting and non-fasting conditions significantly but only their subclass distributions. Compared to the control group, under non-fasting conditions participants with IGT and IFG or T2D show a substantial increase of plasma concentrations of those lipoproteins that are produced in the intestinal tract. The intestinal insulin resistance becomes strongly observable.

Riesgo cardiovascular en pacientes con FINDRISC-C mayor o igual a 12

Introducción: la herramienta FINDRISC permite calcular el riesgo de desarrollar diabetes con punto de corte para Colombia de 12.  Existe evidencia de que el riesgo cardiovascular se incrementa a medida que lo hace el puntaje, pero en Colombia no existe información cuando es ≥ 12. Objetivo: establecer el riesgo cardiovascular (RCV) en pacientes con FINDRISK-C ≥ 12 mediante score Framingham ajustado para Colombia.  Materiales y métodos: subanálisis transversal retrospectivo en 796 pacientes a quienes se les aplicó el cuestionario FINDRISC-C, de ellos 293 con puntaje ≥ 12 y 262 cumplieron los criterios de elegibilidad. Antes se les calculó el RCV mediante análisis uni y multivariado, significancias estadísticas y análisis de correspondencias múltiple. Resultados: 262 pacientes, 63% mujeres, 87% tuvieron sobrepeso y obesidad, promedio de perímetro abdominal 97 cm, 10% eran fumadores y 48% tenían antecedente familiar de diabetes mellitus tipo 2. Se encontró una media de RCV de 8,10 (IC 7,29-8,91), al estratificar por FINDRISC-C la media para cada una de las categorías fue: FINDRISC-C moderado 7,83; FINDRISC-C alto 7,87, FINDRISC-C muy alto 12,61.  La prevalencia de dislipidemia fue de 46,2 % (IC 95%: 40-50) siendo mayor en hombres (53,6%). Conclusión: los pacientes con FINDRISC-C ≥ 12 tienen un RCV entre moderado y alto, existiendo tendencia al incremento del porcentaje de riesgo calculado según score Framingham ajustado para Colombia, a medida que aumenta el puntaje FINDRISC-C.  La prevalencia de dislipidemia en pacientes con FINDRISC-C ≥ 12 fue elevada.

Clinical Outcomes Among Working Adults Using the Health Integrator Smartphone App: Analyses of Prespecified Secondary Outcomes in a Randomized Controlled Trial

Background

There is a need to find new methods that can enhance the individuals’ engagement in self-care and increase compliance to a healthy lifestyle for the prevention of noncommunicable diseases and improved quality of life. Mobile health (mHealth) apps could provide large-scale, cost-efficient digital solutions to implement lifestyle change, which as a corollary may enhance quality of life.

Objective

Here we evaluate if the use of a smartphone-based self-management system, the Health Integrator app, with or without telephone counseling by a health coach, had an effect on clinical variables (secondary outcomes) of importance for noncommunicable diseases.

Methods

The study was a 3-armed parallel randomized controlled trial. Participants were randomized to a control group or to 1 of 2 intervention groups using the Health Integrator app with or without additional telephone counseling for 3 months. Clinical variables were assessed before the start of the intervention (baseline) and after 3 months. Due to the nature of the intervention, targeting lifestyle changes, participants were not blinded to their allocation. Robust linear regression with complete case analysis was performed to study the intervention effect among the intervention groups, both in the entire sample and stratifying by type of work (office worker vs bus driver) and sex.

Results

Complete data at baseline and follow-up were obtained from 205 and 191 participants, respectively. The mean age of participants was 48.3 (SD 10) years; 61.5% (126/205) were men and 52.2% (107/205) were bus drivers. Improvements were observed at follow-up among participants in the intervention arms. There was a small statistically significant effect on waist circumference (β=–0.97, 95% CI –1.84 to –0.10) in the group receiving the app and additional coach support compared to the control group, but no other statistically significant differences were seen. However, participants receiving only the app had statistically significantly lower BMI (β=–0.35, 95% CI –0.61 to –0.09), body weight (β=–1.08, 95% CI –1.92 to –0.26), waist circumference (β=–1.35, 95% CI –2.24 to –0.45), and body fat percentage (β=–0.83, 95% CI –1.65 to –0.02) at follow-up compared to the controls. There was a statistically significant difference in systolic blood pressure between the two intervention groups at follow-up (β=–3.74, 95% CI –7.32 to –0.16); no other statistically significant differences in outcome variables were seen.

Conclusions

Participants randomized to use the Health Integrator smartphone app showed small but statistically significant differences in body weight, BMI, waist circumference, and body fat percentage compared to controls after a 3-month intervention. The effect of additional coaching together with use of the app is unclear.

Trial Registration

ClinicalTrials.gov NCT03579342; https://clinicaltrials.gov/ct2/show/NCT03579342

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-019-6595-6

Effect of periodontal treatment on diabetes-related healthcare costs: a retrospective study

INTRODUCTION

Periodontitis has been considered a sixth complication of diabetes. The aim of this study was to assess the impact of periodontal treatment on diabetes-related healthcare costs in patients with diabetes.

RESEARCH DESIGN AND METHODS

A retrospective analysis was done, exploiting unique and large-scale claims data of a Dutch health insurance company. Data were extracted for a cohort of adults who had been continuously insured with additional dental coverage for the years 2012-2018. Individuals with at least one diabetes-related treatment claim in 2012 were included for analysis. A series of panel data regression models with patient-level fixed effects were estimated to assess the impact of periodontal treatment on diabetes-related healthcare costs.

RESULTS

A total of 41 598 individuals with diabetes (age range 18-100 years; 45.7% female) were included in the final analyses. The median diabetes-related healthcare costs per patient in 2012 were €38.45 per quarter (IQR €11.52-€263.14), including diagnoses, treatment, medication and hospitalization costs. The fixed effect models showed €12.03 (95% CI -€15.77 to -€8.29) lower diabetes-related healthcare costs per quarter of a year following periodontal treatment compared with no periodontal treatment.

CONCLUSIONS

Periodontitis, a possible complication of diabetes, should receive appropriate attention in diabetes management. The findings of this study provide corroborative evidence for reduced economic burdens due to periodontal treatment in patients with diabetes.

Metabolic Syndrome and Diabetes Risk Among Young Adult Students in the Health Sciences from Kathmandu, Nepal

Background

The widespread dissemination of unhealthy dietary habits, childhood-teenage obesity, and sedentary lifestyle in young adults has paved the way for public health burden metabolic syndrome and early onset of type 2 diabetes mellitus. The aim of this study was to assess the prevalence and risk factors for metabolic syndrome and diabetes among young adult students.

Methods

This cross-sectional study was conducted among students of age group (18 to 25 years) studying at Manmohan Memorial Institute of Health Sciences and Central Institute of Science and Technology. The diabetes risk score of each individual was calculated by the Finnish Diabetes Risk Score (FINDRISC tool). Independent risk factors for diabetes and metabolic syndrome were measured by multivariable logistic regression analysis. The p-value of <0.05 was considered statistically significant in this study.

Results

A total of 825 students were recruited and 739 (89.6%) students completed the study with all the fulfilled criteria. The metabolic syndrome (Harmonized Joint Scientific Statement (HJSS) criteria) was present in 7.1%, and the most prevalent defining component was low HDL-C (78%); 74.8% of students were under low risk, 22.18% were at slightly elevated risk, 2.02% were at moderate risk, and 1.01% were at high risk of diabetes. The cardiometabolic risk factors like BMI, TC, and LDL-C were higher at a significant level (p<0.001) with an increased diabetes risk score. Independent lifestyle risk factor for metabolic syndrome was current smoking (AOR, 4.49, 95% CI 1.38–14.62) whereas, an independent lifestyle risk factor for diabetes was low adherence to physical exercise (AOR, 4.81, 95% CI, 2.90–7.99).

Conclusion

Metabolic syndrome is present, although in low numbers in young adults putting them at risk to develop diabetes in the near future. Early assessment of metabolic syndrome and diabetes risk in young may provide insights for preventive and control plans for risk population.

Performance and costs of multiple screening strategies for type 2 diabetes: two population-based studies in Shanghai, China

INTRODUCTION

To compare the performance and the costs of various assumed screening strategies for type 2 diabetes mellitus (T2DM) among Chinese adults, and identify an optimal one for the population.

RESEARCH DESIGN AND METHODS

Two multistage-sampling surveys were conducted in Shanghai, China, in 2009 and 2017. All participants were interviewed, had anthropometry, measured fasting plasma glucose (FPG), hemoglobin A1c (A1c) and/or postprandial glucose. The 1999 WHO diagnostic criteria was used to identify undiagnosed T2DM. A previously developed Chinese risk assessment system and a specific risk assessment system developed in this study were applied to calculate diabetes risk score (DRS) 1 and 2. Optimal screening strategies were selected based on the sensitivity, Youden index and the costs using the 2009 survey data as the training set and the 2017 survey data as the validation set. A twofold cross-validation was also performed.

RESULTS

Of numerous assumed strategies, FPG ≥5.6 mmol/L alone performed well (Youden index of 71.8%) and cost least (US$18.4 for each case detected), followed by the strategy of DRS2 ≥8 combining with FPG ≥5.6 mmol/L (Youden index of 71.7% and US$20.2 per case detected) and the strategy of DRS1 ≥17 combining with FPG ≥5.6 mmol/L (Youden index of 72.0% and US$21.6 per case detected). However, FPG alone resulted in more subjects requiring oral glucose tolerance test (OGTT) than did combining with DRS. The strategy of FPG ≥5.6 mmol/L combining with A1c ≥4.7% achieved a Youden index of 72.1%, but had a cost as high as US$48.8 for each case identified. Twofold cross-validation also supported the use of FPG alone, but with an optimal cut-off of 6.1 mmol/L.

CONCLUSIONS

Our results support the use of FPG alone in T2DM screening in Chinese adults. DRS may be used combining with FPG in populations with available electronic health records to reduce the number of OGTT and save costs of screening.

[Oral health assessment of seniors under outpatient care by family doctors : Development and validation of the geriatric outpatient oral health screening]

Hintergrund

Einschränkungen der Mundgesundheit ambulant betreuter Senioren in Deutschland werden trotz hoher Prävalenz im hausärztlich-geriatrischen Bereich nicht routinemäßig erfasst. Da Senioren Hausärzte mit höherem Alter häufiger aufsuchen als Zahnärzte, stellt sich die Frage, ob reduzierte Mundgesundheit im Praxisalltag mit einem interdisziplinären Screeninginstrument identifiziert werden kann.

Ziel der Arbeit

Ziel der Arbeit ist, ein Screeninginstrument für reduzierte Mundgesundheit für Hausärzte zu entwickeln und dieses durch zahnmedizinische Befunde zu validieren.

Material und Methoden

Das geriatrische ambulante Mundgesundheits-Screening (GAMS) als subjektives Screeninginstrument wurde entwickelt, um für geriatrische Patienten relevante zahnmedizinische Aspekte wie Kauprobleme, Schmerzen, Parodontitis, Mundgeruch oder Mundtrockenheit in dichotomen Fragen abzubilden. Zudem erfolgt die Einschätzung der Dringlichkeit eines Zahnarztbesuches durch den Behandler. Es wurden n = 75 Patienten eingeschlossen und der GAMS sowie eine zahnärztliche Untersuchung zur Validierung durchgeführt.

Ergebnisse

Bei subjektiver Einschätzung als auch im zahnmedizinischen Befund zeigte sich reduzierte Mundgesundheit, insbesondere bei Risikofaktoren für die Entwicklung systemischer Komorbiditäten wie Dysphagie und Mangelernährung, wobei Mundgesundheitsprobleme durch die Patienten unterschätzt wurden. Einbisse, Kauschwierigkeiten und Mundtrockenheit zeigten ausreichende Übereinstimmung zwischen oralem Befund und subjektiver Einschätzung.

Diskussion

Der GAMS könnte beitragen, die Erwägung und Berücksichtigung von Mundgesundheitsproblemen bei geriatrischen Patienten im hausärztlichen Setting zu erleichtern und die Zusammenarbeit mit Zahnmedizinern im Sinne europäischer Handlungsempfehlungen fördern.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00391-020-01730-5) enthalten.

App-technology to improve lifestyle behaviors among working adults - the Health Integrator study, a randomized controlled trial

BACKGROUND

Mobile health, mHealth is recognized as a strategy to improve lifestyle behaviors. Research targeting specific lifestyle behaviors has shown that interventions using smartphones can be effective. However, few studies have evaluated solutions with multicomponent interventions, tailoring the intervention to the specific needs of the participant using a combination of mHealth and conventional treatment. To accomplish this, we developed Health Integrator, an mHealth platform with services and offers in the areas of diet, physical activity, sleeping habits, stress, alcohol and tobacco use. In the system, the user selects an area of intervention together with a health coach and set weekly goals. This study protocol presents the design and methodology of the Health Integrator Study, a randomized controlled trial to promote improved lifestyle behaviors.

METHODS

A three-arm parallel randomized controlled trial (1:1:1) is conducted in the Stockholm County, Sweden. In total, 209 employees at a four different companies representing both white and blue collar workers, have been recruited. Participants are randomized to either a control group or to one of two intervention groups receiving a 3-month lifestyle behavior change program including either 1) use of Health Integrator and monthly health coaching sessions or 2) only Health Integrator. At baseline and follow-up after 3- and 6-months, all participants answer questionnaires assessing lifestyle behaviors and quality of life. At baseline and the 3-month follow-up (end of intervention period), weight, height, waist circumference and blood pressure are measured, and all participants wear an Actigraph accelerometer for 7 days to assess physical activity. Blood lipid profile and HbA1c are measured among all participants at baseline. If baseline measures fall outside the normal range, a second measurement is done after 3 months.

DISCUSSION

The Health Integrator Intervention Study will evaluate if a personalized intervention combining mHealth and conventional programs for lifestyle change, with or without additional health coach sessions, can improve lifestyle behaviors and quality of life. Based on the results from this trial, Health Integrator can easily be implemented within a broad public.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03579342 . Retrospectively registered, first submitted May 8, 2018.

Diagnostic performance of HbA1c for diabetes in Arab vs. European populations: a systematic review and meta-analysis

AIM

To examine differences in the performance of HbA_1c for diagnosing diabetes in Arabs compared with Europeans.

METHODS

The PubMed, Embase and Cochrane library databases were searched for records published between 1998 and 2015. Estimates of sensitivity, specificity and log diagnostic odds ratios for an HbA_1c cut-point of 48 mmol/mol (6.5%) were compared between Arabs and Europeans, using a bivariate linear mixed-model approach. For studies reporting multiple cut-points, population-specific summary receiver operating characteristic (SROC) curves were constructed. In addition, sensitivity, specificity and Youden Index were estimated for strata defined by HbA_1c cut-point and population type. Database searches yielded 1912 unique records; 618 full-text articles were reviewed. Fourteen studies met the inclusion criteria; hand-searching yielded three additional eligible studies. Three Arab (N = 2880) and 16 European populations (N = 49 127) were included in the analysis.

RESULTS

Summary sensitivity and specificity for a HbA_1c cut-point of 48 mmol/mol (6.5%) in both populations were 42% (33-51%), and 97% (95-98%). There was no difference in area under SROC curves between Arab and European populations (0.844 vs. 0.847; P = 0.867), suggesting no difference in HbA_1c diagnostic accuracy between populations. Multiple cut-point summary estimates stratified by population suggest that Arabs have lower sensitivity and higher specificity at a HbA_1c cut-point of 44 mmol/mol (6.2%) compared with European populations. Estimates also suggest similar test performance at cut-points of 44 mmol/mol (6.2%) and 48 mmol/mol (6.5%) for Arabs.

CONCLUSIONS

Given the low sensitivity of HbA_1c in the high-risk Arab American population, we recommend a combination of glucose-based and HbA_1c testing to ensure an accurate and timely diagnosis of diabetes.

[Screening and prevention of diabetes]

A valid and efficient screening for individual diabetes risk is a highly welcomed tool in primary care and specialist medical practice. It is needed to detect early stages of diabetes risk and prediabetes and to start interventions that have the aim to prevent diabetes and also other chronic diseases from developing. The oral glucose tolerance test is the gold standard, but it is difficult to perform in an evidence-based manner in primary care. Furthermore, measuring fasting and 2-h postprandial glucose values detects only late stages of the pathophysiological development of type 2 diabetes. Interestingly, the 1-h glucose value is highly predictive of future diabetes risk, but is rarely used in primary care. Therefore, risk scores are commonly used to evaluate diabetes risk, but unfortunately, they generally do not mirror the relevance of increased risk due to the person's own lifestyle. Measuring waist circumference is another possibility, because the waist is directly associated with the amount of visceral fat, which again directly correlates with the pathophysiology of diabetes development. A further possibility is the EZSCAN™ technology. The EZSCAN™ is based on reverse iontophoresis, a new technology to detect very early forms of peripheral neuropathies, which are commonly associated with early diabetes risk stages. It is important to perform diabetes screening in a targeted manner, in both medical and paramedical environments, and it is mandatory to add targeted interventions, based on the screening evaluated diabetes risk.

Detecting type 2 diabetes and prediabetes among asymptomatic adults in the United States: modeling American Diabetes Association versus US Preventive Services Task Force diabetes screening guidelines

BACKGROUND

Screening to detect prediabetes and diabetes enables early prevention and intervention. This study describes the number and characteristics of asymptomatic, undiagnosed adults in the United States who could be detected with prediabetes and type 2 diabetes using the American Diabetes Association (ADA) guidelines compared to the United States Preventive Services Task Force (USPSTF) guidelines.

METHODS

We developed predictive models for undiagnosed diabetes and prediabetes using polytomous logistic regression from data on risk factors in the 2003-2010 National Health and Nutrition Examination Survey (n = 19,056). We applied these predictive models to the 2010 Medical Expenditure Panel Survey, which contains health care use data, to generate probabilities of undiagnosed diabetes and undetected prediabetes for each adult. We summed individual probabilities to estimate the number of adults who would be detected with prediabetes and/or type 2 diabetes if screened under ADA or USPSTF guidelines. We analyzed health care use patterns of people at high risk for diabetes.

RESULTS

In 2010, 59.1 million adults met the USPSTF screening criteria including 24.4 million people with undetected prediabetes and 3.7 million people with undiagnosed diabetes. In comparison, among the 86.3 million people who met the ADA screening criteria, there were 33.9 million with undetected prediabetes and 4.6 million with undiagnosed type 2 diabetes. The ADA guidelines detected 38.9% more cases of prediabetes and 24.3% more cases of type 2 diabetes compared to the USPSTF guidelines. Subgroup analysis showed that ADA guidelines would detect 78% more cases of diabetes among the age 54 and younger population, in 40% more blacks, and in more than twice as many Hispanics than USPSTF guidelines. Only 58% of adults meeting ADA guidelines and 70% meeting USPSTF guidelines had ≥ 1 primary care office visit in 2010.

CONCLUSIONS

Compared to USPSTF guidelines, ADA guidelines would screen more people and detect more cases of both prediabetes and type 2 diabetes, though a substantial percentage of patients with undetected cases had no contact with a primary care provider in 2010. Addressing the problem of large numbers of undetected prediabetes and type 2 diabetes cases will require new strategies for screening.