Foot abnormalities in Canadian Aboriginal adolescents with Type 2 diabetes

A fact-finding survey on pre-ulcerative lesions of foot in patients with diabetes: analysis using the Diabetes Study from the Center of Tokyo Women's Medical University 2018 (DIACET 2018)

Aims/introduction

We aimed to identify the frequency and risk factors of pre-ulcerative lesions of foot in Japanese individuals with diabetes.

Materials and methods

This was a single-center cross-sectional observational study. We conducted a questionnaire survey of 5029 individuals with diabetes (mean age 63 years; 2185 women; 1015 individuals with type 1 diabetes and 4014 individuals with type 2 diabetes) who (a) participated in the Diabetes Study from the Center of Tokyo Women's Medical University: DIACET 2018, and (b) responded to the presence of pre-ulcerative lesions of foot. A pre-ulcerative lesions of foot was defined as a calluses, ingrown nails, or symptoms of fungal infection. The associations between pre-ulcerative lesions of foot and commonly available clinical information were examined using the logistic regression analysis.

Results

412 of 1015 (40.6%) individuals with type 1 diabetes and 1585 of 4014 (39.5%) individuals with type 2 diabetes reported having any type of pre-ulcerative lesions of foot. The frequency of calluses, ingrown nails, and symptoms of fungal infection, respectively, were 16.8%, 15.8%, and 21.9% in type 1 diabetes and 10.5%, 18.5%, and 24.7% in type 2 diabetes. In the separate analysis by type of diabetes, common risk factors found to be significantly correlated with pre-ulcerative lesions of foot were female gender, numbness in the feet and foot deformation.

Conclusion

Proactive foot screening by health care professionals was considered important, especially in individuals with type 1 and type 2 diabetes with advanced complications and foot deformation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-023-00649-7.

High prevalence of periodontitis in children and adolescents with type 2 diabetes

BACKGROUND

The aim of the present study was to determine the prevalence of periodontitis in children and adolescents with type 2 diabetes, and if poor glycemic control is associated with increasing prevalence of the disease.

METHODS

This is a cross-sectional study involving children and adolescents with type 2 diabetes. A questionnaire related to oral health care history and oral health behaviors was administered to each participant and they then underwent a full-mouth oral evaluation. In addition, clinical and metabolic parameters were extracted from the clinical chart.

RESULTS

One hundred and twenty one children and adolescents (8-17 years, 11 months) participated. Overall, 45.5% presented some degree of periodontitis, with 10 (8.3%) mild, 36 (29.8%) moderate, and nine (7.4%) severe. The periodontitis group (PD-group) had higher mean gingival and plaque indexes, periodontal probing depth, and clinical attachment loss than the group without periodontitis (NoPD-group) (p<0.05). A statistically significant relationship between the prevalence of periodontitis and glycosylated hemoglobin (HbA1c) was verified in the bivariate (odds ratio [OR] 1.31 [95% CI, 1.13-1.53], p = 0.001) and multivariate (OR, 1.29 [95% CI, 1.03-1.61], p = 0.03) analysis. For the adjustment variables, associations were verified for duration of diabetes, age, body mass index z-score, lack of running water, insulin use, and acanthosis nigricans.

CONCLUSIONS

Children and adolescents with type 2 diabetes presented high rates of periodontitis comparable with that seen in previous studies in youth with diabetes. Uncontrolled HbA1c influences prevalence of periodontal disease. The lack of matched control group and radiographs are limitations of the study. Comprehensive periodontal examination is essential for children and adolescents with type 2 diabetes to prevent, identify, and treat periodontitis early.

Structural, Dermal and Ungual Characteristics of the Foot in Patients with Type II Diabetes

Background and Objectives: Diabetes is a chronic and metabolic disease, considered as an important public health problem. The objective of this study was to determine the prevalence of podiatric pathology in type II diabetic patients. Materials and Methods: An observational descriptive study of prevalence in the endocrinology service of Complexo Hospitalario Universitario A Coruña (CHUAC) (A Coruña-Spain) was carried out (n = 153). Type II diabetic patients included, of legal age who signed the informed consent. Sociodemographic variables were studied (age, sex, body mass index (BMI), smoking habit, alcohol consumption, family history), disease variables (time of evolution of diabetes, treatments, low-density lipoprotein (LDL), high-density lipoprotein (HDL), glucose), podiatric variables: measurement of the footprint, metatarsal and digital formula, nail, skin, hindfoot and forefoot alterations. The data collection was done in 2018 and the data analysis was carried out in 2019. Results: The patients with type II diabetes had greater age, obesity and arterial hypertension it compared to the general population. Diabetic patients had a higher prevalence of flat feet than the general population (71.2% vs. 20.7%, p < 0.001), with a predominance of normal foot according to the podoscope. The predominant podological pathology was the presence of claw toes (94.8%), followed by dermal (78.4%) and nail (71.9%) alterations, and the Hallux Valgus (66.0%). The Clarke angle and the Chippaux index showed a Kappa concordance index of 0.26 with the type of footprint measured with the podoscope. The Staheli index showed a Kappa index of 0.27 associated with an observed agreement of 54%. Conclusions: This study shows that foot problems continue to be prevalent in subjects with type II diabetes mellitus and for this reason, podiatry is essential in its treatment.

Diabetes care in the dispersed population of Greenland. A new model based on continued monitoring, analysis and adjustment of initiatives taken

Diabetes used to be a rare condition among Inuit in Greenland. However, research in recent decades has shown a high prevalence of undiagnosed diabetes. Addressing diabetes in the geographically dispersed population of Greenland presents a challenge to the health care system. In 2008, a new model of diabetes care was introduced in Greenland that included continual monitoring, analysis, and adjustment of initiatives taken. The overall aim of this review was to review the feasibility of the monitoring of an ongoing national diabetes care programme. After ten years of observation it was clear that monitoring of such a programme based on information in electronic medical records in Greenland was feasible. It was found that the majority of the population in Greenland was in contact with the health care system. Increased diagnostic activity resulted in an increased prevalence of diagnosed diabetes. The quality of diabetes care in Greenland and the testing effectiveness of gestational diabetes were improved. Microvascular complications were frequently observed among Greenlandic diabetic patients, except for retinopathy that was as an exception. In summary, this model may improve diabetes care and potentially care for other chronic conditions in Greenland, and may also be helpful in other remote settings where chronic disease care is difficult.Abbreviations: AD: Anno Domini; ADA: American Diabetes Association; BC: Before Christ; BMI: Body Mass Index; BP: Blood Pressure; CWB: Capillary Whole Blood; EMR: Electronic Medical Record; EASD: European Association for Study of Diabetes; GA: Gestational Age; GDM: Gestational Diabetes Mellitus; FIGO: The International Federation of Gynaecology and Obstetrics; HbA1c: Glycosylated haemoglobin; IDF: International Diabetes Federation; LDL: Low density lipoprotein; NDQIA: National Diabetes Quality Improvement Alliancel; NICE: National Institute for Health and Care Excellence; OECD: Organisation for Economic Co-operation and Development; OGTT: Oral Glucose Tolerance Test; QIH: Queen Ingrid Hospital; RCT: Randomised Controlled Tria;l T1D: Type 1 Diabetes; T2D: Type 2 Diabetes; UACR: Urine Albumin Creatinine Ratio; WHO: World Health Organisation.

Risk Factors and Frequency of Ingrown Nails in Adult Diabetic Patients

The present study evaluated the properties of nails, frequency of ingrown nails in patients with type 2 diabetes mellitus (DM), risk factors for developing ingrown nails, and effect of diabetic polyneuropathy and vasculopathy on the development and outcome of ingrown nails. Our 6-month epidemiologic prospective study included 300 patients with type 2 DM attending a DM outpatient clinic for routine examinations. The general characteristics and foot changes of the study population were investigated. Diabetic polyneuropathy and vasculopathy were evaluated using a biothesiometer, monofilament tests, and arterial Doppler ultrasonography. The frequency of ingrown nails was 13.6%. Multivariate analysis with logistic regression showed that body mass index (odds ratio [OR] 1.077, 95% confidence interval [CI] 1.007 to 1.15; p = .03), previous trauma (OR 2.828, 95% CI 1.017 to 7,867, p = .042), a weak dorsalis pedis pulse (OR 2.72, 95% CI 1.17 to 6.30, p = .02), trimming type (OR 2.3, 95 CI 1.06 to 4.98), p = .35), onychogryphosis (OR 9.036, 95% CI 2.34 to 34.87, p = .001), and subungual hyperkeratosis (OR 4.3, 95% CI 1.99 to 9.3, p = .001) were predictive variables for ingrown nails in our population. The incidence of onychomycosis was significantly greater in patients with ingrown nails (p = .032) than in patients without ingrown nails. The nail curvature ratio was greater in the patients with ingrown nails than in the group with normal nails. Arterial Doppler ultrasound examinations showed peripheral arterial disease in 19 patients (46.9%) with ingrown nails. The prevalence of ingrown nails was greater in the patients with DM than in the healthy population. Our results indicate that nail type, nail morphology, and diabetic vasculopathy affect the formation and evolution of ingrown nails.

Earlier onset of complications in youth with type 2 diabetes

OBJECTIVE

To evaluate the risk of complications in youth with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Population-based cohorts of 342 youth (1-18 years of age) with prevalent type 2 diabetes, 1,011 youth with type 1 diabetes, and 1,710 nondiabetic control youth were identified between 1986 and 2007 from a clinical registry and linked to health care records to assess long-term outcomes using ICD-9CM and ICD-10CA codes.

RESULTS

Youth with type 2 diabetes had an increased risk of any complication (hazard ratio 1.47 [95% CI 1.02-2.12]). Significant adverse clinical factors included age at diagnosis (1.08 [1.02-2.12]), HbA1c (1.06 [1.01-1.12]), and, surprisingly, renin-angiotensin-aldosterone system (RAAS) inhibitor use (1.75 [1.27-2.41]). HNF-1α G319S polymorphism was protective in the type 2 diabetes cohort (0.58 [0.34-0.99]). Kaplan-Meier statistics revealed an earlier diagnosis of renal and neurologic complications in the type 2 diabetes cohort, manifesting within 5 years of diagnosis. No difference in retinopathy was seen. Cardiovascular and cerebrovascular diseases were rare; however, major complications (dialysis, blindness, or amputation) started to manifest 10 years after diagnosis in the type 2 diabetes cohort. Youth with type 2 diabetes had higher rates of all outcomes than nondiabetic control youth and an overall 6.15-fold increased risk of any vascular disease.

CONCLUSIONS

Youth with type 2 diabetes exhibit complications sooner than youth with type 1 diabetes. Younger age at diagnosis is potentially protective, and glycemic control is an important modifiable risk factor. The unexpected adverse association between RAAS inhibitor use and outcome is likely a confounder by indication; however, further evaluation in young people is warranted.

Preliminary analysis of immune activation in early onset type 2 diabetes

INTRODUCTION

First Nations and other Aboriginal children are disproportionately affected by cardiometabolic diseases, including type 2 diabetes (T2D). In T2D, the disruption of insulin signalling can be driven by pro-inflammatory immunity. Pro-inflammatory responses can be fueled by toll-like receptors (TLR) on immune cells such as peripheral blood mononuclear cells (PBMC, a white blood cell population). TLR4 can bind to lipids from bacteria and food sources activating PBMC to produce cytokines tumour necrosis factor (TNF)-α and interleukin (IL)-1β. These cytokines can interfere with insulin signalling. Here, we seek to understand how TLR4 activation may be involved in early onset T2D. We hypothesized that immune cells from youth with T2D (n = 8) would be more reactive upon TLR4 stimulation relative to cells from age and body mass index (BMI)-matched controls without T2D (n = 8).

METHODS

Serum samples were assayed for adipokines (adiponectin and leptin), as well as cytokines. Freshly isolated PBMC were examined for immune reactivity upon culture with TLR4 ligands bacterial lipopolysaccharide (LPS, 2 and 0.2 ng/ml) and the fatty acid palmitate (200 µM). Culture supernatants were evaluated for the amount of TNF-α and IL-1β produced by PBMC.

RESULTS

Youth with T2D displayed lower median serum adiponectin levels compared to controls (395 vs. 904 ng/ml, p < 0.05). PBMC isolated from youth with and without T2D produced similar levels of TNF-α and IL-1β after exposure to the higher LPS concentration. However, at the low LPS dose the T2D cohort exhibited enhanced IL-1β synthesis relative to the control cohort. Additionally, exposure to palmitate resulted in greater IL-1β synthesis in PBMCs isolated from youth with T2D versus controls (p < 0.05). These differences in cytokine production corresponded to greater monocyte activation in the T2D cohort.

CONCLUSION

These preliminary results suggest that cellular immune responses are exaggerated in T2D, particularly with respect to IL-1β activity. These studies aim to improve the understanding of the biology behind early onset T2D and its vascular complications that burden First Nations people.

A research review: exploring the health of Canada's Aboriginal youth

Objective

To compare the current state of health research on Aboriginal and non-Aboriginal youth in Canada.

Design

A search of published academic literature on Canadian Aboriginal youth health, including a comprehensive review of both non-Aboriginal and Aboriginal youth research, was conducted using MEDLINE and summarized.

Methodology

A MEDLINE search was conducted for articles published over a 10-year period (2000–2010). The search was limited to research articles pertaining to Canadian youth, using various synonyms for “Canada,” “youth,” and “Aboriginal.” Each article was coded according to 4 broad categories: Aboriginal identity, geographic location, research topic (health determinants, health status, health care), and the 12 key determinants of health proposed by the Public Health Agency of Canada (PHAC).

Results

Of the 117 articles reviewed, only 34 pertained to Aboriginal youth, while the remaining 83 pertained to non-Aboriginal youth. The results revealed major discrepancies within the current body of research with respect to the geographic representation of Aboriginal youth, with several provinces missing from the literature, including the northern territories. Furthermore, the current research is not reflective of the demographic composition of Aboriginal youth, with an under-representation of Métis and urban Aboriginal youth. Health status of Aboriginal youth has received the most attention, appearing in 79% of the studies reviewed compared with 57% of the non-Aboriginal studies. The number of studies that focus on health determinants and health care is comparable for both groups, with the former accounting for 62 and 64% and the latter comprising 26 and 19% of Aboriginal and non-Aboriginal studies, respectively. However, this review reveals several differences with respect to specific focus on health determinants between the two populations. In non-Aboriginal youth studies, all the 12 key determinants of health of PHAC are explored, whereas in Aboriginal youth studies the health profile remains incomplete and several key determinants and health indicators are neglected.

Conclusions

The current studies are not reflective of the demographic and geographic profiles of Aboriginal youth in Canada, and they have also failed to provide a comprehensive examination of their unique health needs and concerns compared with studies on non-Aboriginal youth.

Characteristics of diabetic patients visiting a podiatry practice in Germany

OBJECTIVE

To describe the foot characteristics of diabetic patients attending a podiatry practice for their first consultation. The objective was to determine how effectively diabetic foot ulcers are being prevented in primary care.

METHOD

All diabetic patients who presented at a podiatry practice between 2006 and 2008 for their first consultation were analysed. Anonymous data were obtained from the standard patient anamnesis sheet completed by the podiatrist. These included results of patient interviews and examinations.

RESULTS

A total of 230 diabetic patients (93.9% had type 2 diabetes mellitus and 6.1% had type 1) were analysed. The mean age was 67.7 years (+/- 10.8). Just under half (47.4%) were female. The mean duration of diabetes was 12.6 years (+/- 10.5) years. 70.4% of the patients had diabetic neuropathy (confidence intervals: 64.5-76.3), of whom 73.2% already had resting foot pain or strain foot pain while walking. 58.3% of the patients had toenail mycosis, and of these 38.1% had the infection in all 10 toenails. Most of the patients had at least one foot deformities (89.6% splayfoot and 37.0% flatfoot). 40.2% had no sensation to microfilament testing on either their right or left foot toes. The overall mean vibration sensation test threshold was 3.7 (+/- 2.3).

CONCLUSION

While there is a structure and strategy for the primary and secondary prevention of the diabetic foot ulcers, its delivery is often ineffective. This audit shows that, in Germany, the detection and prevention of diabetic foot problems in podiatric practices happens far too late.

Clinical management of type 2 diabetes in indigenous youth

Youth-onset type 2 diabetes is a serious public health problem for Indigenous people throughout the world. This article reviews the epidemiology, disease burden, treatment, and challenges in achieving successful clinical management of this disorder in Indigenous youth. Screening criteria and the complications and comorbidities of type 2 diabetes are also reviewed.

Global complication rates of type 2 diabetes in Indigenous peoples: A comprehensive review

INTRODUCTION AND OBJECTIVE

The world's Indigenous peoples are experiencing an unprecedented epidemic of type 2 diabetes [T2DM] but little has been published describing the complications burden. The objective of this paper was to conduct a systematic review of T2DM complications in Indigenous populations worldwide.

METHODS

A literature review was conducted using PubMed and EMBASE to examine available complications data. Country, Indigenous population, authors, publication year, total sample size, Indigenous sample size, age, methodology, and prevalence of nephropathy, end-stage renal disease, retinopathy, neuropathy, lower extremity amputations, cardiovascular disease, hospitalizations and mortality due to diabetes were recorded.

RESULTS

One-hundred and eleven studies were selected. Results revealed a disproportionate burden of disease complications among all Indigenous peoples regardless of their geographic location. Complication rates were seen to vary widely across Indigenous groups.

DISCUSSION

Gaps were found in the published literature on complications among Indigenous populations, especially those living in underdeveloped countries. These gaps may be in part due to the challenges caused by varying operational practices, research methodologies, and definitions of the term Indigenous, making documentation of rates among these peoples problematic. Comprehensive surveillance applying standardized definitions and methodologies is needed to design targeted prevention and disease management strategies for Indigenous peoples with T2DM.

Prevalence and risk factors for neuropathy in a Canadian First Nation community

OBJECTIVE

The purpose of this study was to determine the prevalence of and risk factors for diabetic neuropathy in a Canadian First Nation population.

RESEARCH DESIGN AND METHODS

This was a community-based screening study of 483 adults. Measures included glucose, A1C, cholesterol, triglycerides, homocysteine, hypertension, waist circumference, height, weight, and foot examinations. Neuropathy was defined as loss of protective sensation determined through application of a 10-g monofilament.

RESULTS

Twenty-two percent of participants had a previous diagnosis of diabetes, and 14% had new diabetes or impaired fasting glucose (IFG). The prevalence of neuropathy increased by glucose level: 5% among those with normal glucose levels, 8% among those with new IFG and diabetes, and 15% among those with established diabetes (P < 0.01). Those with neuropathy were more likely to have foot deformities (P < 0.01) and callus (P < 0.001) than those without neuropathy. Among those with dysglycemia (>or=6.1 mmol/l), the mean number of foot problems for those with insensate feet was 3 compared with 0.3 among those with sensation (P < 0.001). In multivariate logistic regression female sex, low education, A1C, smoking, and homocysteine were independently associated with neuropathy, after controls for age.

CONCLUSIONS

Neuropathy prevalence is high, given the young age of our participants (mean 40 years) and was present among those with undiagnosed diabetes. The high number and type of foot problems places this population at increased risk for ulceration; the low level of foot care in the community increases the risk. Homocysteine is a risk factor that may be related to lifestyle and requires further investigation.

Comorbidities and microvascular complications of type 2 diabetes in children and adolescents

The comorbidities of type 2 diabetes in children and adolescents are mainly related to coexistent insulin resistance and compounded by poverty. The prevalence of dyslipidemia, fatty liver, and hypertension may not be higher than the rates in obese children and adolescents, but the stakes are higher in children with diabetes because the diabetes confers a higher cardiovascular risk. This risk is exaggerated further in children with poor hygiene, smoking, and primary renal disease. Sexuality, contraception, preconception counseling, and psychiatric conditions require unique considerations in youth with type 2 diabetes.