Type 2 diabetes in children and adolescents--the next epidemic?

An evaluation of both serum Klotho/FGF-23 and apelin-13 for detection of diabetic nephropathy

PURPOSE

The aim of our study is to evaluate whether serum Klotho/FGF-23 and apelin-13 can be used as new biomarkers for detection of development of nephropathy.

METHODS

In this cross-sectional study, 88 type 2 diabetes mellitus (T2DM) patients and 38 healthy controls were included. The mean duration of T2DM was 11.4 ± 9.7 years. T2DM individuals were categorized into two groups as group 1 with e-GFR < 60 mL/min/1.73 m2 and group 2 with e-GFR > 60 mL/min/1.73 m2. They were also divided into two groups according to their 24 h urine albumin levels, classifying them as follows: normoalbuminuria if less than 30 mg/day and albuminuria if more than 30 mg/day.

RESULTS

Mean serum Klotho levels in the T2DM group were observed to be significantly higher than in the control group. Serum apelin-13 levels were observed to be significantly lower in the T2DM group compared to the control group (p < 0.001). In the diabetic group, apelin-13 levels were positively correlated with age, waist circumference, and albuminuria while they were negatively correlated with e-GFR. Apelin-13 levels were seen to be significantly higher in group 1 (p < 0.001).

CONCLUSION

Apelin-13 levels were found to be significantly higher in individuals with diabetic nephropathy than in those without diabetic nephropathy. In the diabetic group, a significant relationship was detected between apelin-13 levels and albumin excretion. Based on these findings, we consider that serum Klotho and apelin-13 levels may have a protective effect on diabetic nephropathy and can additionally be used as a biomarker to predict diabetic nephropathy.

Hepcidin, soluble transferrin receptor and IL-6 levels in obese children and adolescents with and without type 2 diabetes mellitus/impaired glucose tolerance and their association with obstructive sleep apnea

PURPOSE

Obesity, type 2 diabetes mellitus (T2DM), and obstructive sleep apnea (OSA) are associated with chronic low-grade inflammation. Iron metabolism is linked with insulin-resistant states and with OSA in adults. The association of body iron status with T2DM in children remains undefined. We aimed to evaluate plasma interleukin-6 (IL-6), hepcidin, and soluble transferrin receptor (sTfR) levels in obese patients with T2DM or impaired glucose tolerance (IGT) and in those without, and the contribution of OSA to their levels.

METHODS

In this cross-sectional study, obese children and adolescents with and without T2DM/IGT underwent overnight polysomnography. Fasting plasma concentrations of IL-6, hepcidin, and sTfR were measured and evaluated according to glycemic status (T2DM/IGT and normal glucose tolerance) and the presence of OSA.

RESULTS

Ten patients with T2DM (age 15.9 ± 3.6 years), 8 with IGT (age 13.1 ± 2.5 years) and 20 subjects with normal glucose tolerance matched for body mass index standard deviation score (age 12.6 ± 3.3 years) were studied. Sleep measures or IL-6, hepcidin, and sTfR levels were not significantly different between the group with T2DM/IGT vs. the control group. No significant differences were found in hepcidin or sTfR levels between patients with OSA and those without. However, patients with OSA showed higher plasma IL-6 values compared with those without (4.56 ± 2.92 vs. 2.83 ± 1.54 pg/ml, P = 0.025), and the highest values were evident in patients affected by both T2DM/IGT and OSA.

CONCLUSIONS

Higher IL-6 levels were associated with both glycemic status and OSA. No differences in body iron regulator levels were found in obese patients with T2DM/IGT compared to those without or in those with OSA compared to those without. Further longitudinal studies in larger population samples are warranted.

Oxidative stress in obese children and adolescents with and without type 2 diabetes mellitus is not associated with obstructive sleep apnea

PURPOSE

Obesity, obstructive sleep apnea (OSA), and type 2 diabetes mellitus (T2DM) are associated with chronic low-grade inflammation and oxidative stress. In adults, increased lipid peroxidation, a marker of oxidative stress, was found in both metabolic syndrome and OSA. Studies on oxidative stress in children with T2DM and OSA are scarce.

METHODS

Plasma oxidized low-density lipoprotein (Ox-LDL) levels were evaluated in obese children and adolescents with/without T2DM, and the contribution of OSA to oxidative stress was investigated.

RESULTS

Ten patients with T2DM, 8 with impaired glucose tolerance (IGT), and 20 body mass index-standard deviation score (BMI-SDS)-matched non-diabetic children (controls) were studied. They all underwent overnight polysomnography. Fasting plasma concentrations of Ox-LDL were measured and compared to the glycemic status and to the presence of OSA. Fourteen patients (36%) were diagnosed with OSA and 21 (55%) with hypertension. There were no significant group differences in plasma Ox-LDL levels or between patients with/without OSA. Plasma Ox-LDL levels were significantly higher among patients with hypertension compared to controls (P = 0.01), while they correlated with homeostasis model assessment (P = 0.02), BMI-SDS (P = 0.049), and systolic blood pressure (P = 0.002).

CONCLUSIONS

The findings of this pilot study suggest that increased lipid peroxidation is associated with insulin resistance and hypertension in obese children and adolescents, while OSA has most likely minor influence.

Review: Obesity and cardiometabolic syndrome in children

The cardiometabolic syndrome is highly prevalent among overweight youth. The risk of developing the cardiometabolic syndrome is likely triggered or exacerbated by concurrent obesity, unhealthy lifestyle/eating habits, and hormonal changes (puberty). Current screening recommendations include measurement of blood pressure, fasting insulin and glucose, and total cholesterol. However, limiting assessments to these measures underestimates cardiometabolic risk in overweight youth, particularly minorities. Early identification of cardiometabolic risk in its incipient stages may justify early and more aggressive intervention to prevent progression and complications. This review provides rationale for additional assessments to determine cardiometabolic risk in overweight youth and recommends treatment options.

Risk of Amyotrophic Lateral Sclerosis in Patients With Diabetes: A Nationwide Population-Based Cohort Study

Background

Glucose intolerance in patients with amyotrophic lateral sclerosis (ALS) has been inconsistently reported. Evidence for the association of ALS and diabetes mellitus is limited. We aimed to assess the overall and age- and sex-specific risks of ALS among patients with diabetes in Taiwan.

Methods

The study cohort included 615 492 diabetic patients and 614 835 age- and sex-matched subjects as a comparison cohort, followed from 2000 to 2008. We estimated the incidence densities of ALS and calculated the relative hazard ratios (HRs) of ALS (ICD-9-CM 335.20) in relation to diabetes using a Cox proportional hazard regression model, with adjustment for potential confounders, including sex, age, geographic area, urbanization status, Charlson Comorbidity Index, frequency of medical visit, and histories of hypertension, hyperlipidemia, and chronic obstructive pulmonary disease.

Results

Over a 9-year period, 255 diabetic and 201 non-diabetic subjects developed ALS, corresponding to incidence densities of 7.42 and 5.06 per 100 000 person-years, respectively. After adjustment for potential confounders, patients with diabetes experienced a significantly elevated HR of 1.35 (95% confidence interval [CI], 1.10–1.67). A higher covariate adjusted HR was noted in men (HR 1.48; 95% CI, 1.13–1.94) than in women (HR 1.17; 95% CI, 0.84–1.64), while men aged ≤65 years showed the most increased HR of 1.67 (95% CI, 1.18–2.36).

Conclusions

This study demonstrated a moderate but significant association of diabetes with ALS onset, and such association is not confounded by socio-demographic characteristics or certain ALS-related co-morbidities. Further studies are warranted to examine whether the findings observed in our study can be replicated.

Oxidative stress and its association with TNF-α-308 G/C and IL-1α-889 C/T gene polymorphisms in patients with diabetes and diabetic nephropathy

Diabetic nephropathy is one of the major complications of type 2 diabetes and it is currently the leading cause of end-stage renal disease. The stimulus for the increase in inflammation in diabetes is still under investigation; however, reactive oxygen species might be a primary source. This study was conducted in four groups in West Indian population: control (235), type 2 diabetes (DM) (214), nephropathy with diabetes (DN) (188) and nephropathy without diabetes (NDN) (196). Oxidative stress markers such as malondialdehyde (MDA), glutathione (GSH), superoxide dismutase and catalase were measured in all the groups. TNF-α-308 G/C and IL-1α-889 C/T polymorphisms were analyzed using PCR-RFLP method. Correlations between genotype frequency and the level of oxidative stress markers were examined. MDA was significantly increased in the patient group in comparison to control group. GSH and SOD were significantly decreased in the patient group in comparison to control group. There was no significant difference observed in genotype frequency of TNF-α in the patient group compared with control group. IL-1α-889 C/T polymorphism may be associated with diabetic nephropathy. Moreover there was no association of TNF-α-308 G/C polymorphism with diabetic nephropathy in West Indian population. The higher serum levels of oxidative stress markers in diabetic patients with nephropathy suggest the possible role of oxidative stress.

Maternal undernutrition induces premature reproductive senescence in adult female rat offspring

OBJECTIVE

To determine the effects of maternal undernutrition (MUN) on the reproductive axis of aging offspring.

DESIGN

Animal (rat) study.

SETTING

Research laboratory.

ANIMAL(S)

Female Sprague-Dawley rats.

INTERVENTION(S)

Food restriction during the second half of pregnancy in rats.

MAIN OUTCOME MEASURE(S)

Circulating gonadotropins, antimüllerian hormone (AMH), ovarian morphology, estrous cyclicity, and gene expression studies in the hypothalamus and ovary in 1-day-old (P1) and aging adult offspring.

RESULT(S)

Offspring of MUN dams had low birth weight (LBW) and by adult age developed obesity. In addition, 80% of adult LBW offspring had disruption of estrous cycle by 8 months of age, with the majority of animals in persistent estrous. Ovarian morphology was consistent with acyclicity, with ovaries exhibiting large cystic structures and reduced corpora lutea. There was an elevation in circulating T, increased ovarian expression of enzymes involved in androgen synthesis, an increase in plasma LH/FSH levels, a reduction in E2 levels, and no changes in AMH in adult LBW offspring compared with in control offspring. Hypothalamic expression of leptin receptor (ObRb), estrogen receptor-α (ER-α), and GnRH protein was altered in an age-dependent manner with increased ObRb and ER-α expression in P1 LBW hypothalami and a reversal of this expression pattern in adult LBW hypothalami.

CONCLUSION(S)

Our data indicate that the maternal nutritional environment programs the reproductive potential of the offspring through alteration of the hypothalamic-pituitary-gonadal axis. The premature reproductive senescence in LBW offspring could be secondary to the development of obesity and hyperleptinemia in these animals in adult life.

Are frequency and severity of sleep-disordered breathing in obese children and youth with and without type 2 diabetes mellitus different?

Obstructive sleep apnea (OSA) is a risk factor for insulin resistance and type 2 diabetes mellitus (T2DM) in adults. Data in children are limited. The aim was to study the frequency and severity of OSA and its association with cardiometabolic risk factors in obese children and adolescents with and without T2DM. In this prospective cross-sectional study, obese children and adolescents with and without T2DM underwent polysomnography and blood tests for fasting lipids, insulin, glucose, liver functions, and C-reactive protein. All participants completed a questionnaire on past and present sleep-disordered breathing (SDB). Results were compared between T2DM and obese non-diabetic controls matched for body mass index-standard deviation score (BMI-SDS) and also according to the glycemic status: T2DM, impaired glucose tolerance (IGT), and normal glycemic control. Eleven patients with T2DM (age 15.9 ± 3.6 years) and 30 BMI-SDS matched non-diabetic subjects (age 12.7 ± 3.0 years) were studied. Among the entire cohort, 45 % had a history of snoring, 26 % reported apneic episodes during sleep, and 65 % had daytime fatigue. There were no significant between-group differences in SDB history or abnormal polysomnographic results [apnea-hypopnea index (AHI) >5/h]. The percentage of subjects with AHI >5/h was 45.5 % in T2DM patients, 25 % in obese patients with IGT, and 18.2 % in obese patients without IGT, although the difference was not statistically significant (p = 0.25). Plasma C-reactive protein levels were related to both glycemic status and OSA severity. The severity of OSA in obese children and adolescents is unrelated to the presence of diabetes. OSA may play a minor role in the development and progression of T2DM in children and adolescents. Further studies in larger cohorts are required.

The selected traditional chinese medicinal formulas for treating diabetic nephropathy: perspective of modern science

With the increasing patients and limited therapeutic options, diabetic nephropathy (DN) is a long-term complication of diabetic mellitus. The precise mechanism of DN is not yet fully understood and the effective blockade of the progression of nephropathy remains a therapeutic challenge. Application of traditional Chinese medicine (TCM) for diabetes and its related complications has received increasing attention due to its wide availability, low side effects, and proven therapeutic mechanisms and benefits. In the current review, we mainly focus on the recent laboratory studies of the TCM formulas including Wu-Ling-San (Poria Five Powder; Wǔ Líng Sǎn), Danggui-Buxue-Tang (Tangkuei and Astragalus Decoction; Dāng Guī Bǔ Xuè Tang), and Danggui-Shaoyao-San (Tangkuei and Paeonia Formula; Dāng Guī Sháo Yào Sǎn), conducted by the Committee on Chinese Medicine and Pharmacy at the Department of Health of Taiwan Government, in the amelioration of DN. These selected TCM formulas have anti-diabetic properties, with antihyperglycemic activity accompanied by amelioration of advanced glycation end product–mediated renal damage in streptozotocin-induced diabetic rats. However, the renoprotective effects of the selected TCM formulas did not correlate with suppressing renal renin–angiotensin system hyperactivity in diabetic rats. These TCM formulas also have the capacity to ameliorate the defective antioxidative defense system, leading to modulation of the oxidative stress, thereby resulting in downregulation of nuclear factor-kB as well as transforming growth factor-β1 and, consequently, attenuation of extracellular matrix components such as fibronectin or type IV collagen expression in diabetic renal cortex tissue. More detailed mechanistic researches and long-term clinical evaluations, as well as evaluation of safety of the selected TCM formulas are needed for their future applications in DN therapy.

Examining the Use of Dietary Fiber in Reducing the Risk of Type 2 Diabetes Mellitus in Latino Youth

Type 2 diabetes mellitus (T2DM) is a steadily growing epidemic in the United States, especially for overweight Latino youth who are among the highest at-risk for T2DM development. Although dietary interventions are not often inferred to patients prior to T2DM diagnosis, they may be implicated in risk reduction. The purpose of this review is to examine the use of dietary fiber in reducing the risk of T2DM in Latino youth. The main results of this examination found that a wide variation in use of dietary fiber intake or supplementation resulted in an overall inverse relationship and association with visceral adipose tissue, metabolic syndrome, and insulin resistance. However, due to inconsistencies in fiber definition and/or implementation, dietary and supplemental fiber intake must be further explored in randomized controlled trials so that more agreement may be reached on fiber recommendations, especially in populations at high risk for T2DM such as Latino youth.

Adherence to therapies in patients with type 2 diabetes

Adherence to therapy is defined as the extent to which a person's behavior in taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider. Patients presenting with type 2 diabetes mellitus are initially encouraged to maintain a healthy diet and exercise regimen, followed by early medication that generally includes one or more oral hypoglycemic agents and later may include an injectable treatment. To prevent the complications associated with type 2 diabetes, therapy frequently also includes medications for control of blood pressure, dyslipidemia and other disorders, since patients often have more than three or four chronic conditions. Despite the benefits of therapy, studies have indicated that recommended glycemic goals are achieved by less than 50% of patients, which may be associated with decreased adherence to therapies. As a result, hyperglycemia and long-term complications increase morbidity and premature mortality, and lead to increased costs to health services. Reasons for nonadherence are multifactorial and difficult to identify. They include age, information, perception and duration of disease, complexity of dosing regimen, polytherapy, psychological factors, safety, tolerability and cost. Various measures to increase patient satisfaction and increase adherence in type 2 diabetes have been investigated. These include reducing the complexity of therapy by fixed-dose combination pills and less frequent dosing regimens, using medications that are associated with fewer adverse events (hypoglycemia or weight gain), educational initiatives with improved patient-healthcare provider communication, reminder systems and social support to help reduce costs. In the current narrative review, factors that influence adherence to different therapies for type 2 diabetes are discussed, along with outcomes of poor adherence, the economic impact of nonadherence, and strategies aimed at improving adherence.

Maternal hypoxia increases the susceptibility of adult rat male offspring to high-fat diet-induced nonalcoholic fatty liver disease

Exposure to an adverse intrauterine environment increases the risk for adult metabolic syndrome. However, the influence of prenatal hypoxia on the risk of fatty liver disease in offspring is unclear. The purpose of the present study was to evaluate the role of reduced fetal oxygen on the development and severity of high-fat (HF) diet-induced nonalcoholic fatty liver disease (NAFLD). Based on design implicating 2 factors, ie, maternal hypoxia (MH) and postnatal HF diet, blood lipid and insulin levels, hepatic histology, and potential molecular targets were evaluated in male Sprague Dawley rat offspring. MH associated with postnatal HF diet caused a significant increase in plasma concentration of triglycerides, free fatty acids, low-density lipoprotein cholesterol, and insulin. Histologically, a more severe form of NAFLD with hepatic inflammation, hepatic resident macrophage infiltration, and progression toward nonalcoholic steatohepatitis was observed. The lipid homeostasis changes and insulin resistance caused by MH plus HF were accompanied by a significant down-regulation of insulin receptor substrate 2 (IRS-2), phosphoinositide-3 kinase p110 catalytic subunit, and protein kinase B. In MH rats, insulin-stimulated IRS-2 and protein kinase B (AKT) phosphorylation were significantly blunted as well as insulin suppression of phosphoenolpyruvate carboxykinase and glucose-6-phosphatase. Meanwhile, a significant up-regulation of lipogenic pathways was noticed, including sterol-regulatory element-binding protein-1 and fatty acid synthase in liver. Our results indicate that maternal hypoxia enhances dysmetabolic liver injury in response to an HF diet. Therefore, the offspring born in the context of maternal hypoxia may require special attention and follow-up to prevent the early development of NAFLD.

Changes in quality of care and costs induced by implementation of a diabetes program in a social security entity of Argentina

PURPOSE

To measure the impact of a diabetes and cardiovascular risk factors program implemented in a social security institution upon short- and long-term clinical/metabolic outcomes and costs of care.

METHODS

Observational longitudinal cohort analysis of clinical/metabolic data and resource use of 300 adult male and female program participants with diabetes before (baseline) and 1 and 3 years after implementation of the program. Data were obtained from clinical records (Qualidiab) and the administration's database.

RESULTS

The implementation of the program in "real world" conditions resulted in an immediate and sustainable improvement of the quality of care provided to people with diabetes incorporated therein. We also recorded a more appropriate oral therapy prescription for hyperglycemia and cardiovascular risk factors (CVRFs), as well as a decrease of events related to chronic complications. This improvement was associated with an increased use of diagnostic and therapeutic resources, particularly those related to pharmacy prescriptions, not specifically used for the control of hyperglycemia and other CVRFs.

CONCLUSION

The implementation of a diabetes program in real-world conditions results in a significant short- and long-term improvement of the quality of care provided to people with diabetes and other CVRFs, but simultaneously increased the use of resources and the cost of diagnostic and therapeutic practices. Since controlled studies have shown improvement in quality of care without increasing costs, our results suggest the need to include management-control strategies in these programs for appropriate medical and administrative feedback to ensure the simultaneous improvement of clinical outcomes and optimization of the use of resources.

Promoting effects of the adipokine, apelin, on diabetic nephropathy

Angiogenesis, increased glomerular permeability, and albuminuria are thought to contribute to the progression of diabetic nephropathy (DN). Apelin receptor (APLNR) and the endogenous ligand of APLNR, apelin, induce the sprouting of endothelial cells in an autocrine or paracrine manner, which may be one of the mechanisms of DN. The aim of this study was to investigate the role of apelin in the pathogenesis of DN. Therefore, we observed apelin/APLNR expression in kidneys from patients with type 2 diabetes as well as the correlation between albuminuria and serum apelin in patients with type 2 diabetes. We also measured the proliferating, migrating, and chemotactic effects of apelin on glomerular endothelial cells. To measure the permeability of apelin in glomerular endothelial cells, we used transwells to detect FITC-BSA penetration through monolayered glomerular endothelial cells. The results showed that serum apelin was significantly higher in the patients with type 2 diabetes compared to healthy people (p<0.05, Fig. 1B) and that urinary albumin was positively correlated with serum apelin (R = 0.78, p<0.05). Apelin enhanced the migration, proliferation, and chemotaxis of glomerular endothelial cells in a dose-dependent manner (p<0.05). Apelin also promoted the permeability of glomerular endothelial cells (p<0.05) and upregulated the expression of VEGFR2 and Tie2 in glomerular endothelial cells (p<0.05). These results indicated that upregulated apelin in type 2 diabetes, which may be attributed to increased fat mass, promotes angiogenesis in glomeruli to form abnormal vessels and that enhanced apelin increases permeability via upregulating the expression of VEGFR2 and Tie2 in glomerular endothelial cells.

Proteomic analysis of kidney and protective effects of grape seed procyanidin B2 in db/db mice indicate MFG-E8 as a key molecule in the development of diabetic nephropathy

Diabetic nephropathy, as a severe microvascular complication of diabetic mellitus, has become the leading cause of end-stage renal diseases. However, no effective therapeutic strategy has been developed to prevent renal damage progression to end stage renal disease. Hence, the present study evaluated the protective effects of grape seed procyanidin B2 (GSPB2) and explored its molecular targets underlying diabetic nephropathy by a comprehensive quantitative proteomic analysis in db/db mice. Here, we found that oral administration of GSPB2 significantly attenuated the renal dysfunction and pathological changes in db/db mice. Proteome analysis by isobaric tags for relative and absolute quantification (iTRAQ) identified 53 down-regulated and 60 up-regulated proteins after treatment with GSPB2 in db/db mice. Western blot analysis confirmed that milk fat globule EGF-8 (MFG-E8) was significantly up-regulated in diabetic kidney. MFG-E8 silencing by transfection of MFG-E8 shRNA improved renal histological lesions by inhibiting phosphorylation of extracellular signal-regulated kinase1/2 (ERK1⁄2), Akt and glycogen synthase kinase-3beta (GSK-3β) in kidneys of db/db mice. In contrast, over-expression of MFG-E8 by injection of recombinant MFG-E8 resulted in the opposite effects. GSPB2 treatment significantly decreased protein levels of MFG-E8, phospho-ERK1/2, phospho-Akt, and phospho-GSK-3β in the kidneys of db/db mice. These findings yield insights into the pathogenesis of diabetic nephropathy, revealing MFG-E8 as a new therapeutic target and indicating GSPB2 as a prospective therapy by down-regulation of MFG-E8, along with ERK1/2, Akt and GSK-3β signaling pathway.

Prevalence of type 2 diabetes in the States of the co-operation council for the Arab States of the Gulf: a systematic review

Aims

The recent and ongoing worldwide expansion in prevalence of Type 2 Diabetes (T2DM) is a considerable risk to individuals, health systems and economies. The increase in prevalence has been particularly marked in the states of the Co-operation Council for the Arab States of the Gulf (GCC), and these trends are set to continue. We aimed to systematically review the current prevalence of T2DM within these states, and also within particular sub-populations.

Methods

We identified 27 published studies for review. Studies were identified by systematic database searches. Medline and Embase were searched using terms such as diabetes mellitus, non-insulin-dependent, hyperglycemia, prevalence, epidemiology and Gulf States. Our search also included scanning reference lists, contacting experts and hand-searching key journals. Studies were judged against pre-determined inclusion and exclusion criteria, and where suitable for inclusion, data extraction and quality assessment was achieved using a specifically-designed tool. All studies where prevalence of diabetes was investigated were eligible for inclusion. The inclusion criteria required that the study population be of a GCC country, but otherwise all ages, sexes and ethnicities were included, resident and migrant populations, urban and rural, of all socioeconomic and educational backgrounds. No limitations on publication type, publication status, study design or language of publication were imposed. However, we did not include secondary reports of data, such as review articles without novel data synthesis.

Conclusions

The prevalence ofT2DM is an increasing problem for all GCC states. They may therefore benefit to a relatively high degree from co-ordinated implementation of broadly consistent management strategies. Further study of prevalence in children and in national versus expatriate populations would also be useful.

Metabolic encephalopathies

Kinnier Wilson coined the term metabolic encephalopathy to describe a clinical state of global cerebral dysfunction induced by systemic stress that can vary in clinical presentation from mild executive dysfunction to deep coma with decerebrate posturing; the causes are numerous. Some mechanisms by which cerebral dysfunction occurs in metabolic encephalopathies include focal or global cerebral edema, alterations in transmitter function, the accumulation of uncleared toxic metabolites, postcapillary venule vasogenic edema, and energy failure. This article focuses on common causes of metabolic encephalopathy, and reviews common causes, clinical presentations and, where relevant, management.

Pathophysiological role and therapeutic implications of inflammation in diabetic nephropathy

Diabetes mellitus and its complications are becoming one of the most important health problems in the world. Diabetic nephropathy is now the main cause of end-stage renal disease. The mechanisms leading to the development and progression of renal injury are not well known. Therefore, it is very important to find new pathogenic pathways to provide opportunities for early diagnosis and targets for novel treatments. At the present time, we know that activation of innate immunity with development of a chronic low grade inflammatory response is a recognized factor in the pathogenesis of diabetic nephropathy. Numerous experimental and clinical studies have shown the participation of different inflammatory molecules and pathways in the pathophysiology of this complication.

Protective effects of gallic acid on hepatic lipid peroxide metabolism, glycoprotein components and lipids in streptozotocin-induced type II diabetic Wistar rats

We evaluated the protective effects of gallic acid (3,4,5-trihydroxybenzoic acid) on hepatic lipid peroxidation products, antioxidants, glycoprotein components, and lipids in streptozotocin-induced type II diabetic rats. To induce type II diabetes, rats were injected with streptozotocin intraperitoneally at a single dose of 40 mg/kg. Gallic acid (10 and 20 mg/kg) treatment was given to diabetic rats orally using an intragastric tube daily for 21 days. Streptozotocin-induced diabetic rats showed a significant increase in the levels of blood glucose, hepatic lipid peroxidation products, glycoprotein components, lipids, and the activity of HMG-CoA reductase and a significant decrease in the levels of plasma insulin and liver glycogen. In addition to this, the activities/levels of hepatic antioxidants were decreased in diabetic rats. Gallic acid (10 and 20 mg/kg) treatment showed significant protective effects on all the biochemical parameters studied in diabetic rats. Thus, our study shows the antihyperglycemic, antilipid peroxidative, antioxidant, and antilipidemic effects of gallic acid in streptozotocin-induced type II diabetic rats. A diet containing gallic acid may be beneficial to type II diabetic patients.

Patient adherence to medication requirements for therapy of type 2 diabetes

Type 2 diabetes is a complex, progressive endocrine and metabolical disease that typically requires substantial lifestyle changes and multiple medications to lower blood glucose, reduce cardiovascular risk and address comorbidities. Despite an extensive range of available and effective treatments, < 50% of patients achieve a glycaemical target of HbA(1c) < 7.0% and about two-thirds die of premature cardiovascular disease. Adherence to prescribed therapies is an important factor in the management of type 2 diabetes that is often overlooked. Inadequate adherence to oral antidiabetes agents, defined as collecting < 80% of prescribed medication, is variously estimated to apply to between 36% and 93% of patients. All studies affirm that a significant proportion of type 2 diabetes patients exhibit poor adherence that will contribute to less than desired control. Identified factors that impede adherence include complex dosing regimens, clinical inertia, safety concerns, socioeconomic issues, ethnicity, patient education and beliefs, social support and polypharmacy. This review explores these factors and potential strategies to improve adherence in patients with type 2 diabetes.

Implications of type 2 diabetes on adolescent reproductive health risk: an expert model

PURPOSE

The purpose of this article was to summarize scientific knowledge from an expert panel on reproductive health among adolescents with type 2 diabetes (T2D).

METHODS

Using a mental model approach, a panel of experts--representing perspectives on diabetes, adolescents, preconception counseling, and reproductive health--was convened to discuss reproductive health issues for female adolescents with T2D.

RESULTS

Several critical issues emerged. Compared with adolescents with type 1 diabetes, (1) adolescents with T2D may perceive their disease as less severe and have less experience managing it, putting them at risk for complications; (2) T2D is more prevalent among African Americans, who may be less trusting of the medical establishment; (3) T2D is associated with obesity, and it is often difficult to change one's lifestyle within family environments practicing sedentary and dietary behaviors leading to obesity; (4) teens with T2D could be more fertile, because obesity is related to earlier puberty; (5) although obese teens with T2D have a higher risk of polycystic ovary syndrome, which is associated with infertility, treatment with metformin can increase fertility; and (6) women with type 2 diabetes are routinely transferred to insulin before or during pregnancy to allow more intensive management.

CONCLUSIONS

Findings from the expert panel provide compelling reasons to provide early, developmentally appropriate, culturally sensitive preconception counseling for teens with T2D.

Disorders of glucose metabolism in sleep-disordered breathing

Despite proliferating literature, the exact relationship between obstructive sleep apnea (OSA) and alterations in glucose metabolism is still controversial. There is growing evidence to suggest that OSA imposes adverse effects on glucose metabolism, but the translation into clinical effect is not well delineated. Many potential mechanisms are being explored, mostly relating to peripheral tissue response to insulin and more recently regarding pancreatic beta cell function of insulin secretion. The effect of OSA on glucose metabolism is likely to be influenced by many personal characteristics. Age, degree of adiposity, lifestyle, comorbidities, and even the stage of glucose disorder itself may modify the relationship between OSA and glucose metabolism. In the biologic system of the human body, all these interact to culminate in clinically relevant outcomes.

Snacking is associated with reduced risk of overweight and reduced abdominal obesity in adolescents: National Health and Nutrition Examination Survey (NHANES) 1999-2004

BACKGROUND

Snacking is common in adolescents; however, it is unclear if there is an association between snacking and overweight or obesity within the context of the overall diet.

OBJECTIVE

This study examined the associations of snacking with weight status and abdominal obesity in adolescents 12-18 y of age (n = 5811).

DESIGN

We conducted secondary analyses of 24-h diet recalls and anthropometric data from the National Health and Nutrition Examination Survey (NHANES) 1999-2004. We classified adolescents by frequency of snack consumption (0, 1, 2, 3, and > or =4 snacks/d) and by the percentage of energy intake from snacks (0%, <10%, 10-19%, 20-29%, 30-39%, and > or =40%). We classified adolescents who had a body mass index (BMI) > or =85th percentile of BMI-for-age as overweight or obese. We defined abdominal obesity as a waist circumference > or =90th percentile. We determined covariate-adjusted prevalences of overweight or obesity and abdominal obesity and odds ratios with SUDAAN software (release 9.0.1; Research Triangle Institute, Research Triangle Park, NC).

RESULTS

Mean values of all obesity indicators studied were inversely associated with snacking frequency and percentage of energy from snacks. The prevalence of overweight or obesity and of abdominal obesity decreased with increased snacking frequency and with increased percentage of energy from snacks. Odds ratios (95% CIs) for overweight or obesity and for abdominal obesity ranged from 0.63 (0.48, 0.85) to 0.40 (0.29, 0.57) and from 0.61 (0.43, 0.86) to 0.36 (0.21, 0.63) for 2 to > or =4 snacks/d, respectively. Reduced risks of overweight or obesity and abdominal obesity were associated with snacking.

CONCLUSION

Snackers, compared with nonsnackers, were less likely to be overweight or obese and less likely to have abdominal obesity.

Protective effects of Pycnogenol on hyperglycemia-induced oxidative damage in the liver of type 2 diabetic rats

Abnormal regulation of glucose and impaired carbohydrate utilization that result from a defective or deficient insulin are the key pathogenic events in type 2 diabetes mellitus (T2DM). Experimental and clinical studies have shown the antidiabetic effects of Pycnogenol (PYC). However, the protective effects of PYC on the liver, a major metabolic organ which primarily involves in glucose metabolism and maintains the normal blood glucose level in T2DM model have not been studied. The present study evaluated the beneficial effect of PYC, French maritime pine bark extract, on hyperglycemia and oxidative damage in normal and diabetic rats. Diabetes was induced by feeding rats with a high-fat diet (HFD; 40%) for 2 weeks followed by an intraperitoneal (IP) injection of streptozotocin (STZ; 40 mg/kg; body weight). An IP dose of 10mg/kg PYC was given continually for 4 weeks after diabetes induction. At the end of the 4-week period, blood was drawn and the rats were then sacrificed, and their livers dissected for biochemical and histopathological assays. In the HFD/STZ group, levels of glycosylated hemoglobin (HbA1c), significantly increased, while hepatic glycogen level decreased. PYC supplementation significantly reversed these parameters. Moreover, supplementation with PYC significantly ameliorated thiobarbituric reactive substances, malonaldehyde, protein carbonyl, glutathione and antioxidant enzymes [glutathione-S-transferase, catalase, superoxide dismutase, glutathione peroxidase and glutathione reductase] in the liver of HFD/STZ rats. These results were supported with histopathological examinations. Although detailed studies are required for the evaluation of the exact protective mechanism of PYC against diabetic complications, these preliminary experimental findings demonstrate that PYC exhibits antidiabetic effects in a rat model of type 2 DM by potentiating the antioxidant defense system. These finding supports the efficacy of PYC for diabetes management.

Pathogenic perspectives for the role of inflammation in diabetic nephropathy

Diabetes and its complications have become a public health problem. One of the most important complications is diabetic nephropathy, which is nowadays the main cause of chronic renal failure. In spite of our greater understanding of this complication, the intimate mechanisms leading to the development and progression of renal injury are not well understood. New perspectives in activated innate immunity and inflammation appear to be relevant factors in the pathogenesis of diabetes. Moreover, different inflammatory molecules, including adipokines, Toll-like receptors, chemokines, adhesion molecules and pro-inflammatory cytokines, may be critical factors in the development of microvascular diabetic complications, including nephropathy. This new pathogenic perspective leads to important therapeutic considerations, with new pathogenic pathways becoming important therapeutic targets that can be translated into clinical treatments for diabetic nephropathy.

Four-fold increase in foot ulcers in type 2 diabetic subjects without an increase in major amputations by a multidisciplinary setting

AIMS

We observed a large increase in type 2 diabetic subjects with foot ulcers in our diabetic outpatient foot clinic and wanted to identify the amputations rate and individuals at risk of amputations by comparing those who had had a regular control in the multidisciplinary foot clinic prior to the amputations and those who had not.

METHODS

We examined all clinical records from the orthopaedic surgery department and the diabetic outpatient foot clinic of diabetic patients who underwent amputations for 6 years.

RESULTS

Eighty-eight patients with type 2 diabetes underwent 142 amputations; 42 major and 100 minor amputations. There was no increase in the number of major amputations in this period. In the group not followed in the foot clinic prior to amputations we showed a greater major amputations rate (p<0.05), although this group had a shorter duration of diabetes and less retinopathy, nephropathy and AMI/stroke. Everyone in both groups had severe neuropathy and ischemia.

CONCLUSION

A multidisciplinary diabetic foot clinic may decrease the risk of major amputations in type 2 diabetic subjects with foot ulcers. Severe neuropathy and ischemia were the most important risk factors.

Tumor necrosis factor-alpha as a therapeutic target for diabetic nephropathy

Activation of innate immunity with the subsequent development of a chronic low-grade inflammatory response is now recognized as a critical factor in the pathogenesis of diabetes mellitus and diabetic complications, including diabetic nephropathy. In the setting of diabetic nephropathy, there is now evidence of the relevant contribution of pro-inflammatory cytokines, with special participation of tumor necrosis factor-alpha (TNF-alpha). This new pathogenic perspective leads to new therapeutic implications derived from modulation of inflammation and inflammatory cytokines. Experimental studies have shown the beneficial renal actions derived from TNF-alpha inhibition with the use of soluble TNF-alpha receptor fusion proteins, chimeric monoclonal antibodies and pentoxifylline (PTF). Clinical application of this strategy is nowadays limited to PTF administration, which has demonstrated significant beneficial effects in patients with diabetic nephropathy. Overall, these studies indicate that inhibition of TNF-alpha might be an efficacious treatment for renal disease secondary to diabetes mellitus.

Obstructive sleep breathing disorders

Obstructive sleep apnea (OSA) is increasingly recognized in children. There is accumulating robust evidence to support early diagnosis and treatment of this condition. The purpose of this review is to provide an update on the epidemiology, clinical features, complications, and treatment of childhood OSA. The authors have also proposed an easy-to-follow flowchart on the management of children with snoring or sleep disturbance for clinical use by busy pediatricians.

Incidence of type 1 and type 2 diabetes in adults and children in Kronoberg, Sweden

All newly diagnosed diabetes in Kronoberg during 3 years was registered, with blood samples from 1630/1666 (97.8%) adults. Those positive for GADab and/or ICA and/or C-peptide<0.25nmol/L (0.7%) were classified as type 1 diabetes, the remaining as type 2. Incidence of type 1 in 0-19-year-olds was 37.8(36.1-39.6, 95%CI) and in 20-100 year-olds 27.1(25.6-27.4) per 100 000 and year, it was bimodal with equal peaks in 0-9 year-olds and in 50-80-year-olds. Adults had type 2 incidence 378 (375-380), children 3.1 (2.6-3.6). Among adults 6.9% had type 1 and 93.1% type 2. Among antibodypositive adults (n=101), GADab were present in 90%, ICA in 71%, both GADab and ICA in 61%. Ophthalmology contact as second source was confirmed for 98%. There were no gender differences in type 1 in any age group, small ones in pediatric subgroups. In type 2 men predominated in ages above 40 years. Incidences of type 1 diabetes in both children and adults were very high and as high above age 50 years as in children. Incidence of type 2 was the highest reported from Sweden, to which new diagnostic criteria, a high degree of case-finding, and many elders, may have contributed, but results may also reflect a true increase in incidence of both types of diabetes.

Childhood obesity: a transtheoretical case management approach

Childhood obesity is an increasing health problem because of its strong associations with chronic health problems in children and adults. Obesity during childhood commonly persists into adulthood and is resistant to interventions that involve only recommendations to decrease caloric intake and to increase caloric expenditure through increased physical activity. The challenge with this approach to childhood obesity is that it is not theoretically based, nor does it consider the child's or the parent's perceptions of the health problem or their transition along the stages of behavioral change. Case management has been proven to be successful in managing various chronic health problems in both adults and children. This article will introduce a new intervention model based on the transtheoretical framework by utilizing case management in a primary care setting to treat childhood obesity.

A Review of the Relationship Between 100% Fruit Juice Consumption and Weight in Children and Adolescents

Studies assessing a relationship between consumption of 100% fruit juice by children and adolescents and weight are contradictory. The purpose of this review was to assess the 9 cross-sectional and 12 longitudinal studies that have looked at this association. Of the 9 cross-sectional studies reviewed, only 3 reported any association. Those studies used small, local convenience samples of preschool children; furthermore, selection criteria were not well defined. One found that preschool children consuming ≥ 12 fluid oz/day of 100% fruit juice had a higher prevalence of overweight than those who consumed less than 12 oz/day (32% vs 9%). Later, a separate study showed that this relationship held only for apple juice. Another study demonstrated an association of overweight and energy from juice. These 3 studies were not nationally representative. Only 3 of the longitudinal studies showed an association between 100% fruit juice consumption and weight; 1 found an association only in adolescent girls, and 2 reported an association in children who were already overweight. None of the longitudinal studies was nationally representative, but 5 had sample sizes of at least 1000, 2 were ethnically diverse, and 3 had geographically separate sites, suggesting that the findings could be applicable to wider populations. Based on the currently available evidence, it can be concluded that there is no systematic association between consumption of 100% fruit juice and overweight in children or adolescents. Data do support consumption of 100% fruit juice in moderate amounts and suggest that consumption of 100% fruit juice may be an important strategy to help children meet the current recommendations for fruit.

Are breakfast consumption patterns associated with weight status and nutrient adequacy in African-American children?

OBJECTIVE

The objective of the present study was to assess whether weight status, nutrient intake and dietary adequacy were associated with breakfast consumption patterns.

DESIGN

A representative sample of the US population was used in a secondary analysis of nutrient intake/diet quality and weight status by breakfast consumption patterns.

SETTING

The 1999-2002 National Health and Nutrition Examination Survey (NHANES).

SUBJECTS

The study sample included African-American (AA) children aged 1-12 years (n 1389).

RESULTS

Forty-five per cent of children aged 1-5 years and 38 % of those aged 6-12 years consumed ready-to-eat cereal (RTEC) at breakfast; while 7.4 % and 16.9 % in those age groups skipped breakfast, respectively. The lowest mean BMI (P <or= 0.05) and mean waist circumference (P <or= 0.05) was found in children 1-12 years of age who consumed RTEC at breakfast compared with other consumption groups. RTEC breakfast consumers had the highest mean intakes of vitamins A, B6 and B12, thiamine, riboflavin, niacin, folate, Ca, Fe and Zn (P <or= 0.05) and the highest Mean Adequacy Ratio (P <or= 0.05). RTEC breakfast consumers also had the highest intake of carbohydrates and total sugars, and the lowest intakes of total fat (P <or= 0.05).

CONCLUSIONS

Consuming RTEC at breakfast was associated with improved weight and nutrient adequacy in AA children. AA children in all breakfast categories still had mean intakes of most nutrients below recommended levels. The implications are that consuming a breakfast meal should be encouraged in these children, and that RTEC at breakfast provides important nutrients and may help promote a healthy weight.

Peripheral neuropathy is an early complication of type 2 diabetes in adolescence

OBJECTIVE

To screen for microvascular complications in adolescents with type 2 diabetes mellitus (T2DM).

SUBJECTS AND METHODS

Seven adolescents with T2DM were assessed for early secondary complications. Median duration of diabetes was 1.8 (0.8-3.0) yr. All were assessed as follows: blood pressure, ophthalmologic examination for diabetic retinopathy, renal function, full blood count and vitamin B12 levels (to exclude B12 malabsorption - a side effect of metformin), random urine for microalbuminuria, an electrocardiogram (ECG) rhythm strip and podiatry performed by an experienced podiatrist. Testing for peripheral neuropathy included foot pulse palpation, tendo-Achilles reflexes, plantar callus test, large nerve fibre function (vibration and threshold for light touch/pressure) assessed by a 128-Hz tuning fork, and by the standard 10-g Semmes-Weinstein monofilament test, and small nerve fibre function (pain) assessed by pinprick neurotip.

RESULTS

Four adolescents had evidence of peripheral neuropathy on clinical examination, with abnormal large and small nerve fibre function. Six had plantar callus present, and four had weak but palpable posterior tibial pulses. All had normal tendo-Achilles reflex and normal response to vibration. None had diabetic retinopathy or hypertension. Renal function, full blood count (FBC), B12 levels and ECGs were normal. None of 120 adolescents with type 1 diabetes mellitus (T1DM) assessed by the same podiatrist had any signs of peripheral neuropathy.

CONCLUSIONS

Unlike T1DM, peripheral neuropathy can be present soon after diagnosis in those with T2DM. Children with T2DM need surveillance for complications from the time of diagnosis.

Neural Systems Controlling the Drive to Eat: Mind Versus Metabolism

With the bleak outlook that 75% of Americans will be overweight or obese in 10 years, it is essential to find efficient help very soon. Knowledge of the powerful and complex neural systems conferring the basic drive to eat is a prerequisite for designing efficient therapies. Recent studies suggest that the cross talk between brain areas involved in cognitive, emotional, and metabolic-regulatory functions may explain why energy homeostasis breaks down for many predisposed individuals in our modern environment.

PRODIACOR: A patient-centered treatment program for type 2 diabetes and associated cardiovascular risk factors in the city of Corrientes, Argentina

OBJECTIVE

To implement a controlled clinical trial (PRODIACOR) in a primary care setting designed 1) to improve type 2 diabetes care and 2) to collect cost data in order to be able to measure cost-effectiveness of three system interventions (checkbook of indicated procedures, patient/provider feedback and complete coverage of medications and supplies) and physician and/or patient education to improve psychological, clinical, metabolic and therapeutic indicators. All three Argentinean health subsectors (public health, social security and the private, prepaid system) are participants in the study. Patients of participating physicians were randomly selected and assigned to one of four groups: control, provider education, patient education, and provider/patient education; the system interventions were provided to all four groups.

BASELINE RESULTS

Mean BMI was 29.8 kg/m(2); most subjects had blood pressure, fasting glucose and total cholesterol above targets recommended by international standards. Only 1% had had microalbuminuria measured, 57% performed glucose self-monitoring, 37% had had an eye examination and 31% a foot examination in the preceding year. Ten percent, 26% and 73% of people with hyperglycemia, hypertension and dyslipidemia, respectively, were not on medications. Most patients treated with either insulin or oral antidiabetic agents were on monotherapy as were those treated for hypertension and dyslipidemia. WHO-5 questionnaire scores indicated that 13% of the subjects needed psychological intervention.

CONCLUSIONS

Baseline data show multiple deficiencies in the process and outcomes of care that could be targeted and improved by PRODIACOR intervention.

The timing of nutrient restriction during rat pregnancy/lactation alters metabolic syndrome phenotype

OBJECTIVE

Modulation of growth of intrauterine growth restricted (IUGR) newborns causes either adult obesity or normalization of body weight and fat. We investigated the impact of rapid versus delayed catch-up growth of IUGR offspring on glucose and lipid profiles.

STUDY DESIGN

From 10 days to term gestation and through lactation, control pregnant rats received ad libitum food, whereas study rats were 50% food restricted. Cross-fostering techniques were used to examine effects of food restriction during pregnancy and/or lactation periods. Glucose and lipid profiles were determined in offspring at ages 1 day, 3 weeks, and 9 months.

RESULTS

Food restriction during pregnancy produced hypoglycemic IUGR pups. Those permitted rapid catch-up growth demonstrated adult obesity with insulin resistance (hyperglycemia/hyperinsulinemia) and hypertriglyceridemia. Conversely, IUGR exhibiting delayed catch-up growth demonstrated normal adult body weight and insulin deficiency (hyperglycemia/hypoinsulinemia) and elevated cholesterol levels as compared with controls. However, these adult offspring had higher glucose though similar insulin levels as control offspring nursed by food restricted dam.

CONCLUSION

The timing and the rate of IUGR newborn catch-up growth causes markedly altered adult phenotypes. Although delayed newborn catch-up growth may be beneficial in the prevention of adult obesity, there may be significant adverse effects on pancreatic function.

Gender-specific programmed hepatic lipid dysregulation in intrauterine growth-restricted offspring

OBJECTIVE

Intrauterine growth restriction demonstrates increased risk of adult metabolic syndrome. The associated hyperlipidemia results from obesity or programmed metabolic abnormalities. Because lipid homeostasis is regulated by the liver, we hypothesized that hepatic structure and lipid content in intrauterine growth restriction would reflect a primary lipid dysfunction.

STUDY DESIGN

From 10 days to term gestation, control pregnant rats received ad libitum diet; study rats were 25% food-restricted (FR). All dams received ad libitum diet throughout lactation. At 3 weeks of age, hepatic lobule size and lipid profile of the pups were determined.

RESULTS

At 3 weeks of age, body and liver weights of the pups were comparable with controls, although with reduced hepatic lobule size. FR males had increased hepatic triglyceride and cholesterol content with elevated sterol regulatory element-binding protein-1c, fatty acid synthase, and lipoprotein lipase expression; FR females exhibited decreased hepatic cholesterol levels. Plasma lipid levels were unchanged in FR males and females.

CONCLUSION

Developmental programming results in sex-dependent altered lipid metabolism with increased risk in males.

Interactions between the "cognitive" and "metabolic" brain in the control of food intake

If the new environment and modern lifestyle cause obesity in individuals with thrifty genes by increasing energy intake, it is important to know by what mechanisms hyperphagia occurs and why energy balance is not kept in check by the homeostatic regulator. The argument is developed that procuring and ingesting food is an evolutionarily conserved survival mechanism that occupies large parts of the brain's computing capacity including not only the hypothalamus but also a number of cortico-limbic structures. These forebrain systems evolved to engage powerful emotions for guaranteed supply and ingestion of beneficial foods from a sparse and often hostile environment. They are now simply overwhelmed with an abundance of food and food cues that is no longer interrupted by frequent famines. After briefly reviewing structure and functions of the relevant cortico-limbic structures and the better-known hypothalamic homeostatic regulator, the review focuses mainly on interactions between the two systems. Although several cortico-limbic processes are sensitive to metabolic depletion and repletion signals, it appears that they are underlying the same reversible leptin resistance that renders hypothalamic circuits insensible to continuously high leptin levels during periods of feast. It is hypothesized that this naturally occurring leptin resistance allowed temporary neutralization of satiety mechanisms and evolved as a response to survive subsequent periods of famine. With today's continuous and abundant food availability for a segment of the population, the powerful cognitive processes to eat and the resulting overweight can partially escape negative feedback control in prone individuals most strongly expressing such thrifty genes.

Self-monitoring of blood glucose levels requires intensive training for use of meters to obtain reliable and clinically relevant measurements

BACKGROUND

Anecdotal reports from pediatric sites have indicated that some blood glucose meters may display wrong and misleading numbers rather than error indications, when operated in deviation from the instructions for use (IFU), eg by manipulating the strip during the count-down phase.

METHODS

This study was performed with 60 patients with diabetes (32 female, 28 male, 21 type 1, 39 type 2, age (mean+/-SD): 56+/-11 years) who measured their blood glucose levels twice with five different blood glucose meters (Precision(R) Xceed [Abbott Medisense], Freestyle Mini [Abbott Medisense], Accu-Chek Comfort [Roche Diagnostics], Accu-Chek Aviva [Roche Diagnostics], and Ascensia Contour [Bayer Vital]). The first measurement was performed in accordance with the IFU, and the second by manipulating the test strip using a standardised inflexion/release procedure during the count-down phase. A standard glucose oxidase method (SuperGL) served as laboratory reference.

RESULTS

All meters worked in full compliance with current accuracy standards when operated according to the IFU. When manipulating the test strip, the results varied considerably: While changes in reliability were acceptable for two devices (Precision Xceed, Freestyle Mini), the other devices produced an unacceptable number of errors and a series of entirely wrong values without error indication.

CONCLUSIONS

The use of all devices is recommended when used according to the IFU. The use under the artificially induced impaired testing conditions is a major concern. This study underlines the importance of appropriate patient training regarding adherence to the IFU of glucose meters.

Obesity and obstructive sleep apnea in children

The prevalence and severity of obesity in children and adolescent is dramatically increasing worldwide with a corresponding increase in the prevalence of obesity-associated morbidities particularly those involving OSAS and metabolic and cardiovascular sequelae. Obstructive sleep apnea and obesity hypoventilation syndrome are important and serious consequences of obesity, and may in fact mediate components of the association between obesity and metabolic and cardiovascular morbidities, most likely via potentiation of inflammatory cascades. It is anticipated that the increased prevalence of obesity in children and adolescents in our society will be accompanied by a steady increase in the incidence of OSAS. In this review, we will examine our current understanding of sleep-disordered breathing and associated morbidities in obese children, and summarize the range of therapeutic modalities currently available for this high-risk population.

The platelet as a therapeutic target for treating vascular diseases and the role of eicosanoid and synthetic PPARgamma ligands

The platelet was traditionally thought only to serve as the instigator of thrombus formation, but now is emerging as a pivotal player in cardiovascular disease and diabetes by inciting and maintaining inflammation. Upon activation, platelets synthesize eicosanoids such as thromboxane A2 (TXA2) and PGE2 and release pro-inflammatory mediators including CD40 ligand (CD40L). These mediators activate not only platelets, but also stimulate vascular endothelial cells and leukocytes. These autocrine and paracrine activation processes make platelets an important target for attenuating inflammation. The growing interest and recent discoveries in platelet biology has lead to the search for therapeutic platelet targets. Recently, platelets, although anucleate, were discovered to possess the transcription factor PPARgamma. Treatment with eicosanoid and synthetic PPARgamma ligands blunts platelet release of the bioactive mediators, soluble (s) CD40L and TXA2, in thrombin-activated platelets. PPARgamma ligand treatment may prove useful for dampening unwanted platelet activation and chronic inflammatory diseases such as cardiovascular disease.

Prevalence of diabetes, metabolic syndrome and metabolic abnormalities in schizophrenia over the course of the illness: a cross-sectional study

Background

Patients with schizophrenia are at high risk of developing metabolic abnormalities.

Method

A prospective study focusing on metabolic disturbances in patients with schizophrenia, including an oral glucose tolerance test, is currently ongoing at our University Hospital and affiliate services. The prevalence of metabolic abnormalities at baseline was assessed in a cohort of 415 patients with schizophrenia. The sample was divided into 4 groups according to duration of illness: first-episode patients (<1.5 years), recent-onset patients (between 1.5 and 10 years), subchronic patients (between 10 and 20 years) and chronic patients (>20 years).

Results

Metabolic abnormalities were already present in first-episode patients, and considerably increased with increasing duration of illness. When compared to the general population matched for age and gender, much higher rates of the metabolic syndrome (MetS) and diabetes were observed for patients with schizophrenia. For MetS, the increase over time was similar to that of the general population. In contrast, the difference in the prevalence of diabetes in patients with schizophrenia and the general population dramatically and linearly increased from 1.6% in the 15–25 age-band to 19.2% in the 55–65 age-band.

Conclusion

Thus, the current data suggest that on the one hand metabolic abnormalities are an inherent part of schizophrenic illness, as they are already present in first-episode patients. On the other hand, however, our results suggest a direct effect of the illness and/or antipsychotic medication on their occurence. The data underscore the need for screening for metabolic abnormalities in patients diagnosed with schizophrenia, already starting from the onset of the illness.