Poor lipid control in type-2 diabetics with and without ischemic heart disease

The achievement of comprehensive control targets among type 2 diabetes mellitus patients of different ages

Objective: To evaluate achievement of comprehensive controls among patients with type 2 diabetes mellitus (T2DM) in different age groups.

Results: The elderly patients had higher control rates for BMI (44.36%), TC (50.83%) and LDL-C (48.27%) than those aged 60-80 years and younger patients (all P <0.05). Multiple logistic regression revealed that elderly patients were more likely to achieve control targets for HbA1c (odd ratio (OR) = 2.19), TC (OR = 1.32), HDL-C (OR = 1.35), and TG (OR = 1.74) than younger patients. This effect was stronger in males (OR_HbA1c = 2.27; OR_TC = 1.41; OR_HDL-C = 1.51; OR_TG = 1.80). By contrast, elderly females were only more likely to achieve HbA1c < 7.0% (OR=1.88).

Conclusions: Our findings suggest that comprehensive control strategies still should be strengthened.

Methods: A total of 3126 T2DM patients were included, and detected blood pressure (BP), body mass index (BMI), glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), postprandial plasma glucose (PPG), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), triglycerides (TG), and high-density lipoprotein cholesterol (HDL-C). We divided patients into three age groups (<60, 60-80 and ≥ 80 years), to assess the differences in achieving the control targets.

High Fat Diet Upregulates Fatty Acid Oxidation and Ketogenesis via Intervention of PPAR-γ

Background/Aims:

Systemic hyperlipidemia and intracellular lipid accumulation induced by chronic high fat diet (HFD) leads to enhanced fatty acid oxidation (FAO) and ketogenesis. The present study was aimed to determine whether activation of peroxisome proliferator-activated receptor-γ (PPAR-γ) by surplus free fatty acids (FA) in hyperlipidemic condition, has a positive feedback regulation over FAO and ketogenic enzymes controlling lipotoxicity and cardiac apoptosis.

Methods:

8 weeks old C57BL/6 wild type (WT) or PPAR-γ^−/− mice were challenged with 16 weeks 60% HFD to induce obesity mediated type 2 diabetes mellitus (T2DM) and diabetic cardiomyopathy. Treatment course was followed by echocardiographic measurements, glycemic and lipid profiling, immunoblot, qPCR and immunohistochemistry (IHC) analysis of PPAR-γ and following mitochondrial metabolic enzymes 3-hydroxy-3- methylglutaryl-CoA synthase (HMGCS2), mitochondrial β-hydroxy butyrate dehydrogenase (BDH1) and pyruvate dehydrogenase kinase isoform 4 (PDK4). In vivo model was translated in vitro, with neonatal rat cardiomyocytes (NRCM) treated with PPAR-γ agonist/antagonist and PPAR-γ overexpression adenovirus in presence of palmitic acid (PA). Apoptosis was determined in vivo from left ventricular heart by TUNEL assay and immunoblot analysis.

Results:

We found exaggerated circulating ketone bodies production and expressions of the related mitochondrial enzymes HMGCS2, BDH1 and PDK4 in HFD-induced diabetic hearts and in PA-treated NRCM. As a mechanistic approach we found HFD mediated activation of PPAR-03B3 is associated with the above-mentioned mitochondrial enzymes. HFD-fed PPAR-γ^−/− mice display decreased hyperglycemia, hyperlipidemia associated with increased insulin responsiveness as compared to HFD-fed WT mice PPAR-γ^−/−−HFD mice demonstrated a more robust functional recovery after diabetes induction, as well as significantly reduced myocyte apoptosis and improved cardiac function.

Conclusions:

PPAR-γ has been described previously to regulate lipid metabolism and adipogenesis. The present study suggests for the first time that increased PPAR-γ expression by HFD is responsible for cardiac dysfunction via upregulation of mitochondrial enzymes HMGCS2, BDH1 and PDK4. Targeting PPAR-γ and its downstream mitochondrial enzymes will provide novel strategies in preventing metabolic and myocardial dysfunction in diabetes mellitus.

Predictors of poor glycaemic control in older patients with type 2 diabetes mellitus

INTRODUCTION

We assessed the predictors of poor glycaemic control among older patients with type 2 diabetes mellitus (T2DM) in Malaysia.

METHODS

This cross-sectional study used the data of 21,336 patients aged ≥ 60 years with T2DM from the Adult Diabetes Control and Management Registry 2008-2009.

RESULTS

Predictors of poor glycaemic control were: age groups 60-69 years (odds ratio [OR] 1.96, 95% confidence interval [CI] 1.66-2.33) and 70-79 years (OR 1.43, 95% CI 1.20-1.71); Malay (OR 1.53, 95% CI 1.41-1.66) and Indian (OR 1.32, 95% CI 1.19-1.46) ethnicities; T2DM durations of 5-10 years (OR 1.46, 95% CI 1.35-1.58) and > 10 years (OR 1.75, 95% CI 1.59-1.91); the use of oral antidiabetic agents only (OR 5.86, 95% CI 3.32-10.34), insulin only (OR 17.93, 95% CI 9.91-32.43), and oral antidiabetic agents and insulin (OR 29.42, 95% CI 16.47-52.53); and elevated blood pressure (OR 1.10, 95% CI 1.01-1.20), low-density lipoprotein cholesterol (OR 1.48, 95% CI 1.38-1.59) and triglycerides (OR 1.61, 95% CI 1.51-1.73). Hypertension (OR 0.71, 95% CI 0.64-0.80), hypertension and dyslipidaemia (OR 0.68, 95% CI 0.61-0.75), pre-obesity (OR 0.89, 95% CI 0.82-0.98) and obesity (OR 0.76, 95% CI 0.70-0.84) were less likely to be associated with poor glycaemic control.

CONCLUSION

Young-old and middle-old age groups (i.e. < 80 years), Malay and Indian ethnicities, longer T2DM duration, the use of pharmacological agents, and elevated blood pressure and lipid levels were associated with poor glycaemic control. The presence of comorbidities, pre-obesity and obesity were less likely to be associated with poor glycaemic control.

Clinical characteristics and complications of patients with type 2 diabetes attending an urban hospital in Bangladesh

AIMS

To investigate the clinical features of patients with type 2 diabetes on oral medication and determine the complications and risk factors in these patients.

METHODS

A cross-sectional was conducted among 515 patients with type 2 diabetes at the outpatient clinics of Bangladesh Institute of Health Science (BIHS) hospital from September to December 2013. We collected data on socio-economic characteristics, clinical status, risk factors, complications, anthropometric measurements and blood tests. Univariate and multivariate logistic regression was performed to identify risk factors associated with diabetes complications.

RESULTS

The mean(±SD) age of the participants was 50.0(±10.1) years and 15.3% were less than 40 years. The mean HbA1c was 8.3(±2.1). Only 28.7% of the participants achieved targets for HbA1c. The overall prevalence of hypertension, obesity and dyslipidemia was 57.5%, 62.6% and 72.7%, respectively. Eye problems were the most common complication (68.9%) followed by chronic kidney diseases (21.3%) and cardiovascular diseases (11.8%). There were significant associations between the complications and age, duration of diabetes and duration of hypertension. In the multivariate analysis adjusting for other confounding variables, only systolic blood pressure was found to be significantly associated with complications [OR 0.809, 95% CI 0.666-0.981 (p-value 0.031)].

CONCLUSION

Results of the study confirm that even under best clinical settings a great majority Bangladeshi adults with type 2 diabetes have uncontrolled diabetes and a high prevalence of risk factors that might contribute to early development of complications. Early screening of high risk groups and proper management of diabetes is recommended to avoid early complications.

Control of glycemia and other cardiovascular disease risk factors in older adults with type 2 diabetes mellitus: data from the Adult Diabetes Control and Management

AIM

The aims of the present study were to assess the control of glycemia and other cardiovascular disease risk factors, and the association between age and these controls among older adults with type 2 diabetes in Malaysia.

METHODS

A cross-sectional study was carried out using cases notified to the Adult Diabetes Control and Management database between 1 January and 31 December 2009. A total of 10 363 people aged over 60 years with type 2 diabetes mellitus were included in the analyses. A standard online case report form was used to record demographic data, clinical factors (diabetes duration, comorbid condition and treatment modalities), cardiovascular disease risk factors, diabetes complications and laboratory assessments. The cardiovascular disease risk factors controls assessed included glycosylated hemoglobin (HbA(1c)) <7.0%, blood pressure, body mass index, waist circumference and lipid profiles.

RESULTS

The proportion of older adults who achieved target HbA(1c) (<7.0%) was 41.7%. A greater proportion of older adults aged ≥80 years significantly achieved the targets of HbA(1c) <7% (P < 0.001), waist circumference (P < 0.001), low-density lipoprotein cholesterol <2.6 mmol/L (P = 0.007) and triglycerides <1.7 mmol/L (P = 0.001) when compared with the younger elderly groups. They were also associated with achieving target HbA(1c) <7.0% (OR = 1.90, 95% CI 1.68-2.26) and triglycerides <1.7 mmol/L (OR = 1.20, 95%CI 1.04-1.46) than those aged 60-69 years.

CONCLUSION

The control of cardiovascular disease risk factors was suboptimal in older adults with type 2 diabetes. The oldest elderly were more likely to achieve target HbA(1c) (<7.0%) and triglycerides (<1.7 mmol/L) than older adults aged 60-69 years.

Aldo-keto reductase and sorbitol dehydrogenase enzymes in Egyptian diabetic patients with and without proliferative diabetic retinopathy

BACKGROUND

Activation of the polyol pathway due to increased aldo-keto reductase (AKR) activity has been implicated in the development of diabetic complications, including proliferative diabetic retinopathy (PDR); however, the relationship between hyperglycaemia-induced activation of the polyol pathway in the retina and PDR is still uncertain.

METHODS

This study was conducted on 73 individuals, who were categorised into three groups: healthy individuals as normal control (15 age-matched subjects), diabetic patients treated with oral hypoglycaemic drugs (OHD, 34 patients), six of whom (17.7 per cent) were diagnosed with PDR and the rest were diagnosed with non-proliferative diabetic retinopathy (NPDR) and diabetic patients treated with insulin (INS, 24 patients), 12 of whom (50 per cent) were diagnosed with PDR and the rest had NPDR.

RESULTS

The AKR level in diabetic subjects showed a significant increase compared with the normal controls. Interestingly, AKR levels were significantly increased in the INS compared with the OHD group. Also the AKR level was significantly increased in the patients with proliferative compared with the non-proliferative retinopathy in both the insulin and oral diabetic groups. The sorbitol dehydrogenase (SDH) level in diabetic patients showed a significant decrease compared with the normal control level. Interestingly, the SDH level was significantly decreased in the INS compared with the OHD group. Also, the SDH level was significantly decreased in patients with proliferative compared with non-proliferative retinopathy in both INS and OHD groups. The HbA(1c) level in both INS and OHD subjects showed a significant increase compared with normal controls. In addition, the triglyceride level in insulin proliferative retinopathy showed a significant increase compared with other groups.

CONCLUSIONS

The AKR level was significantly increased in patients with proliferative compared with non-proliferative retinopathy in both insulin and oral diabetic groups. The SDH level was significantly decreased in patients with proliferative compared with non-proliferative retinopathy in both insulin and oral diabetic groups. Both AKR and SDH could be used as indicators for diabetic control.

Quality of type 2 diabetes management in the states of the Co-operation Council for the Arab States of the Gulf: a systematic review

Type 2 diabetes mellitus is a growing, worldwide public health concern. Recent growth has been particularly dramatic in the states of The Co-operation Council for the Arab States of the Gulf (GCC), and these and other developing economies are at particular risk. We aimed to systematically review the quality of control of type 2 diabetes in the GCC, and the nature and efficacy of interventions. We identified 27 published studies for review. Studies were identified by systematic database searches. Medline and Embase were searched separately (via Dialog and Ovid, respectively; 1950 to July 2010 (Medline), and 1947 to July 2010 (Embase)) on 15/07/2009. The search was updated on 08/07/2010. Terms such as diabetes mellitus, non-insulin-dependent, hyperglycemia, hypertension, hyperlipidemia and Gulf States were used. Our search also included scanning reference lists, contacting experts and hand-searching key journals. Studies were judged against pre-determined inclusion/exclusion criteria, and where suitable for inclusion, data extraction/quality assessment was achieved using a specifically-designed tool. All studies wherein glycaemic-, blood pressure- and/or lipid- control were investigated (clinical and/or process outcomes) were eligible for inclusion. No limitations on publication type, publication status, study design or language of publication were imposed. We found the extent of control to be sub-optimal and relatively poor. Assessment of the efficacy of interventions was difficult due to lack of data, but suggestive that more widespread and controlled trial of secondary prevention strategies may have beneficial outcomes. We found no record of audited implementation of primary preventative strategies and anticipate that controlled trial of such strategies would also be useful.

PPARγ-induced cardiolipotoxicity in mice is ameliorated by PPARα deficiency despite increases in fatty acid oxidation

Excess lipid accumulation in the heart is associated with decreased cardiac function in humans and in animal models. The reasons are unclear, but this is generally believed to result from either toxic effects of intracellular lipids or excessive fatty acid oxidation (FAO). PPARγ expression is increased in the hearts of humans with metabolic syndrome, and use of PPARγ agonists is associated with heart failure. Here, mice with dilated cardiomyopathy due to cardiomyocyte PPARγ overexpression were crossed with PPARα-deficient mice. Surprisingly, this cross led to enhanced expression of several PPAR-regulated genes that mediate fatty acid (FA) uptake/oxidation and triacylglycerol (TAG) synthesis. Although FA oxidation and TAG droplet size were increased, heart function was preserved and survival improved. There was no marked decrease in cardiac levels of triglyceride or the potentially toxic lipids diacylglycerol (DAG) and ceramide. However, long-chain FA coenzyme A (LCCoA) levels were increased, and acylcarnitine content was decreased. Activation of PKCα and PKCδ, apoptosis, ROS levels, and evidence of endoplasmic reticulum stress were also reduced. Thus, partitioning of lipid to storage and oxidation can reverse cardiolipotoxicity despite increased DAG and ceramide levels, suggesting a role for other toxic intermediates such as acylcarnitines in the toxic effects of lipid accumulation in the heart.