Estimating the population prevalence of diagnosed and undiagnosed diabetes

Unmasking the silent epidemic: a comprehensive systematic review and meta-analysis of undiagnosed diabetes in Ethiopian adults

Background

Undiagnosed diabetes mellitus poses a significant global public health concern, exerting a substantial impact on the well-being of individuals, their families, and societies at large. Those individuals with undiagnosed diabetes miss opportunities to maintain quality of life and prevent diabetes-related complications. Even if there are ample primary studies on undiagnosed diabetes in Ethiopia, the results reveal conflicting results. Therefore, a comprehensive national picture of undiagnosed diabetes is essential for designing effective strategies at the national level.

Methods

This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for prevalence studies (PROSPERO ID: CRD42021266676). PubMed, Web of Science and the World Health Organization's Hinari portal were searched using a strategy developed in collaboration with Liberians. The inclusion criteria comprised studies reporting undiagnosed diabetes in Ethiopia. Two independent reviewers conducted a quality assessment using a 10-item appraisal tool. Meta-analysis and meta-regression were performed using a random-effects model.

Result

Twenty-five studies with 22,193 participants met the inclusion criteria. The pooled prevalence of undiagnosed diabetes among the Ethiopian adult population was 5.68% (95% CI: 4.53 - 6.83, I2 = 75.4). Factors significantly associated with undiagnosed diabetes include age, waist circumference, overweight, family history of diabetes, and a history of hypertension.

Conclusion

Our systematic review found a noteworthy prevalence of undiagnosed diabetes in Ethiopia. The majority of factors linked with undiagnosed diabetes in this review were modifiable. This underscores the importance of targeted factors and public health interventions to improve early detection and reduce the burden of undiagnosed diabetes and its complications in Ethiopia.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42021266676.

High prevalence of diabetes in a regional Australian hospital highlights the need to prioritise inpatient diabetes care

Regional centres have smaller workforces in acute diabetes care compared to their metropolitan counterparts. A cross-sectional audit performed at Albury Hospital identified a high prevalence (34%) of diabetes for inpatients compared with metropolitan centres. The high prevalence highlights the need for all healthcare services to consider appropriate resources for the management of diabetes in people admitted to hospital.

Patterns of Gestational Hypertension or Preeclampsia Across 2 Pregnancies in Relationship to Chronic Hypertension Development: A Retrospective Cohort Study

BACKGROUND

Gestational hypertension (GHTN) and preeclampsia are established risk indicators for chronic hypertension. While recurrence is associated with a greater risk, it is unclear whether there are differences in risk when these gestational complications occur for the first time in an earlier pregnancy versus first occurrence in a subsequent one. We hypothesized that the absence of recurrence reflects a transition toward a lower hypertension risk trajectory, whereas a new occurrence in a later pregnancy indicates a transition toward elevated risk.

METHODS AND RESULTS

We analyzed linked data in Quebec, Canada, from public health care insurance administrative databases and birth, stillbirth, and death registries. Our retrospective cohort study included mothers with 2 singleton deliveries between April 1990 and December 2012. The primary exposure was patterns of GHTN or preeclampsia across 2 pregnancies (GHTN/preeclampsia in neither, first only, second only, or both). The outcome was incident chronic hypertension. We performed an adjusted multivariable Cox regression analysis. Among 431 980 women with 2 singleton pregnancies, 27 755 developed hypertension during the follow-up period. Compared with those without GHTN/preeclampsia, those with GHTN/preeclampsia only in the first pregnancy had a 2.7-fold increase in hazards (95% CI, 2.6-2.8), those with GHTN/preeclampsia only in the second had a 4.9-fold increase (95% CI, 4.6-5.1), and those with GHTN/preeclampsia in both pregnancies experienced a 7.3-fold increase (95% CI, 6.9-7.6). Patterns and estimates were similar when we considered GHTN and preeclampsia separately.

CONCLUSIONS

The magnitude of hypertension risk is associated with the number and sequence of GHTN/preeclampsia-affected pregnancies. Considering both allows more personalized risk estimates.

Incident Diabetes in Women With Patterns of Gestational Diabetes Occurrences Across 2 Pregnancies

Importance

Gestational diabetes is a type 2 diabetes risk indicator, and recurrence further augments risk. In women with a single occurrence across 2 pregnancies, it is unclear whether first- vs second-pregnancy gestational diabetes differ in terms of risk.

Objective

To compare the hazards of incident diabetes among those with gestational diabetes in the first, in the second, and in both pregnancies with women without gestational diabetes in either.

Design, Setting, and Participants

This was a retrospective cohort study with cohort inception from April 1, 1990, to December 31, 2012. Follow-up was April 1, 1990, to April 1, 2019. Participants were mothers with 2 singleton deliveries between April 1, 1990, and December 31, 2012, without diabetes before or between pregnancies, who were listed in public health care insurance administrative databases and birth, stillbirth, and death registries in Quebec, Canada. Data were analyzed from July to December 2023.

Exposure

Gestational diabetes occurrence(s) across 2 pregnancies.

Main outcomes and measures

Incident diabetes from the second delivery until a third pregnancy, death, or the end of the follow-up period, whichever occurred first.

Results

The 431 980 women with 2 singleton deliveries studied had a mean (SD) age of 30.1 (4.5) years at second delivery, with a mean (SD) of 2.8 (1.5) years elapsed between deliveries; 373 415 (86.4%) were of European background, and 78 770 (18.2%) were at the highest quintile of material deprivation. Overall, 10 920 women (2.5%) had gestational diabetes in their first pregnancy, 16 145 (3.7%) in their second, and 8255 (1.9%) in both (12 205 incident diabetes events; median [IQR] follow-up 11.5 [5.3-19.4] years). First pregnancy-only gestational diabetes increased hazards 4.35-fold (95% CI, 4.06-4.67), second pregnancy-only increased hazards 7.68-fold (95% CI, 7.31-8.07), and gestational diabetes in both pregnancies increased hazards 15.8-fold (95% CI, 15.0-16.6). Compared with first pregnancy-only gestational diabetes, second pregnancy-only gestational diabetes increased hazards by 76% (95% CI, 1.63-1.91), while gestational diabetes in both pregnancies increased it 3.63-fold (95% CI, 3.36-3.93).

Conclusions and relevance

In this retrospective cohort study of nearly half a million women with 2 singleton pregnancies, both the number and ordinal pregnancy of any gestational diabetes occurrence increased diabetes risk. These considerations offer greater nuance than an ever or never gestational diabetes dichotomy.

Identifying Ontarians with Type 2 Diabetes Mellitus in Administrative Data: A Comparison of Two Case Definitions

INTRODUCTION

This study compared two previously validated sensitive and specific diabetes case definitions to explore the impact of different classification methods in Ontario ICES administrative data.

METHODS

This study included patients captured by the Ontario Diabetes Database with type 2 diabetes using either the sensitive cohort definition (≥ 2 physician visits for diabetes within 1 year or ≥ 1 drug claim for diabetes or ≥ 1 hospitalization with diabetes), or the specific cohort definition (≥ 3 physician visits for diabetes within 1 year), between October 1, 2013 to September 30, 2015. Each cohort's demographic and clinical features were described using descriptive analysis.

RESULTS

Using sensitive and specific definitions, 1,093,812 and 783,228 patients with type 2 diabetes were identified, respectively. Overall, the demographic and clinical characteristics were similar between cohorts. Patients in the sensitive cohort had mean age of 64.1 years and were 52.4% male, compared to 64.8 years and 53.6% male in the specific cohort. In the sensitive and specific cohorts respectively, 64.4% and 55.7% of patients reported one-year mean HbA1c of < 7% (53 mmol/mol) and 25.3% and 31.5% reported levels between 7.0-8.5% (53-69 mmol/mol).

CONCLUSIONS

Although sample sizes were different between sensitive and specific cohorts, demographic and clinical characteristics were similar.

Acute Diabetes-Related Complications in Patients Receiving Chemoradiotherapy for Head and Neck Cancer

Patients with cancer and diabetes face unique challenges. Limited data are available on diabetes management in patients undergoing concurrent chemoradiotherapy (CCRT), a curative intent anticancer therapy commonly associated with glucocorticoid administration, weight fluctuations and enteral feeds. This retrospective case-control study examined the real-world incidence of acute diabetes-related complications in patients with head and neck cancer receiving CCRT, along with the impact of diabetes on CCRT tolerance and outcomes.

METHODS

Consecutive patients with head and neck squamous cell or nasopharyngeal cancer who underwent definitive or adjuvant CCRT between 2010 and 2019 at two large cancer centers in Australia were included. Clinicopathological characteristics, treatment complications and outcomes were collected from medical records.

RESULTS

Of 282 patients who received CCRT, 29 (10.3%) had pre-existing type 2 diabetes. None had type 1 diabetes. The majority (74.5%) required enteral feeding. A higher proportion of patients with diabetes required admission to a high-dependency or intensive care unit (17.2 versus 4.0%, p = 0.003). This difference was driven by the group who required insulin at baseline (n = 5), of which four (80.0%) were admitted to a high-dependency unit with diabetes-related complications, and three (60.0%) required omission of at least one cycle of chemotherapy.

CONCLUSIONS

Patients with diabetes requiring insulin have a high risk of acute life-threatening diabetes-related complications while receiving CCRT. We recommend multidisciplinary management involving a diabetes specialist, educator, dietitian, and pharmacist, in collaboration with the cancer care team, to better avoid these complications.

Considering gestational diabetes and gestational hypertension history across two pregnancies in relationship to cardiovascular disease development: A retrospective cohort study

AIMS

Gestational diabetes (GDM) and hypertension (GHTN) occurrences signal elevated cardiovascular disease (CVD) risk. There is little study of occurrence and recurrence of these conditions in relationship to CVD. Among women with two singleton pregnancies, we aimed to quantify CVD risk in relationship to the number of GDM/GHTN occurrences.

METHODS

In this Quebec-based retrospective cohort study (n = 431,980), we ascertained the number of GDM/GHTN occurrences over two pregnancies and assessed for CVD over a median of 16.4 years (cohort inception 1990-2012, outcomes 1990-2019). We defined CVD as a composite of myocardial infarction, stroke, and angina, requiring hospitalization and/or causing death. We adjusted Cox proportional hazards models for offspring size, preterm/term birth status, maternal age group, time between deliveries, ethnicity, deprivation level, and co-morbid conditions.

RESULTS

Compared to absence of GDM/GHTN in either pregnancy, one GDM/GHTN occurrence increased CVD hazards by 47% (hazard ratio [HR] = 1.47, 95% confidence interval [CI] 1.35-1.61), two occurrences nearly doubled hazards (HR = 1.91, 95% CI 1.68-2.17), and three or more approximately tripled CVD hazards (HR = 2.93, 95% CI 2.20-3.90). Individual components of the composite demonstrated similar findings.

CONCLUSIONS

Health care providers and mothers should consider a complete history of GDM/GHTN occurrences to ascertain the importance and urgency of preventive action.

Associations of Diabetes-related and Health-related Quality of Life With Glycemic Levels in Adolescents With Type 1 Diabetes Preparing to Transition to Adult Care

OBJECTIVES

As adolescents with type 1 diabetes (T1D) progress to adulthood, they assume responsibility for diabetes self-management while dealing with competing life demands, decreasing parental support, and the transfer to adult care. Lower perceived quality of life (QOL) may hamper diabetes management, which is associated with suboptimal glycemic levels. Our objective was to determine associations of diabetes- and health-related QOL with glycemic management (glycated hemoglobin [A1C]) in adolescents with T1D before their transfer to adult care.

METHODS

We conducted a cross-sectional analysis of baseline data from the Group Education Trial to Improve Transition (GET-IT- T1D) in adolescents with T1D (16 to 17 years of age). Participants completed validated questionnaires measuring diabetes-related QOL (PedsQL 3.2 Diabetes Module) and health-related QOL (PedsQL 4.0 Generic Core Scales). Associations of QOL Total and subscale scores with A1C were assessed using linear regression models adjusted for sex, diabetes duration, socioeconomic status, insulin pump use, and mental health comorbidity.

RESULTS

One hundred fifty-three adolescents with T1D were included (mean age, 16.5 [standard deviation, 0.3] years). Diabetes-related QOL Total scores (adjusted β=-0.04; 95% confidence interval [CI], -0.05 to -0.02) as well as subscale scores for Diabetes Symptoms (adjusted β=-0.02; 95% CI, -0.04 to -0.00) and Diabetes Management (adjusted β=-0.04; 95% CI, -0.05 to -0.02) were inversely associated with A1C. Health-related QOL Total scores were not associated with A1C, but Psychosocial Health subscale scores were (adjusted β=-0.01; 95% CI, -0.03 to -0.00).

CONCLUSION

Our results suggest that strategies focussing on diabetes-related QOL and psychosocial health may help prepare adolescents for the increasing responsibility of diabetes self-care.

The magnitude of undiagnosed diabetes mellitus, prediabetes, and associated factors among adults living in Debre Tabor town, northcentral Ethiopia: A community-based cross-sectional study

Background

Diabetes mellitus (DM) is a worldwide public health problem. The burden of diabetes has been continuously increasing from day to day, especially in developing countries like Ethiopia. Globally, half of all cases of diabetes mellitus are undiagnosed. Diabetes mellitus can be easily handled if it is detected early. There is limited evidence on the magnitude of undiagnosed diabetics and prediabetes at the community level in Ethiopia, particularly in the study area.

Objective

To assess the magnitude of undiagnosed diabetes mellitus, prediabetes, and associated factors among adults living in Debre Tabor town.

Methods

A community-based cross-sectional study was conducted in Debre Tabor town from October to December 2021. A total of 407 participants were selected using a multistage sampling technique. A pretested structural questionnaire was used to collect demographic, behavioral, and clinical data. Anthropometric measurements were taken with standardized and calibrated equipment. A fasting venous blood sample was collected for blood glucose level determination. Logistic regression was used to identify risk factors. A P-value ≤0.05 was considered statistically significant.

Result

The magnitude of undiagnosed diabetes mellitus and prediabetes was found to be 4.5% (95% CI: 2.9-7.4) and 14.5% (95% CI: 11.1-18.1), respectively. Older age (AOR: 6.50, 95% CI: 1.82-23.21), abnormal body mass index (AOR: 6.84, 95% CI: 1.91-24.54), systolic hypertension (AOR: 8.74, 95% CI: 2.53-30.19), and family history of diabetes mellitus (FHDM) (AOR: 12.45, 95% CI: 3.63-42.65) were significantly associated with undiagnosed diabetes mellitus. Using saturated oil (AOR: 1.97, 95% CI: 1.09-3.55), having a high waist circumference (AOR: 2.16, 95% CI: 1.20-3.87), and being hypertensive (AOR: 2.26, 95% CI: 1.04-4.96) were all significantly associated with Prediabetes.

Conclusion

Adults in Debre Tabor town have a high prevalence of undiagnosed diabetes and prediabetes. A variety of modifiable risk factors were also identified. As a result, focusing the prevention strategy on such modifiable risk factors may help to minimize the prevalence of undiagnosed diabetes mellitus and prediabetes as well as future disease complications.

Socio-economic inequalities in undiagnosed, untreated, and uncontrolled diabetes mellitus in Bangladesh: is there a gender difference?

OBJECTIVES

We aimed to determine: (1) the prevalence and socio-economic distribution of undiagnosed, untreated, and uncontrolled diabetes mellitus (DM); (2) the relationship between socio-economic status (SES) and undiagnosed, untreated, and uncontrolled DM; and (3) if this relationship is mediated by gender.

STUDY DESIGN

Cross-sectional nationally representative household-based survey.

METHODS

We used data from the Bangladesh Demographic Health Survey from 2017 to 18. Our findings were based on the responses of 12,144 individuals aged 18 years and older. As a measure of SES, we focused on standard of living (hereinafter referred to as wealth). The study's outcome variables were prevalence of total (diagnosed + undiagnosed), undiagnosed, untreated, and uncontrolled DM. We used three regression-based approaches-adjusted odds ratio, relative inequality index, and slope inequality index-to assess different aspects of SES differences in the prevalence of total, undiagnosed, untreated, and uncontrolled DM. We used logistic regression analysis to look at the adjusted association between SES and the outcomes after gender stratification to see whether gender status moderates the association between SES and the targeted outcomes.

RESULTS

In our sample analysis, the age-adjusted prevalence of total, undiagnosed, untreated, and uncontrolled DM was 9.1%, 61.4%, 64.7%, and 72.1%, respectively. Females had a higher prevalence of DM and undiagnosed, untreated, and uncontrolled DM than males. When compared to people in the poor SES group, people in the rich and middle SES groups had 2.60 times (95% confidence interval [CI] 2.05-3.29) and 1.47 times (95% CI 1.18-1.83) higher chance of developing DM. When compared to individuals in the poor SES group, those in the rich SES groups were 0.50 (95% CI 0.33-0.77) and 0.55 times (95% CI 0.36-0.85) less likely to have undiagnosed and untreated DM.

CONCLUSIONS

In Bangladesh, rich SES groups were more likely than poor SES groups to have DM, whereas poor SES groups with DM were less likely than rich SES groups to be aware of their disease and obtain treatment. The government and other concerned parties are urged by this study to pay more attention to developing suitable policy measures to reduce the risk of DM, particularly among rich SES groups, as well as targeted efforts to screen for and diagnose DM in socio-economically disadvantaged groups.

The economic burden of excessive sugar consumption in Canada: should the scope of preventive action be broadened?

Objective

Excessive sugar consumption is an established risk factor for various chronic diseases (CDs). No earlier study has quantified its economic burden in terms of health care costs for treatment and management of CDs, and costs associated with lost productivity and premature mortality. This information, however, is essential to public health decision-makers when planning and prioritizing interventions. The present study aimed to estimate the economic burden of excessive free sugar consumption in Canada.

Methods

Free sugars refer to all monosaccharides and disaccharides added to foods plus sugars naturally present in honey, syrups, and fruit juice. Based on free sugar consumption reported in the 2015 Canadian Community Health Survey–Nutrition and established risk estimates for 16 main CDs, we calculated the avoidable direct health care costs and indirect costs.

Results

If Canadians were to comply with the free sugar recommendation (consumption below 10% of total energy intake (TEI)), an estimated $2.5 billion (95% CI: 1.5, 3.6) in direct health care and indirect costs could have been avoided in 2019. For the stricter recommendation (consumption below 5% of TEI), this was $5.0 billion (95% CI: 3.1, 6.9).

Conclusion

Excessive free sugar in our diet has an enormous economic burden that is larger than that of any food group and 3 to 6 times that of sugar-sweetened beverages (SSBs). Public health interventions to reduce sugar consumption should therefore consider going beyond taxation of SSBs to target a broader set of products, in order to more effectively reduce the public health and economic burden of CDs.

Undiagnosed Diabetes Mellitus and Its Predictors Among Socially Marginalized Menja Communities in Southwest Ethiopia

Background:

Diabetes mellitus (DM) is a metabolic disorder marked by a persistently high blood glucose level over a prolonged period of time linked to either defects in insulin secretion, insulin action, or both. It is responsible for 537 million adult cases and 6.7 million deaths in 2021. However, about half of the people with diabetes go undiagnosed. Low-income and socially disadvantaged communities are the most vulnerable to the disease. Despite this fact, nothing has been done among these communities, so this study aimed to assess the extent of undiagnosed diabetes and its predictors among the socially marginalized Menja communities of Southwest Ethiopia, 2021.

Methods

A community-based cross-sectional study was done in the Menja communities from April 21/2021 to June 30/2021. The required sample size was calculated using the single population proportion formula and systematic sampling techniques were employed to select the households. Data were collected through face-to-face interviews utilizing an interviewer-administered questionnaire to collect socio-demographic and behavioral characteristics, and anthropometric measurements were taken from each participant. Diabetes was defined as participants who had an FBG ≥ 126 mg/dL or RBG &gt; 200 mg/dL. The multivariate logistic regression model was used to identify the predictors of diabetes; adjusted OR with a 95% CI was computed to assess the strength of associations.

Results

The prevalence of undiagnosed DM among the socially marginalized Menja communities was 14.7% [95% CI: (11.1–18.3)], and sex-specific prevalence was 16.8%, and 11.1% for men and women respectively. Factors like alcohol consumption (AOR = 3.0, 95% CI 1.49 to 6.05), family history of DM 4.4 (AOR = 4.37, 95% CI 2.04 to 9.35), lower vegetable consumption 3.5 (1.19–10.31) (AOR = 3.5, 95% CI 1.19 to 10.31), and less physical exercise 3.3 (AOR = 3.34, 95% CI 1.61 to 6.90) were the independent predictors that increase the risk of diabetes among Menja communities.

Conclusion and Recommendations

Undiagnosed diabetes was high as compared to other settings. Alcohol use, family history of diabetes, vegetable consumption, and physical exercise were predictors of diabetes. Hence, the study suggests frequent screening and treatment for high-risk groups. Minimizing alcohol drinking, frequent vegetable consumption, and physical exercises were recommended measures for the prevention and control of DM among the population of Ethiopia.

Predictors of Undiagnosed Diabetes among Middle-Aged and Seniors in China: Application of Andersen's Behavioral Model

Undiagnosed diabetes is a threat to public health. This study aims to identify potential variables related to undiagnosed diabetes using Andersen’s behavioral model. Baseline data including blood test data from the China Health and Retirement Longitudinal Study (CHARLS) were adopted. First, we constructed health service related variables based on Andersen model. Second, univariate analysis and multiple logistic regression were used to analyze the relations of variables to undiagnosed diabetes. The strength of relationships was presented by odds ratios (ORs) and 95% confidence intervals (CIs). Finally, the prediction of multiple logistic regression model was assessed using the Receiver Operating Characteristic (ROC) curve and the area under the ROC curve (AUC). According to diagnosis standards, 1234 respondents had diabetes, among which 560 were undiagnosed and 674 were previously diagnosed. Further analysis showed that the following variables were significantly associated with undiagnosed diabetes: age as the predisposing factor; medical insurance, residential places and geographical regions as enabling factors; having other chronic diseases and self-perceived health status as need factors. Moreover, the prediction of regression model was assessed well in the form of ROC and AUC. Andersen model provided a theoretical framework for detecting variables of health service utilization, which may not only explain the undiagnosed reasons but also provide clues for policy-makers to balance health services among diverse social groups in China.

Exercise-nutrient interactions for improved postprandial glycemic control and insulin sensitivity

Type 2 diabetes (T2D) is a rapidly growing yet largely preventable chronic disease. Exaggerated increases in blood glucose concentration following meals is a primary contributor to many long-term complications of the disease that decrease quality of life and reduce lifespan. Adverse health consequences also manifest years prior to the development of T2D due to underlying insulin resistance and exaggerated postprandial concentrations of the glucose-lowering hormone insulin. Postprandial hyperglycemic and hyperinsulinemic excursions can be improved by exercise, which contributes to the well-established benefits of physical activity for the prevention and treatment of T2D. The aim of this review is to describe the postprandial dysmetabolism that occurs in individuals at risk for and with T2D, and highlight how acute and chronic exercise can lower postprandial glucose and insulin excursions. In addition to describing the effects of traditional moderate-intensity continuous exercise on glycemic control, we highlight other forms of activity including low-intensity walking, high-intensity interval exercise, and resistance training. In an effort to improve knowledge translation and implementation of exercise for maximal glycemic benefits, we also describe how timing of exercise around meals and post-exercise nutrition can modify acute and chronic effects of exercise on glycemic control and insulin sensitivity. Novelty: Exaggerated postprandial blood glucose and insulin excursions are associated with disease risk. Both a single session and repeated sessions of exercise improve postprandial glycemic control in individuals with and without T2D. The glycemic benefits of exercise can be enhanced by considering the timing and macronutrient composition of meals around exercise.

Association of Self-Efficacy, Transition Readiness and Diabetes Distress With Glycemic Control in Adolescents With Type 1 Diabetes Preparing to Transition to Adult Care

OBJECTIVES

Adolescence and emerging adulthood are associated with inadequate medical follow up, suboptimal glycemic control and higher risk for adverse outcomes. Our aim in this study was to determine whether self-efficacy, transition readiness or diabetes distress is associated with glycemic control (glycated hemoglobin [A1C]) among adolescents with type 1 diabetes (T1D) preparing to transition to adult care.

METHODS

We conducted a cross-sectional study of adolescents (age 17 years) with T1D followed at the Montreal Children's Hospital Diabetes Clinic 1 year before transferring to adult care. Participants completed validated questionnaires on self-efficacy (Self-Efficacy for Diabetes Self-Management Measure [SEDM], score 1 to 10), transition readiness (Am I ON TRAC? For Adult Care questionnaire [TRAC], score ≥8 indicates readiness) and diabetes distress (Diabetes Distress Scale for Adults with Type 1 Diabetes [T1-DDS], score ≥3 indicates distress). The primary outcome was A1C (%) 1 year before transfer. We examined associations of self-efficacy, transition readiness and diabetes distress with A1C using multivariate linear and logistic regression models adjusted for sex, age at diagnosis and socioeconomic status.

RESULTS

Of 74 adolescents with T1D (29 males, 39.1%), 27 (36.4%) had suboptimal glycemic control (A1C ≥9.0%). Less than half were transition-ready (TRAC questionnaire score ≥8) and 14% had diabetes distress (T1-DDS score ≥3). SEDM was not associated with A1C. Adolescents considered ready for transition were less likely to have suboptimal glycemic control (odds ratio, 0.30; 95% confidence interval, 0.09 to 0.99), whereas adolescents with diabetes distress were more likely to have suboptimal glycemic control (odds ratio, 6.24; 95% confidence interval, 1.06 to 36.75).

CONCLUSIONS

Improving health-care transition within pediatric care should focus on both transition readiness and diabetes distress to help improve adolescents' glycemic control and prepare them for adult care.

Factors associated with sarcopenia screened by finger-circle test among middle-aged and older adults: a population-based multisite cross-sectional survey in Japan

BACKGROUND

Previous epidemiological studies have demonstrated the prevalence and relationship of various factors associated with sarcopenia in older adults; however, few have examined the status of sarcopenia in middle-aged adults. In this study, we aimed to, 1) evaluate the validity of the finger-circle test, which is potentially a useful screening tool for sarcopenia, and 2) determine the prevalence and factors associated with sarcopenia in middle-aged and older adults.

METHODS

We conducted face-to-face surveys of 525 adults, who were aged 40-91 years and resided in Settsu City, Osaka Prefecture, Japan to evaluate the validity of finger-circle test. The finger-circle test evaluated calf circumference by referring to an illustration printed on the survey form. The area under the receiver operating characteristic curves (AUROC) was plotted to evaluate the validity of the finger-circle test for screening sarcopenia and compared to that evaluated by skeletal muscle mass index (SMI) measured using bioimpedance. We also conducted multisite population-based cross-sectional anonymous mail surveys of 9337 adults, who were aged 40-97 years and resided in Settsu and Hannan Cities, Osaka Prefecture, Japan. Participants were selected through stratified random sampling by sex and age in the elementary school zones of their respective cities. We performed multiple logistic regression analysis to explore associations between characteristics and prevalence of sarcopenia.

RESULTS

Sarcopenia, defined by SMI, was moderately predicted by a finger-circle test response showing that the subject's calf was smaller than their finger-circle (AUROC: 0.729, < 65 years; 0.653, ≥65 years); such subjects were considered to have sarcopenia. In mail surveys, prevalence of sarcopenia screened by finger-circle test was higher in older subjects (approximately 16%) than in middle-aged subjects (approximately 8-9%). In a multiple regression model, the factors associated with sarcopenia were age, body mass index, smoking status, self-reported health, and number of meals in all the participants.

CONCLUSIONS

Sarcopenia, screened by the finger-circle test, was present not only among older adults but also among middle-aged adults. These results may provide useful indications for developing public health programs, not only for the prevention, but especially for the management of sarcopenia.

TRIAL REGISTRATION

UMIN000036880, registered prospectively May 29, 2019,  https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000042027.

Regional differences in the management of cardiovascular risk factors among adults with diabetes: An evaluation of the Diabetes Collaborative Registry

AIMS

To compare cardiovascular risk factor control in adults with diabetes participating in a national diabetes registry to those in the general population and to ascertain regional differences in diabetes care.

METHODS

Adults with diagnosed diabetes in the Diabetes Collaborative Registry (DCR) were compared with those in the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2016; standardized mean difference (SMD) > 0.2 defined significance. Regional differences were assessed in the DCR cohort; p < .05 defined significance.

RESULTS

The DCR cohort was older (61 vs. 57 years, SMD = 0.38), more insured (99.7% vs. 91.0%, SMD = 0.42), and less ethnically diverse (83% non-Hispanic white vs. 76%, SMD = 0.30) compared with NHANES. The proportion of overweight/obesity, A1c < 7% (<53 mmol/mol), and BP < 140/90 were similar, but DCR participants had higher proportion with LDL < 2.59 mmol/L (61% vs. 41%, SMD = 0.39) and fewer tobacco users (17% vs. 32%, SMD = 0.35). Regionally, obesity, lack of glycaemic control, and tobacco use were highest in the Midwest, BP control was the lowest in the South, and LDL control was lowest in the Northeast.

CONCLUSIONS

Significant regional differences in diabetes care delivery and outcomes were identified using a national diabetes registry. Serial analyses of the DCR may supplement national evaluations to deepen our understanding of diabetes care in the US.

Efficient treatment of outliers and class imbalance for diabetes prediction

Learning from outliers and imbalanced data remains one of the major difficulties for machine learning classifiers. Among the numerous techniques dedicated to tackle this problem, data preprocessing solutions are known to be efficient and easy to implement. In this paper, we propose a selective data preprocessing approach that embeds knowledge of the outlier instances into artificially generated subset to achieve an even distribution. The Synthetic Minority Oversampling TEchnique (SMOTE) was used to balance the training data by introducing artificial minority instances. However, this was not before the outliers were identified and oversampled (irrespective of class). The aim is to balance the training dataset while controlling the effect of outliers. The experiments prove that such selective oversampling empowers SMOTE, ultimately leading to improved classification performance.

Gestational diabetes associated with incident diabetes in childhood and youth: a retrospective cohort study

BACKGROUND

Indicators of childhood- and youth-onset diabetes may be useful for early detection of diabetes; there is a known association between composite exposure of parental type 2 diabetes and gestational diabetes mellitus with childhood- and youth-onset diabetes. We examined associations between gestational diabetes mellitus and incidence of childhood- and youth-onset diabetes in offspring.

METHODS

Using public health insurance administrative databases from Quebec, Canada, we randomly selected singleton live births with maternal gestational diabetes mellitus (1990-2007) and matched them 1:1 with singleton live births without gestational diabetes mellitus. Follow-up was to Mar. 31, 2012. We examined associations of diabetes in offspring with maternal gestational diabetes mellitus through unadjusted and adjusted Cox proportional hazards models. In secondary analyses, we separately considered age groups ranging from birth to age 12 years, and age 12 to 22 years.

RESULTS

Incidence of pediatric diabetes (per 10 000 person-years) was higher in offspring born to mothers with gestational diabetes mellitus (4.52, 95% confidence interval [CI] 4.47-4.57) than in mothers without gestational diabetes mellitus (2.4, 95% CI 2.37-2.46). In an adjusted Cox proportional hazards model, maternal gestational diabetes mellitus was associated with development of pediatric diabetes overall (birth to age 22 yr: hazard ratio [HR] 1.77, 95% CI 1.41-2.22), during childhood (birth to age 12 yr: HR 1.43, 95% CI 1.09-1.89), and in youth (age 12 to 22 yr: HR 2.53, 95% CI 1.67-3.85).

INTERPRETATION

Gestational diabetes mellitus is associated with incident diabetes in offspring during childhood and adolescence. Future studies are needed to examine longer-term outcomes in patients with pediatric diabetes with a maternal history of gestational diabetes mellitus, to ascertain how they compare with other patients with childhood- or youth-onset diabetes, in terms of disease severity and outcomes.

Group education for adolescents with type 1 diabetes during transition from paediatric to adult care: study protocol for a multisite, randomised controlled, superiority trial (GET-IT-T1D)

INTRODUCTION

Transition from paediatric to adult care is challenging for adolescents and emerging adults (ages 18 to 30 years) with type 1 diabetes (T1D). This transition is characterised by a deterioration in glycaemic control (haemoglobin A1c (HbA1c)), decreased clinical attendance, poor self-management and increased acute T1D-related complications. However, evidence to guide delivery of transition care is lacking. Given the effectiveness of group education in adult diabetes glycaemic control and improvements in qualitative measures in paediatric diabetes, group education is a potentially feasible and cost-effective alternative for the delivery of transition care. In emerging adults with T1D, we aim to assess the effectiveness of group education visits compared with usual care on HbA1c, T1D-related complications, psychosocial measures and cost-effectiveness after the transfer to adult care.

METHODS AND ANALYSIS

In a multisite, assessor-blinded, randomised, two-arm, parallel-group, superiority trial, 212 adolescents with T1D (ages 17 years) are randomised to 12 months group education versus usual T1D care before transfer to adult care. Visits in the active arm consist of group education sessions followed by usual T1D care visits every 3 months. Primary outcome is change in HbA1c measured at 24 months. Secondary outcomes are delays in establishing adult diabetes care, T1D-related hospitalisations and emergency department visits, severe hypoglycaemia, stigma, self-efficacy, diabetes knowledge, transition readiness, diabetes distress, quality of life and cost-effectiveness at 12 and 24 months follow-up. Analysis will be by intention-to-treat. Change in HbA1c will be calculated and compared between arms using differences (95% CI), along with cost-effectiveness analysis. A similar approach will be conducted to examine between-arm differences in secondary outcomes.

ETHICS AND DISSEMINATION

The study was approved by McGill University Health Centre Research Ethics Board (GET-IT/MP-37-2019-4434, version 'Final 1.0 from November 2018). Study results will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03703440.

Prevalence of undiagnosed diabetes mellitus and associated factors among adult residents of Bahir Dar city, northwest Ethiopia: a community-based cross-sectional study

OBJECTIVE

To assess the prevalence of undiagnosed diabetes mellitus (DM) and associated factors among adult inhabitants of Bahir Dar city, northwest Ethiopia.

DESIGN

A community-based cross-sectional study was conducted on adults (n=607) of Bahir Dar city from 10 March to 20 May 2018.

MEASUREMENTS

Data were collected using structured interviewer-administered questionnaire, and anthropometric measurements were taken from each participant. Fasting blood sugar (FBS) level was determined by samples taken early in the morning and readings of FBS≥126 mg/dL were classified as diabetes. The multivariate logistic regression model was fitted to identify the predictors of undiagnosed DM; adjusted OR (AOR) with a 95% CI was computed to assess the strength of associations.

RESULT

The study revealed that the prevalence of undiagnosed DM was 10.2% with 95% CI 7.9 to 12.9. Ever checked blood glucose level (AOR=1.91, 95% CI 1.03 to 3.51), don't know the symptoms of diabetes (AOR=2.06, 95% CI 1.08 to 3.89), family history of DM (AOR=2.5, 95% CI 1.21 to 5.18) and body mass index (BMI) ≥25 kg/m² (AOR=1.98, 95% CI 1.09 to 3.60) were factors associated with undiagnosed DM.

CONCLUSION

The magnitude of undiagnosed diabetes was high. Family history of DM, ever checked blood glucose level, don't know about the symptoms of diabetes and overweight BMI were predictors of undiagnosed DM. Hence, screening and treatment are mandatory for high-risk groups. In addition, this study suggests frequent screening for those with family history and awareness creating about the disease for early detection and treatment.

Identifying pediatric diabetes cases from health administrative data: a population-based validation study in Quebec, Canada

Background

Type 1 diabetes is one of the most common chronic diseases in childhood with a worldwide incidence that is increasing by 3-5% per year. The incidence of type 2 diabetes, traditionally viewed as an adult disease, is increasing at alarming rates in children, paralleling the rise in childhood obesity. As the rates of diabetes increase in children, accurate population-based assessment of disease burden is important for those implementing strategies for health services delivery. Health administrative data are a powerful tool that can be used to track disease burden, health services use, and health outcomes. Case validation is essential in ensuring accurate disease identification using administrative databases.

Aim

The aim of our study was to define and validate a pediatric diabetes case ascertainment algorithm (including any form of childhood-onset diabetes) using health administrative data.

Research design and methods

We conducted a two-stage method using linked health administrative data and data extracted from charts. In stage 1, we linked chart data from a large urban region to health administrative data and compared the diagnostic accuracy of various algorithms. We selected those that performed the best to be validated in stage 2. In stage 2, the most accurate algorithms were validated with chart data within two other geographic areas in the province of Quebec.

Results

Accurate identification of diabetes in children (ages ≤15 years) required four physician claims or one hospitalization (with International Classification of Disease codes within 1 year (sensitivity 91.2%, 95% confidence interval [CI] 89.2-92.9]; positive predictive value [PPV] 93.5%, 95% CI 91.7-95.0) or using only four physician claims in 2 years (sensitivity 90.4%, 95% CI 88.3-92.2; PPV 93.2%, 95% CI 91.7-95.0). Separating the physician claims by 30 days increased the PPV of all algorithms tested.

Conclusion

Patients with child-onset diabetes can be accurately identified within health administrative databases providing a valid source of information for health care resource planning and evaluation.

Public health monitoring of hypertension, diabetes and elevated cholesterol: comparison of different data sources

Background

Three data sources are generally used in monitoring health on the population level. Health interview surveys (HISs) are based on participants' self-report. Health examination surveys (HESs) yield more objective data, and also persons who are unaware of their elevated risks can be detected. Medical records (MRs) and other administrative registers also provide objective data, but their availability, coverage and quality vary between countries. We summarized studies comparing self-reported data with (i) measured data from HESs or (ii) MRs. We aimed to describe differences in feasibility and comparability of different data sources for monitoring (i) elevated blood pressure or hypertension (ii) elevated blood glucose or diabetes and (iii) elevated total cholesterol.

Methods

We conducted a literature search to identify studies, which validated self-reported measures against objective measures. We found 30 studies published since the year 2000 fulfilling our inclusion criteria (targeted to adults and comparing prevalence among the same persons).

Results

Hypertension and elevated total cholesterol were prone to be under-estimated in HISs. The under-estimate was more pronounced, when the HIS data were compared with HES data, and lower when compared with MRs. For diabetes, the HISs and the objective methods resulted in fairly similar prevalence rates.

Conclusion

The three data sources measure different manifestations of the risk factors and cannot be expected to yield similar prevalence rates. Using HIS data only may lead to under-estimation of elevated risk factor levels or disease prevalence. Whenever possible, information from the three data sources should be evaluated and combined.

SGLT2 inhibitors and cardioprotection: a matter of debate and multiple hypotheses

Sodium-glucose co-transporter 2 (SGLT2) inhibitors inhibit glucose re-absorption in the proximal renal tubules. Two trials have shown significant reductions of cardiovascular (CV) events with empagliflozin and canagliflozin, which could not be attributed solely to their antidiabetic effects. The aim of the review is the critical presentation of suggested mechanisms/hypotheses for the SGLT2 inhibitors' cardioprotection. The search of the literature revealed many possible cardioprotective mechanisms, because SGLT2 inhibitors (i) increase natriuresis and act as diuretics with unique properties leading to a reduction in preload and myocardial stretch (the diuretic hypothesis); (ii) decrease blood pressure and afterload (the blood pressure lowering hypothesis), (iii) favor the production of ketones, which can act as a 'superfuel' in the cardiac and renal tissue (the 'thrifty substrate' hypothesis), (iv) improve many metabolic variables (the metabolic effects hypothesis), (v) exert many anti-inflammatory effects (the anti-inflammatory effects hypothesis), (vi) can act through the angiotensin II type II receptors in the context of simultaneous renin-angiotensin-aldosterone-system (RAAS) blockade leading to vasodilation and positive inotropic effects (the RAAS hypothesis), (vii) directly decrease the activity of the upregulated in heart failure Na⁺-H⁺ exchanger in myocardial cells leading to restoration of mitochondrial calcium handling in cardiomyocytes (the sodium hypothesis). Additionally, some SGLT2 inhibitors exhibit also SGLT1 inhibitory action possibly resulting in an attenuation of oxidative stress in ischemic myocardium (the SGLT1 inhibition hypothesis). Thus, many mechanisms have been suggested (and possibly act cumulatively) for the cardioprotective effects of SGLT2 inhibitors.

Socioeconomic Inequalities of Undiagnosed Diabetes in a Resource-Poor Setting: Insights from the Cross-Sectional Bangladesh Demographic and Health Survey 2011

Diabetes mellitus is rising disproportionately but is not frequently diagnosed until complications appear, which results in adverse health consequences. We estimated the prevalence of undiagnosed diabetes among adult diabetic patients and associated socioeconomic inequalities in Bangladesh. We used nationally representative cross-sectional Bangladesh Demographic and Health Survey (BDHS) 2011 data. Among patients with diabetes, we identified undiagnosed cases as having fasting plasma glucose ≥ 7.0 mmol/L, never having taken prescribed medicine and being told by health professionals. Among 938 patients with diabetes, 53.4% remained undiagnosed. The poorest (75.9%) and rural (59.0%) patients had significantly higher undiagnosed cases than the richest (36.0%) and urban (42.5%), respectively. Multiple logistic regression analysis revealed that the likelihood of being undiagnosed was lower among patients with age ≥ 70 years vs. 35–39 years (adjusted odds ratio (AOR) = 0.35; 95% confidence interval (CI) 0.19, 0.64) and patients with higher education vs. no education (AOR = 0.36; 95% CI 0.21, 0.62). Conversely, a high level of physical activity and being in a poor socioeconomic quintile were associated with a higher risk of remaining undiagnosed for diabetes. The Concentration Index (C) also showed that undiagnosed diabetes was largely distributed among the socioeconomically worse-off group in Bangladesh (C = −0.35). Nationwide diabetes screening programs may reduce this problem in Bangladesh and other similar low-income settings.

State and Local Chronic Disease Surveillance Using Electronic Health Record Systems

OBJECTIVES

To assess the feasibility of chronic disease surveillance using distributed analysis of electronic health records and to compare results with Behavioral Risk Factor Surveillance System (BRFSS) state and small-area estimates.

METHODS

We queried the electronic health records of 3 independent Massachusetts-based practice groups using a distributed analysis tool called MDPHnet to measure the prevalence of diabetes, asthma, smoking, hypertension, and obesity in adults for the state and 13 cities. We adjusted observed rates for age, gender, and race/ethnicity relative to census data and compared them with BRFSS state and small-area estimates.

RESULTS

The MDPHnet population under surveillance included 1 073 545 adults (21.8% of the state adult population). MDPHnet and BRFSS state-level estimates were similar: 9.4% versus 9.7% for diabetes, 10.0% versus 12.0% for asthma, 13.5% versus 14.7% for smoking, 26.3% versus 29.6% for hypertension, and 22.8% versus 23.8% for obesity. Correlation coefficients for MDPHnet versus BRFSS small-area estimates ranged from 0.890 for diabetes to 0.646 for obesity.

CONCLUSIONS

Chronic disease surveillance using electronic health record data is feasible and generates estimates comparable with BRFSS state and small-area estimates.

Correcting hazard ratio estimates for outcome misclassification using multiple imputation with internal validation data

OBJECTIVE

Outcome misclassification may occur in observational studies using administrative databases. We evaluated a two-step multiple imputation approach based on complementary internal validation data obtained from two subsamples of study participants to reduce bias in hazard ratio (HR) estimates in Cox regressions.

METHODS

We illustrated this approach using data from a surveyed sample of 6247 individuals in a study of statin-diabetes association in Quebec. We corrected diabetes status and onset assessed from health administrative data against self-reported diabetes and/or elevated fasting blood glucose (FBG) assessed in subsamples. The association between statin use and new onset diabetes was evaluated using administrative data and the corrected data. By simulation, we assessed the performance of this method varying the true HR, sensitivity, specificity, and the size of validation subsamples.

RESULTS

The adjusted HR of new onset diabetes among statin users versus non-users was 1.61 (95% confidence interval: 1.09-2.38) using administrative data only, 1.49 (0.95-2.34) when diabetes status and onset were corrected based on self-report and undiagnosed diabetes (FBG ≥ 7 mmol/L), and 1.36 (0.92-2.01) when corrected for self-report and undiagnosed diabetes/impaired FBG (≥ 6 mmol/L). In simulations, the multiple imputation approach yielded less biased HR estimates and appropriate coverage for both non-differential and differential misclassification. Large variations in the corrected HR estimates were observed using validation subsamples with low participation proportion. The bias correction was sometimes outweighed by the uncertainty introduced by the unknown time of event occurrence.

CONCLUSION

Multiple imputation is useful to correct for outcome misclassification in time-to-event analyses if complementary validation data are available from subsamples. Copyright © 2017 John Wiley & Sons, Ltd.

Stigma and Its Impact on Glucose Control Among Youth With Diabetes: Protocol for a Canada-Wide Study

BACKGROUND

Stigma in chronic disease involves unwarranted rejection, judgement, or exclusion by others based on the chronic disease itself.

OBJECTIVE

We aim to determine the prevalence of stigma among youth and young adults with type 1 diabetes in Canada, to assess associations between stigma and glycemic control, and to explore ways to address stigma related to type 1 diabetes.

METHODS

The study includes 3 distinct phases: (1) refinement of survey questions, (2) assessment of test-retest reliability, and (3) a data collection and analysis phase (online survey and mailed-in capillary blood sample to assess hemoglobin A1c). A total of 380 youth and young adults (14 to 24 years old) with type 1 diabetes are being recruited through social media and clinic posters.

RESULTS

Phases 1 and 2 are complete, and phase 3 is in progress. Thirty participants completed phase 2. The survey includes the Barriers to Diabetes Adherence in adolescent scale (intraclass correlation [ICC]=0.967, 95% CI 0.931-0.984), the Self-Efficacy for Diabetes Self-Management measure (ICC=0.952, 95% CI 0.899-0.977), the World Health Organization-5 Well-Being Index (ICC=0.860, 95% CI 0.705-0.933), 12 closed-ended questions, and an additional 5 open-ended questions to explore challenges and solutions developed by the team of experts, including a patient representative.

CONCLUSIONS

This will be the first large-scale survey to estimate the prevalence of stigma in young people with type 1 diabetes. The results of this study will allow for an appreciation of the magnitude of the problem and the need for developing and implementing solutions. This work is intended to provide an initial understanding of youth perspectives on the challenges of living with type 1 diabetes and will serve as a foundation for future research and action to help youth improve their experience of living with diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02796248, https://clinicaltrials.gov/ct2/show/NCT02796248 (Archived at http://www.webcitation.org/6mhenww3o).

Severity of coronary artery disease and retinal microvascular signs in patients with diagnosed versus undiagnosed diabetes: cross-sectional study

BACKGROUND

There is increasing evidence that a considerable proportion of patients with diabetes remain undiagnosed and untreated, however, it is unclear whether this is associated with more severe coronary artery disease (CAD) and microvasculature changes compared with diagnosed patients. We assessed CAD extent and severity, along with changes to the retinal microvascular structure in participants with undiagnosed versus diagnosed type 2 diabetes.

METHODS

Participants of the Australian Heart Eye Study were stratified into participants with previously diagnosed diabetes (n=489), undiagnosed diabetes (n=76) and no diabetes (n=1,112). Retinal vessel caliber was measured from digital retinal images. Extent and severity of CAD was assessed using Extent and Gensini scores from angiography findings, respectively.

RESULTS

Participants with undiagnosed and diagnosed diabetes versus those with no diabetes (reference group) had increased odds of being in the highest quartile of Gensini scores, multivariate adjusted odds ratios (OR) =7.02 [95% confidence interval (CI), 2.04-24.1] and OR =2.76 (95% CI, 1.67-4.55), respectively. Participants with undiagnosed and diagnosed diabetes versus those with no diabetes also had increased odds of being in the highest quartile of Extent scores, multivariate adjusted OR =7.63 (95% CI, 2.15-27.10) and OR =3.72 (95% CI, 2.22-6.27), respectively. No significant differences were observed in retinal vessel caliber between participants with undiagnosed versus diagnosed diabetes.

CONCLUSIONS

The present study demonstrated that participants with undiagnosed diabetes compared to those with previously diagnosed diabetes, had a stronger likelihood of having more severe and extensive CAD. However, retinal microvascular signs did not differ by diabetes status.

Mortality risk in admitted patients with diabetes mellitus according to treatment

AIMS

Investigate the importance of treating diabetes by evaluating mortality risk of untreated and medically-treated diabetic patients.

METHODS

Historical prospectively collected observational data of hospitalized patient ≥18years, admitted for any-cause to medical wards, between January 2011 and December 2013. Main outcome was all-cause mortality at end of follow-up.

RESULTS

Cohort included 35,340 patients (51% male, median age 70years); 24,159 without diabetes and 11,181 with diabetes. Within the diabetic group, 2,188 patients (20%) were not receiving medical treatment for diabetes and 8993 were being treated as follows: 4550 (41%) non-insulin monotherapy; 1550 (14%) non-insulin combination therapy; 2,893 (26%) insulin. Hazard ratios were compared for the entire follow-up, indicating a significant difference in overall survival between medically untreated DM and all groups, except insulin-treated. Subset analysis with adjustment for age, gender, BMI, alcohol and smoking indicated a significant survival difference between untreated DM and all groups. Rates of hypertension, ischemic heart disease, renal failure, and congestive heart disease were higher in the untreated and insulin-treated diabetic patients than in the nondiabetic and diabetic patients on non-insulin treatment.

CONCLUSIONS

Lack of treatment for diabetes might have serious consequences. Further studies are needed to see if targeted treatment approach may decrease mortality.

HbA1c and Risks of All-Cause and Cause-Specific Death in Subjects without Known Diabetes: A Dose-Response Meta-Analysis of Prospective Cohort Studies

Whether HbA_1c levels are associated with mortality in subjects without known diabetes remains controversial. Moreover, the shape of the dose–response relationship on this topic is unclear. Therefore, a dose–response meta-analysis was conducted. PubMed and EMBASE were searched. Summary hazard ratios (HRs) were calculated using a random-effects model. Twelve studies were included. The summary HR per 1% increase in HbA_1c level was 1.03 [95% confidence interval (CI) = 1.01–1.04] for all-cause mortality, 1.05 [95% CI = 1.02–1.07) for cardiovascular disease (CVD) mortality, and 1.02 (95% CI = 0.99–1.07) for cancer mortality. After excluding subjects with undiagnosed diabetes, the aforementioned associations remained significant for CVD mortality only. After further excluding subjects with prediabetes, all aforementioned associations presented non-significance. Evidence of a non-linear association between HbA_1c and mortality from all causes, CVD and cancer was found (all P_{non-linearity} < 0.05). The dose–response curves were relatively flat for HbA_1c less than around 5.7%, and rose steeply thereafter. In conclusion, higher HbA_1c level is associated with increased mortality from all causes and CVD among subjects without known diabetes. However, this association is driven by those with undiagnosed diabetes or prediabetes. The results regarding cancer mortality should be treated with caution due to limited studies.

Prevalence of Prediabetes and Undiagnosed Diabetes in Canada (2007-2011) According to Fasting Plasma Glucose and HbA1c Screening Criteria

OBJECTIVE

To provide the first population-based estimates of prediabetes and undiagnosed type 2 diabetes prevalence in Canada.

RESEARCH DESIGN AND METHODS

We combined two fasting subsamples of the Canadian Health Measures Survey, which were restricted to nonpregnant adults ≥20 years of age (N = 3,494). Undiagnosed diabetes was defined as not having self-reported type 2 diabetes but having blood glucose measures that met Canadian guidelines (i.e., fasting plasma glucose [FPG] level of ≥7.0 mmol/L or hemoglobin A1c [HbA1c] level of ≥6.5% [≥48 mmol/mol]). Prediabetes was defined as an FPG level of ≥6.1 and <7.0 mmol/L or an HbA1c level of ≥6.0% and <6.5% (≥42 and <48 mmol/mol). All estimates were weighted using survey sampling weights. CIs were calculated with the bootstrap method.

RESULTS

According to FPG levels, the prevalence of undiagnosed type 2 diabetes in Canadian adults was 1.13% (95% CI 0.79, 1.62), contributing to ∼20% of total type 2 diabetes prevalence (5.62 [95% CI 4.52, 6.95]). Compared with FPG levels, the undiagnosed prevalence was greater using HbA1c level as a criterion (3.09% [95% CI 1.97, 4.81]), ∼41% of the total number of cases of diabetes (7.55 [95% CI 5.98, 9.49]). The HbA1c-only criterion resulted in a threefold increase in prediabetes prevalence overall and a sixfold increase among females (FPG 2.22%, HbA1c 13.31%). Screening based on FPG only identified older undiagnosed case patients, with a mean age of 58.7 years (95% CI 59.9, 63.4). Similarly, using HbA1c identified younger individuals with prediabetes, with reduced BMI and waist circumference compared with FPG levels.

CONCLUSIONS

In this first study of a nationally representative sample with biospecimen measures, we found that the prevalence of undiagnosed type 2 diabetes and prediabetes was significantly higher using HbA1c levels compared with FPG levels. Further evaluation is needed to fully assess the impact of using the HbA1c criterion.

Contributions of increasing obesity and diabetes to slowing decline in subclinical coronary artery disease

Background

Our previous study of nonelderly adult decedents with nonnatural (accident, suicide, or homicide) cause of death (96% autopsy rate) between 1981 and 2004 revealed that the decline in subclinical coronary artery disease (CAD) ended in the mid‐1990s. The present study investigated the contributions of trends in obesity and diabetes mellitus to patterns of subclinical CAD and explored whether the end of the decline in CAD persisted.

Methods and Results

We reviewed provider‐linked medical records for all residents of Olmsted County, Minnesota, who died from nonnatural causes within the age range of 16 to 64 years between 1981 and 2009 and who had CAD graded at autopsy. We estimated trends in CAD risk factors including age, sex, systolic blood pressure, diabetes (qualifying fasting glucose or medication), body mass index, smoking, and diagnosed hyperlipidemia. Using multiple regression, we tested for significant associations between trends in CAD risk factors and CAD grade and assessed the contribution of trends in diabetes and obesity to CAD trends. The 545 autopsied decedents with recorded CAD grade exhibited significant declines between 1981 and 2009 in systolic blood pressure and smoking and significant increases in blood pressure medication, diabetes, and body mass index ≥30 kg/m². An overall decline in CAD grade between 1981 and 2009 was nonlinear and ended in 1994. Trends in obesity and diabetes contributed to the end of CAD decline.

Conclusions

Despite continued reductions in smoking and blood pressure values, the previously observed end to the decline in subclinical CAD among nonelderly adult decedents was apparent through 2009, corresponding with increasing obesity and diabetes in that population.

Dapagliflozin in patients with type 2 diabetes mellitus

Dapagliflozin is a selective and reversible inhibitor of sodium-glucose linked transporter type 2 (SGLT2), which mediates approximately 90% of active renal glucose reabsorption in the early proximal tubule of the kidney. Dapagliflozin significantly reduces glucose reabsorption and decreases serum glucose concentration in an insulin-independent manner. The decrease of glucose reabsorption by dapagliflozin has also been associated with a reduction in body weight. Furthermore, the drug modestly reduces blood pressure levels through weight loss and its action as osmotic diuretic. Dapagliflozin has been approved as monotherapy in patients with type 2 diabetes mellitus (T2DM) who cannot tolerate metformin or in combination with other antidiabetic drugs, with the exception of pioglitazone due to the theoretical increased risk of bladder cancer. The drug should not be prescribed in patients with moderate or severe renal impairment or in patients at risk for developing volume depletion. Dapagliflozin is associated with increased incidence of genital and lower urinary tract infections, but these infections are usually mild to moderate and respond to standard antimicrobial treatment. Based on current evidence, dapagliflozin is a useful drug for patients with T2DM with a favorable safety profile. However, further research regarding the effects of dapagliflozin on cardiovascular outcomes is needed.

Protective effects of Salvia miltiorrhiza injection against learning and memory impairments in streptozotocin-induced diabetic rats

The aim of this study was to explore the protective effects of Salvia miltiorrhiza injection against learning and memory impairment in streptozotocin (STZ)-induced diabetic rats and the possible mechanism involved. Sprague Dawley male rats (n=30) were randomized into three groups: Diabetes, diabetes treated with S. miltiorrhiza injection and normal control. Diabetes was induced by an intraperitoneal injection of STZ (65 mg/kg). The S. miltiorrhiza injection-treated rats received an intraperitoneal injection of S. miltiorrhiza (5 ml/kg/day) while the rats of the other two groups were administered an intraperitoneal injection of the same volume of 0.9% saline for four weeks. After four weeks of treatment, the escape latency and search strategies in the rats were assessed by the Morris water maze test. The protein levels of mitogen-activated protein kinase phosphatase-1 (MKP-1) were also assessed by immunohistochemistry. Four weeks after the induction of diabetes, the body weight of the diabetic rats was significantly lower and the blood glucose concentration was significantly higher than that of the control rats. S. miltiorrhiza injection was observed to improve the blood glucose and learning ability (P<0.05). Compared with the control group, the expression of MKP-1 was significantly decreased in the hippocampal area of the diabetes group; S. miltiorrhiza injection-treated rats showed an increased expression compared with the diabetic rats, but the expression remained lower than that of the normal control group (P<0.05). In conclusion, S. miltiorrhiza injection can improve the learning and memory decline of diabetic rats. The changes in expression of MKP-1 under hyperglycemia may play a role in the protective effects of S. miltiorrhiza against dementia in diabetic rats.

Epidemiological ramifications of diagnosing diabetes with HbA1c levels

AIMS

To compare the prevalence of diabetes by history and using the fasting plasma glucose (FPG) criterion alone, the HbA1c criterion alone or either one in those not known to have diabetes.

METHODS

Analysis of NHANES population ≥20years old from 1999 through 2010.

RESULTS

In those diagnosed by laboratory tests, 86% met the FPG criterion and 53% met the HbA1c criterion. The prevalence of diabetes (history or laboratory test) was significantly increased when the FPG criterion was used compared with the HbA1c criterion in the entire (11.5% vs 10.5%, P=0.018) and Caucasian (10.6% vs 9.2%, P=0.022) populations. In contrast, there were no significant differences in the prevalence when only the FPG criterion was used compared with only the HbA1c criterion in Hispanics (12.9% vs 12.1% P=0.386) and African Americans (14.5 vs 14.3%, P=0.960). Using history and either criterion in those not known to have it, diabetes increased by 61% in this 12year period in adults ≥20years old.

CONCLUSIONS

Using the FPG rather than the HbA1c criterion to diagnose diabetes in those without a history significantly increased the total prevalence of diabetes in Caucasians but not in African Americans or Hispanics.

Reduced health-related quality of life in body constitutions of yin-xu, and yang-xu, stasis in patients with type 2 diabetes: taichung diabetic body constitution study

Aim. To evaluate how health-related quality of life (HRQOL) and traditional Chinese medicine (TCM) constitutions of Yin-Xu, Yang-Xu, and Stasis are related in type 2 diabetes patients. Method. Seven hundred and five subjects were recruited in 2010 for this study from a Diabetes Shared Care Network in Taiwan. Generic and disease-specific HRQOL were assessed by the short form 36 (SF-36) and the diabetes impact measurement scale (DIMS). Constitutions of Yin-Xu, Yang-Xu, and Stasis were then assessed by the body constitution questionnaire (BCQ), a questionnaire consisting of 44 items that evaluate the physiological state based on subjective symptoms and signs. Results. Estimated effects of the Ying-Xu and Stasis on all scales of the SF-36 were significantly negative, while estimated effects of the Yang-Xu on all scales (except for SF, RE, MH, and MCS) were significantly negative. For DIMS, the estimated effects of the Ying-Xu and Stasis on all scales were significantly negative except for Stasis on well-being, while Yang-Xu has a significantly negative effect only on symptoms. Conclusions. This study demonstrates that TCM constitutions of Yin-Xu, Yang-Xu, and Stasis are closely related to a reduction in HRQOL. These findings support the need for further research into the impact of intervention for TCM constitutions on HRQOL in patients with type 2 diabetes.

Spousal diabetes as a diabetes risk factor: a systematic review and meta-analysis

BACKGROUND

Diabetes history in biologically-related individuals increases diabetes risk. We assessed diabetes concordance in spouses (that is, biologically unrelated family members) to gauge the importance of socioenvironmental factors.

METHODS

We selected cross-sectional, case-control and cohort studies examining spousal association for diabetes and/or prediabetes (impaired fasting glucose or impaired glucose tolerance), indexed in Medline, Embase or Scopus (1 January 1997 to 28 February 2013). Effect estimates (that is, odds ratios, incidence rate ratios, and so on) with body mass index (BMI) adjustment were pooled separately from those without BMI adjustment (random effects models) to distinguish BMI-dependent and independent concordance.

RESULTS

Searches yielded 2,705 articles; six were retained (n = 75,498 couples) for systematic review and five for meta-analysis. Concordance was lowest in a study that relied on women's reports of diabetes in themselves and their spouses (effect estimate 1.1, 95% CI 1.0 to 1.30) and highest in a study with systematic assessment of glucose tolerance (2.11, 95% CI 1.74 to 5.10). The random-effects pooled estimate adjusted for age and other covariates but not BMI was 1.26 (95% CI 1.08 to 1.45). The estimate with BMI adjustment was lower (1.18, 95% CI 0.97 to 1.40). Two studies assessing between-spouse associations of diabetes/prediabetes determined by glucose testing reported high concordance (OR 1.92, 95% CI 1.55 to 2.37 without BMI adjustment; 2.32, 95% CI 1.87 to 3.98 with BMI adjustment). Two studies did not distinguish type 1 and type 2 diabetes. However given that around 95% of adults is type 2, this is unlikely to have influenced the results.

CONCLUSIONS

Our pooled estimate suggests that a spousal history of diabetes is associated with a 26% diabetes risk increase. Recognizing shared risk between spouses may improve diabetes detection and motivate couples to increase collaborative efforts to optimize eating and physical activity habits.

Glucose as a risk predictor in acute medical emergency admissions

AIMS

The aims of this study were to examine the relationship between admission blood glucose and mortality in a large, unselected cohort of acutely ill medical patients and to assess the impact of diabetes on this relationship.

METHODS

We studied the broad pattern of acute medical admissions over an eight year period and the impact of admission serum glucose on in-hospital mortality. Significant predictors of outcome, including acute illness severity and co-morbidity, were entered into a multivariate regression model, adjusting the univariate estimates of the glycaemic status on mortality.

RESULTS

There were 45,068 consecutive acute medical emergency admissions between 2005 and 2012. The normoglycaemic (>4.0 ≤7.0 mmol/l) cohort (86%) had a 3.9% in-hospital mortality. Both hypoglycaemia (OR: 3.23: 95% CI: 2.59-4.04; p<0.001) and hyperglycaemia (OR: 2.1; 95% CI: 1.9-2.4; p<0.001) predicted an increased risk of an in-hospital death. Neither of these increased risks were fully adjusted nor explained by a highly predictive outcome model, using multiple acute illness parameters. Hyperglycaemia did not carry similar adverse prognostic implications for patients with diabetes.

CONCLUSION

In patients without diabetes, an abnormal serum glucose is independently predictive of an increased mortality among the broad cohort of acute emergency medical patients. Similar disturbances of glucose homeostasis for patients with diabetes do not confer equivalent adverse prognostic implications.

Effects of glucagon-like peptide-1 receptor agonists on renal function

Glucagon-like peptide-1 (GLP-1) receptor agonists result in greater improvements in glycemic control than placebo and promote weight loss with minimal hypoglycemia in patients with type 2 diabetes mellitus. A number of case reports show an association of GLP-1 receptor agonists, mainly exenatide, with the development of acute kidney injury. The present review aims to present the available data regarding the effects of GLP-1 receptor agonists on renal function, their use in subjects with chronic renal failure and their possible association with acute kidney injury. Based on the current evidence, exenatide is eliminated by renal mechanisms and should not be given in patients with severe renal impairment or end stage renal disease. Liraglutide is not eliminated by renal or hepatic mechanisms, but it should be used with caution since there are only limited data in patients with renal or hepatic impairment. There is evidence from animal studies that GLP-1 receptor agonists exert protective role in diabetic nephropathy with mechanisms that seem to be independent of their glucose-lowering effect. Additionally, there is evidence that GLP-1 receptor agonists influence water and electrolyte balance. These effects may represent new ways to improve or even prevent diabetic nephropathy.