Glycemic control in diabetic American Indians. Longitudinal data from the Strong Heart Study

Change in physical activity, food choices and hemoglobin A1c among American Indians and Alaska Natives with type 2 diabetes

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At baseline, physically active participants with higher healthy food scores had lower HbA1c levels than non-active participants.

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Over the three-year period, women who increased physical activity and/or healthy food consumption had slightly decreased HbA1c.

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Changes in physical activity and HbA1c differed by gender.

The prevalence of diabetes among American Indian and Alaska Native (AI/AN) adults is the highest of all United States racial/ethnic groups. Health behaviors, including regular physical activity and healthy food choices, are important components in the management of diabetes. We estimated the cross-sectional association between physical activity and healthy food scores, separately, and combined (PAHF) with hemoglobin A1c (HbA1c) over three years of the Special Diabetes Program for Indians-Healthy Heart demonstration project (SDPI-HH) intervention. The relationship between physical activity and food choices was also examined. Among 3,039 SDPI-HH participants at baseline, those reporting being physically active and having high healthy food scores had statistically significant lower HbA1c (mean = 7.67 ± 2.01) compared to inactive participants with low healthy food scores (7.90 ± 1.92). Among the 1,150 SDPI-HH participants who attended the three-year follow-up visit, participants who increased physical activity, consumption of healthy foods, or both had a larger decrease in HbA1c (β = -0.29, P = 0.03) over the study period compared to participants with no improvement in physical activity or increase in consuming healthy foods. This association was statistically significant among women (β = -0.35, P = 0.04) but not among men (β = -0.08, P = 0.70). Our findings indicated that an increase in healthier behaviors, including physical activity and healthy food choices, was associated with a small improvement in HbA1c in the subset of women who participated in the SDPI-HH through the three-year follow up. Although the decrease in HbA1c was small, physical activity and healthy food choices are important behaviors to incorporate into everyday life among AI/AN adults, particularly those with diabetes.

Reconsidering the HbA1c Cutoff for Diabetes Diagnosis Based on a Large Chinese Cohort

INTRODUCTION

The HbA1c has been considered as the 'gold standard' in diabetes diagnosis and management, however, age, gender and body mass index (BMI) might have certain effects on HbA1c. We are aiming to further investigate the correlation between age and HbA1c, and whether it was affected by gender and BMI.

METHODS

A cross-sectional survey including 135,893 nondiabetic individuals who took the physical examination between 2013 and 2017 was conducted. The subjects were grouped by gender, age and BMI, and the interactive and independent effects of the 3 factors on the HbA1c were detected. The median and 95% confidence interval (CI) of HbA1c levels were calculated.

RESULTS

The HbA1c levels gradually increased along with age, both in female and male, and there is a positive association between BMI and the HbA1c. The difference on HbA1c in gender was associated with both age and BMI, the age-related increase in HbAlc was accentuated in the subgroup with higher BMI, and there was a marked accentuation of the positive association between BMI and HbA1c as age increased. In almost all the young and middle-aged (aged 20-59) subgroups, the 97.5^th percentiles of HbA1c levels were lower than 6.5%, suggesting that the single HbA1c cutoff value is probably not applicable to the young and middle-aged population.

CONCLUSIONS

We recommend that the effects of age, gender and BMI should be taken into consideration when using HbA1c for the diagnosis and management of diabetes, especially in the young and middle-aged population.

Uncontrolled diabetes mellitus: prevalence and risk factors among people with type 2 diabetes mellitus in an Urban District of Karachi, Pakistan

AIMS

This study aimed to explore the prevalence of, and factors associated with, uncontrolled diabetes mellitus (UDM) in a community setting in Pakistan.

METHODOLOGY

A single-center, cross-sectional study, conducted in a community-based specialized care center (SCC) for diabetes in District Central Karachi, in 2003, registered 452 type 2 DM participants, tested for HbA1c and interviewed face-to-face for other information. Logistic regression analysis was conducted to identify factors associated with UDM.

RESULTS

Prevalence of UDM among diabetes patients was found to be 38.9% (95% CI: 34.4-43.4%). Multivariable logistic regression model analysis indicated that age <50 years (OR: 1.9; 95% CI: 1.2-2.9), being diagnosed in a hospital (vs. a clinic) (OR: 1.8; 95% CI: 1.1-2.8), diabetes information from a doctor or nurse only (vs. multiple sources) (OR: 1.8; 95% CI: 1.2-2.9), higher monthly treatment cost (OR: 1.3; 95% CI: 1.1-1.6; for every extra 500 PKR), and higher consumption of tea (OR: 1.5; 95% CI: 1.0-2.2; for every 2 extra cups) were independently associated with UDM.

CONCLUSION

The prevalence of UDM was approximately 39% among persons with type 2 diabetes visiting a community based SCC for diabetes. Modifiable risk factors such as sources of diabetes information and black tea consumption can be considered as potential targets of interventions in Karachi.

Serum prolidase enzyme activity and oxidative stress levels in patients with diabetic neuropathy

Previous studies have suggested that prolidase and nitric oxide (NO) regulate many processes, such as collagen synthesis and matrix remodeling. Oxidative stress plays an important role in the development of microvascular complications in diabetic patients. Data on serum prolidase activity in patients with diabetes mellitus or diabetic neuropathy (DN) are limited and conflicting. The aim of this study was to measure serum prolidase activity, NO, total antioxidant status (TAS), and malondialdehyde (MDA) levels in patients with DN. Forty-five patients with DN and 40 healthy controls were enrolled. Serum prolidase activity, TAS, MDA, and NO levels were determined. Serum MDA and NO levels were significantly higher in DN patients than controls (p = 0.002, p = 0.001, respectively), while prolidase activity and TAS levels were lower (p = 0.003, p = 0.001, respectively). Prolidase activity was negatively correlated with NO and MDA (r = -0.911, p < 0.001; r = -0.905, p < 0.001, respectively), while positively correlated with TAS (r = 0.981, p < 0.001) in DN patients. The current study is the first showing the decreased serum prolidase enzyme activity. Our results suggest that decreased collagen turnover may occur in DN patients, who have increased oxidative stress and increased NO levels. Decreased prolidase activity seems to be associated with increased NO levels and oxidative stress along with decreased antioxidant levels in DN. Therefore, decreased prolidase activity may play a role in pathogenesis of DN. Prospective clinical studies are necessary to confirm these findings.

Does good clinical practice at the primary care improve the outcome care for diabetic patients? Gender differences

BACKGROUND

The Middle East region is predicted to have one of the highest prevalence of diabetes mellitus (DM) in the world. This is the first study in the region to assess treatment outcome of DM according to gender.

OBJECTIVE

To assess the quality and effectiveness of diabetes care provided to patients attending primary care settings according to gender in the State of Qatar.

DESIGN

It is an observational cohort study.

SETTING

The survey was carried out in primary health care (PHC) centers in the State of Qatar.

SUBJECTS AND METHODS

The study was conducted from January 2010 to August 2010 among diabetic patients attending (PHC) centers. Of the 2334 registered with diagnosed diabetes, 1705 agreed and gave their consent to take part in this study, thus giving a response rate of 73.1%. Face to face interviews were conducted using a structured questionnaire including socio-demographic, clinical and satisfaction score of the patients.

RESULTS

Majority of subjects were diagnosed with type 2 DM (84.9%). A significantly larger proportion of females with DM were divorced or widowed (9.1%) in comparison to males with DM (3.4%; p<0.001). A significantly larger proportion of females were overweight (46.5%; p=0.009) and obese (29.5%; p=0.003) in comparison to males. Males reported significantly greater improvements in mean values of blood glucose (mmol/l) (-2.11 vs. -0.66; p=0.007), HbA1c (%) (-1.44 vs. -0.25; p=0.006), cholesterol (mmol/l) (-0.16 vs. 0.12; p=0.053) and systolic blood pressure (mmHg) (-9.04 vs. -6.62; p<0.001) in comparison to females. While there was a remarkable increase in male patients with normal range of fasting blood glucose (FBG; 51.6%) as compared to the FBG measurement 1 year before (28.5%: p<0.001) there was only a slight increase in females normal range FBG during this period from 28.0% to 30.4% (p=0.357).

CONCLUSION

The present study revealed that the current form of PHC centers afforded to diabetic patients provided significantly improved outcomes for males, but only minor improved outcomes for females. This study reinforces calls for a gender-specific approach to diabetes care.

Arsenic exposure, diabetes prevalence, and diabetes control in the Strong Heart Study

This study evaluated the association of arsenic exposure, as measured in urine, with diabetes prevalence, glycated hemoglobin, and insulin resistance in American Indian adults from Arizona, Oklahoma, and North and South Dakota (1989-1991). We studied 3,925 men and women 45-74 years of age with available urine arsenic measures. Diabetes was defined as a fasting glucose level of 126 mg/dL or higher, a 2-hour glucose level of 200 mg/dL or higher, a hemoglobin A1c (HbA1c) of 6.5% or higher, or diabetes treatment. Median urine arsenic concentration was 14.1 µg/L (interquartile range, 7.9-24.2). Diabetes prevalence was 49.4%. After adjustment for sociodemographic factors, diabetes risk factors, and urine creatinine, the prevalence ratio of diabetes comparing the 75th versus 25th percentiles of total arsenic concentrations was 1.14 (95% confidence interval: 1.08, 1.21). The association between arsenic and diabetes was restricted to participants with poor diabetes control (HbA1c ≥8%). Arsenic was positively associated with HbA1c levels in participants with diabetes. Arsenic was not associated with HbA1c or with insulin resistance (assessed by homeostatic model assessment to quantify insulin resistance) in participants without diabetes. Urine arsenic was associated with diabetes control in a population from rural communities in the United States with a high burden of diabetes. Prospective studies that evaluate the direction of the relation between poor diabetes control and arsenic exposure are needed.

Differences in risk factors for coronary heart disease among diabetic and nondiabetic individuals from a population with high rates of diabetes: the Strong Heart Study

CONTEXT

Coronary heart disease (CHD) is the leading cause of death in the United States.

OBJECTIVE

This study compares differences in risk factors for CHD in diabetic vs. nondiabetic Strong Heart Study participants.

DESIGN

This was an observational study.

SETTING

The study was conducted at three centers in Arizona, Oklahoma, and North and South Dakota.

PARTICIPANTS

Data were obtained from 3563 of 4549 American Indians free of cardiovascular disease at baseline.

INTERVENTION(S)

CHD events were ascertained during follow-up.

MAIN OUTCOME MEASURE

CHD events were classified using standardized criteria.

RESULTS

In diabetic and nondiabetic participants, 545 and 216 CHD events, respectively, were ascertained during follow-up (21,194 and 22,990 person-years); age- and sex-adjusted incidence rates of CHD were higher for the diabetic group (27.5 vs. 12.1 per 1,000 person-years). Risk factors for incident CHD common to both groups included older age, male sex, prehypertension or hypertension, and elevated low-density lipoprotein cholesterol. Risk factors specific to the diabetic group were lower high-density lipoprotein cholesterol, current smoking, macroalbuminuria, lower estimated glomerular filtration rate, use of diabetes medication, and longer duration of diabetes. Higher body mass index was a risk factor only for the nondiabetic group. The association of male sex and CHD was greater in those without diabetes than in those with diabetes.

CONCLUSIONS

In addition to higher incidence rates of CHD events in persons with diabetes compared with those without, the two groups differed in CHD risk factors. These differences must be recognized in estimating CHD risk and managing risk factors.

Predictors of suboptimal glycaemic control in type 2 diabetes patients: the role of medication adherence and body mass index in the relationship between glycaemia and age

AIMS

To analyse predictors of glycaemic control including medication adherence and body mass index (BMI) in UK general practice patients with sub-optimally controlled type 2 diabetes.

METHODS

Baseline demographic, health- and treatment-related measures were evaluated as predictors of one year glycaemic control defined separately as HbA(1c)≤ 7.5% and a continuous measure of HbA(1c) concentration, using multivariate regression models. Significant predictors were adjusted for objectively assessed medication adherence and BMI.

RESULTS

One-year HbA(1c) concentration was associated with baseline HbA(1c) (p<0.001), BMI (p=0.02), and inversely associated with age (p=0.007) and objectively assessed adherence. Adherent patients had one-year (adjusted) HbA(1c) concentration 0.65% (95% CI -1.04, -0.25; p=0.001) lower than nonadherent. Odds ratios (95% CI) of HbA(1c)≤ 7.5% for 10-year higher age were 1.63 (1.08, 2.45); for adherent compared to non-adherent patients 1.89 (0.84, 4.25); for patients receiving >5 compared to ≤ 5 medications 0.32 (0.13, 0.76); and for each 1% increment in baseline HbA(1c) 0.48 (0.31, 0.73).

CONCLUSIONS

The lower HbA(1c) achieved from greater adherence to glucose lowering treatment is comparable to that achieved with additional medication. Relationships between older age and better glycaemic control are not explained by better adherence, but may partly relate to lower BMI.

No altered blood pressure and serum markers of oxidative stress after a long time dietary fish oil in the genetically 9 month-old type-2 diabetes Zucker rat

In this study, we investigated the effect of a high n-3 fatty acid diet (eicosapentaenoic and docosahexaenoic acids) in Zucker obese and lean rats on blood pressure in association with physiological parameters, serum biochemistry and oxidative stress analysis. After 150 days of treatment, dietary fish oil supplementation in Zucker obese rats (9 months of age) reduces bodyweight gain and serum triglyceridemia and nitrite levels, increases serum glucose and angiotensin converting enzyme activity, but does not alter blood pressure, cholesterol levels and serum markers of oxidative stress (malondialdehyde, glutathione), compared to the Zucker rats fed control diet. According to these results, we can consider that after 150 days of treatment, fish oil is not enough to regulate parameters involved in the metabolic syndrome, such as cholesterolemia and blood pressure, in a 9 month-old genetically type-2 diabetes rat.

Changes in levels of haemoglobin A1c during the first 6 years after diagnosis of clinical type 2 diabetes

OBJECTIVE

To assess the variability in levels of glycosylated haemoglobin (HbA(1c)) during the first six years after diagnosis of clinical type 2 diabetes in relation to possible predictors.

MATERIAL AND METHODS

Data were from a population-based sample from general practice of 581 newly diagnosed diabetic patients aged 40 or over. Estimation of HbA(1c) was centralized. The changes in levels of HbA(1c) were described by HbA(1c) at diagnosis and a regression line fitted to the HbA(1c) measurements after 1-year follow-up for each patient. The predictive effect of patient characteristics for changes in HbA(1c) was investigated in a multivariate mixed model.

RESULTS

During the first year after diabetes diagnosis, HbA(1c) dropped to near normal average level and then started rising almost linearly. A sharp rise in long-term glycaemic level was observed in approximately a quarter of the patients, especially the relatively young. Of 581 patients, 156 (26.9%) patients, however, experienced a fall in HbA(1c) after 1-year follow-up and another quarter showed constant or only slowly rising HbA(1c). The changes in levels of HbA(1c) were only predicted by diagnostic HbA(1c) and age.

CONCLUSIONS

During the first 6 years after the diagnosis of clinical type 2 diabetes, changes in levels of HbA(1c) show considerable inter-individual variability with age as the only long-term predictor. The results indicate that it is important to monitor changes in HbA(1c) more closely and intensify treatment of those often relatively young patients who actually experience the beginning of an apparently relentless deterioration of their glycaemic control.

Factors associated with glycemic control after an inpatient program

In this study, we investigated the factors predicting poor glycemic control after an inpatient program. Using the hospital database from April 1999 to May 2003, we retrospectively identified patients with type 2 diabetes mellitus and hemoglobin A(1C) (HbA(1C)) of at least 8.0% at the time of admission for an inpatient program. In the primary analysis, factors potentially related to poor glycemic control (HbA(1C) > or =7.0%) at 6 months after admission were investigated. Stepwise multivariate regression analysis identified the duration of diabetes (odds ratio, 2.43; 95% confidence interval [CI], 1.54-3.82; P < .001), period from the first attendance at our hospital until admission (odds ratio, 1.60; 95% CI, 1.01-2.54; P = .047), and number of admissions (odds ratio, 2.28; 95% CI, 1.36-3.82; P = .002) as predictors of poor glycemic control. In the secondary analysis, factors related to poor glycemic response (an absolute decrease of HbA(1C) by <1.5% from the baseline) at 6 months after admission were investigated. Stepwise multivariate regression analysis identified the duration of diabetes (odds ratio, 2.17; 95% CI, 1.19-3.93; P = .011), period from the first attendance at our hospital until admission (odds ratio, 2.17; 95% CI, 1.43-3.29; P < .001), treatment of diabetes at discharge (oral hypoglycemic agents: odds ratio, 2.52; 95% CI, 1.15-5.51; P = .021; insulin: odds ratio, 4.44; 95% CI, 1.96-10.07; P < .001), baseline HbA(1C) (odds ratio, 0.44; 95% CI, 0.37-0.53; P < .001), and addition of new medications (odds ratio, 0.41; 95% CI, 0.27-0.62; P < .001) as predictors of poor glycemic control.

Increasing prevalence and low awareness, treatment and control of diabetes mellitus among Chinese adults: the InterASIA study

AIMS

To estimate the prevalence rates of impaired fasting glucose (IFG) and diabetes mellitus (DM) and to evaluate the awareness, treatment, and control of DM in the Chinese adult population.

METHODS

The International Collaborative Study of Cardiovascular Disease in ASIA (InterASIA), a cross-sectional study, was conducted in 2000-2001. A nationally representative sample of 15,236 Chinese adults between 35 and 74 years old who had fasting plasma glucose measured were used for the present research. Awareness, treatment, and control of DM were defined by subjects self-reporting a DM diagnosis and the use of a prescription medication or nonpharmacological intervention for DM, and had a fasting plasma glucose <126mg/dl, respectively.

RESULTS

The prevalence rates of IFG and DM in Chinese adults aged 35-74 years were 7.33 and 5.49%, respectively, with the age-standardized prevalence also 7.33 and 5.49%, respectively. Among patients with DM, 23.66% were aware of their DM, 20.33% were taking prescribed medication or nonpharmacological interventions, and 8.28% had fasting plasma glucose <126mg/dl. Among diabetics who reported a prior diagnosis of DM, 85.22% were taking prescription medication or nonpharmacological interventions and 35% had fasting plasma glucose <126mg/dl.

CONCLUSIONS

The prevalence rate of DM among Chinese adults has been increasing in recent years. The rates of awareness, treatment and control of DM are relatively low. Improving the awareness, treatment, and control is urgently needed for the intervention of DM in the Chinese adult population.

Relationship between total oxidant status and severity of diabetic nephropathy in type 2 diabetic patients

BACKGROUND AND AIM

Data on oxidative stress in type 2 diabetic patients with diabetic nephropathy is scant. The objective of this study was to investigate possible associations between total oxidant status (TOS) and the severity of diabetic nephropathy in type 2 diabetic patients by using a novel automated measurement method.

METHODS AND RESULTS

Thirty-six patients with diabetic nephropathy (group 1), 25 diabetic patients without nephropathy (group 2) and 30 controls (group 3) were enrolled. Serum total antioxidant capacity (TAC), TOS levels and oxidative stress index (OSI) were determined. The severity of the disease was determined with microalbuminuria levels. TAC was lower, while TOS and OSI were higher in group 1 than in group 3 (P<0.01, P<0.001, P<0.001; respectively). There were no statistically significant differences between group 2 and group 3 with respect to TAC, TOS and OSI (all P>0.05). Group 1 had higher TOS and OSI than group 2 (both P<0.05), but there was no statistically significant difference with respect to TAC. Significant correlations were observed between microalbuminuria levels, and TAC, TOS and OSI levels (r=-0.616, P<0.001; r=0.488, P<0.01; r=0.567, P<0.001; respectively).

CONCLUSION

Our results suggest that oxidative stress is increased in patients with diabetic nephropathy compared to diabetic patients without nephropathy and this increase seems to be related to the severity of microalbuminuria levels.

A study of antidiabetic and antioxidant effects of Helichrysum graveolens capitulums in streptozotocin-induced diabetic rats

Helichrysum graveolens (Bieb.) Sweet (Asteraceae) grows widely in Turkey. Capitulums of H. graveolens are used in the treatment of many diseases such as jaundice and wound healing and as a diuretic in the rural areas of Anatolia. The decoction from the capitulums of the plant is consumed for the symptoms of diabetes mellitus in folk medicine. In the present study, the hypoglycemic, antihyperglycemic, and antioxidant potentials of water and ethanol extracts of H. graveolens were evaluated by using in vivo methods in normal and streptozotocin-induced diabetic rats. Blood glucose levels of animals were measured by the glucose oxidase method. The antioxidant activity of these extracts was also studied in liver, kidney, and heart tissues. In order to determine antioxidant activity, tissue malondialdehyde and reduced glutathione levels were measured by using spectrophotometric methods. The experimental data obtained from water and ethanol extracts of capitulums confirmed the folkloric utilization. In order to discuss the role of polyphenolic components in the relevant activity, total phenol and flavonoid contents of each extract were also determined using the Folin-Ciocalteu reagent, and a positive correlation was observed.

Current smoking and type 2 diabetes among patients in selected Indian Health Service clinics, 1998-2003

OBJECTIVES

In non-American Indian/Alaska Native groups, current smoking prevalence is similar for those with or without diabetes (26%) We analyzed current smoking prevalence in American Indian/Alaska Natives by diabetes status.

METHODS

Data were extracted from Indian Health Service clinic visit information from 1998 to 2003. After consolidation into unique patient records, the sample comprised 71221 patients aged 14 years or older with both diabetes and current smoking information.

RESULTS

Cross-sectional results indicated that diabetic American Indian/Alaska Natives were significantly more likely than those without diabetes to be current smokers (29.8% vs 18.8%; P<.01). Smoking rates were 2 to 3 times higher among diabetic American Indians and Alaska Natives for each age category (P<.001), and current smokers with diabetes were more likely than nonsmokers to have glycosylated hemoglobin A1c levels at 8.0% or higher (P <.05).

CONCLUSIONS

American Indian/Alaska Natives with diabetes at all sites and age categories were found to smoke at significantly higher rates than those without diabetes. Smoking cessation programs should target diabetic patients to more effectively prevent complications and promote successful management of diabetes in American Indians/Alaska Natives.

Facteurs déterminants du contrôle glycémique des patients diabétiques de type 2 suivis en première ligne

PURPOSE

To determine the factors associated with poor glycemic control in type 2 diabetic patients followed in primary care units in Sousse, Tunisia.

METHODS

A cross-sectional study was conducted on a representative sample of type 2 diabetic patients followed at least two years in primary health care units in Sousse, Tunisia. Data were gathered from three sources: a self-administrated questionnaire, analysis of patient files and HbA1c level. HbA1c level was measured with turbidimetric immunoinhibition assay. Patients were considered well-controlled if glycated hemoglobin (HbA1c) was less than 7%, according to the American Diabetics Association (ADA) recommendations.

RESULTS

The study enrolled 404 type 2 diabetic patients. The mean age was 60.5+/-10.89 years, sex-ratio was 0.5, and mean disease duration 8.7+/-6.1 years. ADA recommendations were met by 16.7% of patients. Multivariate analysis using variables in relation with the patient, his/her family, the disease, the treatment and the health care unit, showed that only poor geographic access to the care center (adjusted OR: 1.89, p=0.009) and Body Mass Index (BMI) less than 30 kg/m2 (adjusted OR: 2.21, p=0.034) were significantly and independently associated with poor glycemic control.

CONCLUSION

Glycemic control in type 2 diabetic patients is poor. It depends strongly on geographic access to health care. Type 2 diabetic patients should be referred, as much as possible, to the nearest health care unit.

The relative effect of self-management practices on glycaemic control in type 2 diabetic patients in Mexico

OBJECTIVE

In this study, we examined the relative impact of self-management activities on glycaemic control in a population at high risk for developing complications.

METHODS

Patients diagnosed with diabetes mellitus of at least 1 year in duration at 30 years of age or older were sampled from the Instituto de Mexico Seguro Social (IMSS) Family Medicine Clinics in Guadalajara, Mexico (n=800). Demographic, clinical and health behaviour variables were used to predict good/poor glycaemic control, as measured by haemoglobin Alc (A1C).

RESULTS

Most (72.24%) patients had poor control (A1C > or = 7.0). Hyperglycaemia was significantly associated with factors not under patient control, such as having diabetes for a longer time [odds ratio (OR) = 2.40, 95% confidence interval (CI) 1.39, 4.14], having a first-degree relative with diabetes (OR= 1.52; 95% CI 1.06, 2.19), and being prescribed anti-diabetic medications, e.g. insulin (OR = 7.88, 95% CI 2.42, 25.63). After controlling for these variables, the only self-management variable that reduced the likelihood of hyperglycaemia was following a special diet (OR=0.49; 95% CI 0.32, 0.76). Furthermore, depression had an important effect on self-management, as those with lower levels of depressive symptoms were more likely to follow a diet and exercise.

DISCUSSION

While patients in this population have little control over many factors associated with glycaemic control, an important exception is diet. However, because of the adverse effect of depression on dieting, both depression management and dietary education are important for this population.

Glycemic control, atherosclerosis, and risk factors for cardiovascular disease in individuals with diabetes: the atherosclerosis risk in communities study

OBJECTIVE

Glycemic control (HbA(1c) [A1C]) is strongly associated with microvascular disease in individuals with diabetes, but its relation to macrovascular disease and atherosclerosis is less clear. This study examines the relationship between A1C, carotid intima-media thickness (IMT), and traditional cardiovascular risk factors in individuals with diabetes.

RESEARCH DESIGN AND METHODS

A cross-sectional study of 2,060 people with diagnosed and undiagnosed (unrecognized) diabetes in the Atherosclerosis Risk in Communities study was performed.

RESULTS

LDL and HDL cholesterol, plasma triglycerides, and waist-to-hip ratio were significantly associated with A1C after multivariable adjustment. African Americans with undiagnosed and diagnosed diabetes had significantly elevated A1C values compared with whites, even after adjustment for potentially confounding factors. There was a graded association between A1C and carotid IMT. In a fully adjusted model in individuals with undiagnosed diabetes, the odds ratio (OR) of being in the highest quartile of IMT versus the lowest was 2.46 (95% CI 1.16-5.03, comparing the highest quartile of A1C to the lowest). In people with diagnosed diabetes, the comparable OR was 2.62 (1.36-5.06).

CONCLUSIONS

This study identified several important associations between A1C and known risk factors for cardiovascular disease and suggested that A1C is independently related to carotid IMT. Chronically elevated glucose levels may contribute to the development of atherosclerosis in people with diabetes, independent of other risk factors.

Meal-related increases in vascular reactivity are impaired in older and diabetic adults: insights into roles of aging and insulin in vascular flow

A fatty meal induces vasodilatation (of both resting and stimulated forearm flow) in healthy young adults, an effect most likely mediated by the vasodilator actions of insulin. We therefore hypothesized that an impaired meal-related vascular response might be an in vivo marker of vascular insulin resistance, related to the presence of diabetes and/or higher age. Postprandial vascular responses were assessed in three groups of subjects: 15 Type 2 diabetic subjects (age 58 ± 8 yr), 15 age-, gender-, and body mass index (BMI)-matched older control subjects (age 57 ± 9 yr), and 15 healthy young control subjects (age 33 ± 7 yr). Studies were carried out before and 3 and 6 h after a standardized high-fat meal (1,030 kcal, 61 g fat). Forearm microvascular flows were measured by strain gauge plethysmography and large-artery function by ultrasound. Resting blood flow and hyperemic area under curve (AUC) flow were not significantly different in diabetic subjects (resting 117 ± 42% and AUC 134 ± 46% of premeal values) compared with age-matched controls (resting 131 ± 39% and AUC 134 ± 47%); however, the response in diabetic subjects was blunted compared with young controls (resting 171 ± 67% and AUC 173 ± 99% of premeal values; P = 0.02 and P = 0.18, respectively). On multiple regression analysis, we found that increasing age (but not BMI or diabetes) was significantly associated with impaired postprandial vascular responses (resting: r = −0.4, P = 0.002; AUC: r = −0.4, P = 0.006). Therefore, meal ingestion results in impaired vasodilator responses in older nondiabetic and diabetic adults, related to aging rather than insulin resistance.

Slowing the progression of diabetic nephropathy and its cardiovascular consequences

This paper incorporates the findings from a multidisciplinary meeting on diabetic nephropathy and its renal and cardiovascular complications into a review article. The epidemic of obesity and the growing elderly population in the United States are primary drivers of a secondary epidemic of incipient type 2 diabetes mellitus and diabetic nephropathy. Current therapies aim to treat blood pressure, particularly with agents that block the renin-angiotensin system, to a target of 130/80 mm Hg. However, even lower blood pressure targets may be optimal. Control of hyperglycemia and dyslipidemia, smoking cessation, exercise, and weight loss all compliment blood pressure control and are achieved most effectively when the patient, provider, and health system are aligned with these goals. Once end-stage renal disease (ESRD) is reached, patients enter the highest cardiovascular risk-state appreciated in human medicine. Because of uniform access to care in the United States, advanced data systems, and circulatory system (intravascular) access in most patients, the ESRD population should be the future sampling frame for newer treatments tested in both prospective cohort and randomized trials. Cardiorenal risk, or the degree of excess cardiovascular risk incurred by patients with chronic kidney disease and ESRD, is a state offering considerable research opportunities for novel cardiovascular risk factors. Future studies should fully consider the possibility that improved outcomes would be achieved at a greater cost; thus, cost-effectiveness studies are essential for understanding the economic aspects of implementation. The goal of an ideal clinical trial would be ESRD prevention; however, pragmatic objectives such as a greater understanding of therapeutic toxicities should also be explored in this population.

Effects of glycaemic control on cardiovascular disease in diabetic American Indians: the Strong Heart Study

AIMS

Diabetes increases the risk of cardiovascular disease (CVD). Only part of this excess risk is explained by diabetes-associated hypertension, obesity, and lipid disorders. Poor glycaemic control may help explain the residual CVD risk. The aim of this study was to determine whether variations in glycaemic control are associated with CVD risk in diabetic individuals.

METHODS

We examined longitudinal data from the Strong Heart Study, a population-based study of CVD and its risk factors among American Indians (a population with a high prevalence of diabetes). Diabetes was defined using the 1998 World Health Organization criteria: fasting plasma glucose >/= 126 mg/dl or 2-h plasma glucose >/= 200 mg/dl. American Diabetes Association guidelines for glycaemic control were used: good, A(1c) < 7%; fair, 7-7.9%; and poor, >/= 8%. The analysis was based on data from diabetic individuals with no CVD at baseline.

RESULTS

During 9 years of follow-up, 494 of the 2011 diabetic participants developed CVD. Although Cox multivariate regression modelling showed dose-response effects of glycaemic control on overall CVD and coronary heart disease (CHD) incidence, the relationships were weakened when adjusted for confounding variables. Kaplan-Meier analysis, however, showed that diabetic individuals with poor baseline glycaemic control had significantly increased proportions of overall CVD and CHD (P = 0.001) during the 9 years of follow-up, compared with those who had good or fair control.

CONCLUSIONS

These findings highlight the importance of risk factors, such as high blood pressure and dyslipidaemia, in increasing CVD risk in those with diabetes.

HbA(1c) levels among American Indian/Alaska Native adults

OBJECTIVE

Type 2 diabetes is a major public health problem among many American Indian/Alaska Native communities. Elevated levels of HbA(1c) have been observed in younger American Indian/Alaska Native adults. The objectives of this study were: 1) to determine whether HbA(1c) levels were elevated among younger American Indian/Alaska Native adults nationally and, if so, 2) to determine the relationship between HbA(1c) levels and age due to treatment type, BMI, renal disease, duration of diabetes, survival, or a poor diabetes health care index.

RESEARCH DESIGN AND METHODS

The national Indian Health Service Diabetes Care and Outcomes Audit was completed for a total of 11,419 American Indian/Alaska Native adults with type 2 diabetes from tribes across the U.S. in 1998. Glucose control was assessed by HbA(1c). BMI, diabetes duration, treatment type, and proteinuria were assessed from the Diabetes Care and Outcomes Audit data. To assess diabetes quality of care, an index was developed from six standard of care Diabetes Care and Outcomes Audit variables.

RESULTS

We found HbA(1c) level decreased with increasing age. HbA(1c) levels were 9.2, 8.9, 8.8, 8.3, and 7.8 for ages 18-39, 40-49, 50-59, 60-69, and > or =70 years, respectively (P < 0.0001). This inverse relationship was not accounted for by differences in BMI, diabetes duration, treatment type, proteinuria, or health care index.

CONCLUSIONS

Among American Indian/Alaska Native adults, HbA(1c) levels were highest in the youngest age-group. With increasing numbers of young American Indian/Alaska Native adults with diabetes, poorer glucose control is expected to bring concomitant increased morbidity and mortality unless more effective and efficient interventions are developed to improve glucose control among young American Indian/Alaska Native adults.

Regional variation in cardiovascular disease risk factors among American Indians and Alaska Natives with diabetes

OBJECTIVE

To compare by region risk factors for cardiovascular disease among American Indian populations with diabetes.

RESEARCH DESIGN AND METHODS

Trained providers from 185 federal, urban, and tribally operated facilities reviewed the records from systematic random samples of the patients included in the local diabetes registries in the 1998 Indian Health Service (IHS) Diabetes Care and Outcomes Audit. Selected measures of cardiovascular risk were aggregated by region and adjusted to calculate regional rates for patients <45 years of age (n = 2,595) and those aged > or =45 years (n = 8,294).

RESULTS

Among the younger group of patients with diabetes, the rates of elevated HbA(1c) (> or =9%) and tobacco use varied significantly among regions. High rates of obesity (78%) and elevated HbA(1c) (56%) were found in the Southwest. High rates of tobacco use (55%) but the lowest rates of elevated HbA(1c) (27%) were found in Alaska. Among patients aged > or =45 years, all measures including rates of proteinuria, cholesterol > or =200 mg/dl, and mean blood pressure > or =130/85 varied significantly among all regions. Tobacco use was highest in the Great Lakes (44%) and Great Plains (42%) regions and lowest in the Southwest (14%) and Colorado Plateau (8%) regions. Proteinuria was found most frequently in the Southwest (35%), Colorado Plateau (30%), and Pacific regions (35%). Older individuals with diabetes were more likely than younger individuals to have proteinuria and blood pressure > or =130/85.

CONCLUSIONS

American Indians and Alaska Natives with diabetes carry a large burden of potentially modifiable cardiovascular risk factors, but there is significant regional variation.

Oxidative stress and nitric oxide related parameters in type II diabetes mellitus: effects of glycemic control

OBJECTIVES

The aim of this study is to investigate the status of oxidative stress and nitric oxide related parameters in type II diabetes mellitus (DM) patients in which heart disease, atherosclerosis, retinopathy, and nephropathy commonly occur, and also to determine the effect of glycemic control on these parameters.

DESIGN AND METHODS

Erythrocyte copper zinc-superoxide dismutase (CuZn-SOD), erythrocyte and plasma selenium dependent glutathione peroxidase (Se-GPx), erythrocyte catalase (CAT) activities, erythrocyte and plasma thiobarbituric acid reactive substances (TBARS) levels; nitrite/nitrate (NO(2)(-)/NO(3)(-)), cyclic guanosine monophosphate (cGMP) and nitrotyrosine levels in plasma of type II DM patients were measured.

RESULTS

Erythrocyte CuZn-SOD activities in type II DM were significantly higher than those of the control subjects (p < 0.05). TBARS levels in type II DM were significantly higher than the control subjects (p < 0.001). Plasma NO(2)(-)/NO(3)(-) levels in type II DM patients both during poor glycemic control and after three months of oral antidiabetic treatment were significantly higher than those of the control subjects (p < 0.001). Plasma cGMP levels in type II DM patients during poor glycemic control were significantly lower than those of control subjects (p < 0.001).

CONCLUSION

These results indicate that oxidative status and nitric oxide metabolism are affected in type II DM patients. We found high CuZn-SOD activity in type II DM patients. This increased activity could not protect the patients against the reactive oxygen species (ROS), since lipid peroxidation (defined by erythrocyte and plasma TBARS levels) still occurs in DM patients. After the therapy with oral antidiabetic agents for three months, erythrocyte SE-GPx and CAT activities were found to be decreased below the control values. Our results suggested that the low cGMP levels in the study may be a good marker of endothelium dysfunction in DM.