Detection of undiagnosed diabetes and other hyperglycemia states: the Atherosclerosis Risk in Communities Study

Development and Validation of Two Self-Reported Tools for Insulin Resistance and Hypertension Risk Assessment in A European Cohort: The Feel4Diabetes-Study

Early identification of type 2 diabetes mellitus (T2DM) and hypertension (HTN) risk may improve prevention and promote public health. Implementation of self-reported scores for risk assessment provides an alternative cost-effective tool. The study aimed to develop and validate two easy-to-apply screening tools identifying high-risk individuals for insulin resistance (IR) and HTN in a European cohort. Sociodemographic, lifestyle, anthropometric and clinical data obtained from 1581 and 1350 adults (baseline data from the Feel4Diabetes-study) were used for the European IR and the European HTN risk assessment index respectively. Body mass index, waist circumference, sex, age, breakfast consumption, alcohol, legumes and sugary drinks intake, physical activity and sedentary behavior were significantly correlated with Homeostatic Model Assessment of IR (HOMA-IR) and/or HTN and incorporated in the two models. For the IR index, the Area Under the Curve (AUC), sensitivity and specificity for identifying individuals above the 75th and 95th of HOMA-IR percentiles were 0.768 (95%CI: 0.721-0.815), 0.720 and 0.691 and 0.828 (95%CI: 0.766-0.890), 0.696 and 0.778 respectively. For the HTN index, the AUC, sensitivity and specificity were 0.778 (95%CI: 0.680-0.876), 0.667 and 0.797. The developed risk assessment tools are easy-to-apply, valid, and low-cost, identifying European adults at high risk for developing T2DM or having HTN.

Predicting Current Glycated Hemoglobin Values in Adults: Development of an Algorithm From the Electronic Health Record

Background

Electronic, personalized clinical decision support tools to optimize glycated hemoglobin (HbA_1c) screening are lacking. Current screening guidelines are based on simple, categorical rules developed for populations of patients. Although personalized diabetes risk calculators have been created, none are designed to predict current glycemic status using structured data commonly available in electronic health records (EHRs).

Objective

The goal of this project was to create a mathematical equation for predicting the probability of current elevations in HbA_1c (≥5.7%) among patients with no history of hyperglycemia using readily available variables that will allow integration with EHR systems.

Methods

The reduced model was compared head-to-head with calculators created by Baan and Griffin. Ten-fold cross-validation was used to calculate the bias-adjusted prediction accuracy of the new model. Statistical analyses were performed in R version 3.2.5 (The R Foundation for Statistical Computing) using the rms (Regression Modeling Strategies) package.

Results

The final model to predict an elevated HbA_1c based on 22,635 patient records contained the following variables in order from most to least importance according to their impact on the discriminating accuracy of the model: age, body mass index, random glucose, race, serum non–high-density lipoprotein, serum total cholesterol, estimated glomerular filtration rate, and smoking status. The new model achieved a concordance statistic of 0.77 which was statistically significantly better than prior models. The model appeared to be well calibrated according to a plot of the predicted probabilities versus the prevalence of the outcome at different probabilities.

Conclusions

The calculator created for predicting the probability of having an elevated HbA_1c significantly outperformed the existing calculators. The personalized prediction model presented in this paper could improve the efficiency of HbA_1c screening initiatives.

Undetected dysglycaemia common in primary care patients treated for hypertension and/or dyslipidaemia: on the need for a screening strategy in clinical practice. A report from EUROASPIRE IV a registry from the EuroObservational Research Programme of the European Society of Cardiology

Background

Dysglycaemia defined as type 2 diabetes (T2DM) and impaired glucose tolerance (IGT), increases the risk of cardiovascular disease (CVD). The negative impact is more apparent in the presence of hypertension and/or dyslipidaemia. Thus, it seems reasonable to screen for dysglycaemia in patients treated for hypertension and/or dyslipidaemia. A simple screening algorithm would enhance the adoption of such strategy in clinical practice.

Objectives

To test the hypotheses (1) that dysglycaemia is common in patients with hypertension and/or dyslipidaemia and (2) that initial screening with the Finnish Diabetes Risk Score (FINDRISC) will decrease the need for laboratory based tests.

Methods

2395 patients (age 18–80 years) without (i) a history of CVD or TDM2, (ii) prescribed blood pressure and/or lipid lowering drugs answered the FINDRISC questionnaire and had an oral glucose tolerance test (OGTT) and HbA1c measured.

Results

According to the OGTT 934 (39%) had previously undetected dysglycaemia (T2DM 19%, IGT 20%). Of patients, who according to FINDRISC had a low, moderate or slightly elevated risk 20, 34 and 41% and of those in the high and very high-risk category 49 and 71% had IGT or T2DM respectively. The OGTT identified 92% of patients with T2DM, FPG + HbA1c 90%, FPG 80%, 2hPG 29% and HbA1c 22%.

Conclusions

(1) The prevalence of dysglycaemia was high in patients treated for hypertension and/or dyslipidaemia. (2) Due to the high proportion of dysglycaemia in patients with low to moderate FINDRISC risk scores its initial use did not decrease the need for subsequent glucose tests. (3) FPG was the best test for detecting T2DM. Its isolated use is limited by the inability to disclose IGT. A pragmatic strategy, decreasing the demand for an OGTT, would be to screen all patients with FPG followed by OGTT in patients with IFG.

Evaluation of the modified FINDRISC to identify individuals at high risk for diabetes among middle-aged white and black ARIC study participants

OBJECTIVE

To evaluate a modified Finnish Diabetes Risk Score (FINDRISC) for predicting the risk of incident diabetes among white and black middle-aged participants from the Atherosclerosis Risk in Communities (ARIC) study.

RESEARCH DESIGN AND METHODS

We assessed 9754 ARIC cohort participants who were free of diabetes at baseline. Logistic regression and receiver operator characteristic (ROC) curves were used to evaluate a modified FINDRISC for predicting incident diabetes after 9 years of follow-up, overall and by race/gender group. The modified FINDRISC used comprised age, body mass index, waist circumference, blood pressure medication and family history.

RESULTS

The mean FINDRISC (range, 2 [lowest risk] to 17 [highest risk]) for black women was higher (9.9 ± 3.6) than that for black men (7.6 ± 3.9), white women (8.0 ± 3.6) and white men (7.6 ± 3.5). The incidence of diabetes increased generally across deciles of FINDRISC for all 4 race/gender groups. ROC curve statistics for the FINDRISC showed the highest area under the curve for white women (0.77) and the lowest for black men (0.70).

CONCLUSIONS

We used a modified FINDRISC to predict the 9-year risk of incident diabetes in a biracial US population. The modified risk score can be useful for early screening of incident diabetes in biracial populations, which may be helpful for early interventions to delay or prevent diabetes.

Ten-year Diabetes Risk Forecast in the Capital of Jordan: Arab Diabetes Risk Assessment Questionnaire Perspective-A Strobe-Complaint Article

The prevalence of diabetes in Jordan has been increasing. The early diagnosis of diabetes is vital to slow its progression. The Arab Risk (ARABRISK) screening tool is a self-administered questionnaire used to determine people who are at high risk for developing diabetes. This study aimed to identify people at high risk for developing type 2 diabetes by using the ARABRISK in the capital of Jordan.A cross-sectional study was conducted with a convenience sample of people in the capital of Jordan. The ARABRISK screening tool was administered to identify the participants' risk for developing diabetes. In addition to descriptive statistics, percentages of the ARABRISK categories were represented, and an independent samples t test was used to explore the differences between men and women. A total of 513 participants with a mean age of 51.94 (SD = 10.33) were recruited; 64.9% of the participants were men (n = 333).The total ARABRISK score ranged from 0 to 25 with a mean score of 12.30 (SD = 4.76). Using the independent samples t test, women (mean = 13.25, SE = 0.10) had significantly higher ARABRISK total scores than men did (mean = 12.95, SE = 0.09), t(141) = -2.23, P = 0.03 in the "moderate risk" category. All of the items in the ARABRISK questionnaire were found to be good predictors of the ARABRISK total scores. Among them, age, body mass index (BMI), and high blood glucose (HBG) were the best predictors as indicated by the standardized regression coefficient (β). Older age, obesity, elevated weight circumference, absence of daily physical activity, daily consumption of fruits/vegetables, presence of high blood pressure (HBP), and HBG were significantly associated with increased odds of high ARABRISK total scores. Neither a history of gestational diabetes nor a positive family history was associated with an increased odds of high ARABRISK total scores.By identifying risk factors in these participants, interventions and lifestyle changes can be suggested and implemented to reduce the risk and incidence of diabetes.

Using neural network as a screening and educational tool for abnormal glucose tolerance in the community

Background

Accurate, simple and non-invasive tools are needed for efficient screening of abnormal glu-cose tolerance (AGT) and educating the general public.

Aim

To develop a neural network-based initial screening and educational model for AGT.

Data and methods

230 subjects with AGT and 3,243 subjects with normal glucose tolerance (NGT) were allocated into training, validation and test sets using stratified randomization. The ratios of AGT versus NGT in three groups were 150:50, 30:570 and 50:950, respectively. A feed-forward neural network (FFNN) was trained to predict 2-hour plasma glucose of 75 g Oral Glucose Tolerance Test (OGTT) using age, family history of diabetes, weight, height, waist and hip circumference. The screening performance was evaluated by the area under the receiver operating characteristic (ROC) curve (AUC) and the partial AUC (in the range of false positive rates between 35 and 65%) and compared to those from logistic regression, linear regression and ADA Risk Test.

Results

Sensitivity, specificity, accuracy and percentage that needed further testing at 7.2 mmol/L in test group were 90.0%(95%CI: 78.6 to 95.7%), 47.7% (95%CI: 44.5 to 50.9%), 49.8% (95%CI: 46.7 to 52.9%) and 54.2% (95%CI: 51.1 to 57.3%) respectively. The entire and partial AUCs were 0.70 (95%CI: 0.62 to 0.78) and 0.26 (95%CI: 0.22 to 0.30). The partial AUC of the NN was higher than those of logistic regression (p = 0.06), linear regression (p = 0.06) and ADA Risk Test (P = 0.006).

Conclusion

NN can be used as a high-sensitive and non-invasive initial screening and educational tool for AGT.

Progression of diabetic retinopathy correlated with muscle perfusion disturbances of the lower limbs, with clinically important diagnostic recommendations

INTRODUCTION

The objective of this study was to investigate the relationship between microvascular and macrovascular disturbances in patients with type 2 diabetes, as shown by results of ophthalmological examination and by vascular and perfusion examinations of the lower limbs.

MATERIAL AND METHODS

A total of 85 patients with type 2 diabetes and an additional cardiovascular risk factor were enrolled in the study. All patients underwent complex ophthalmological examination, including fundus colour photography and fluorescein angiography, and were divided into two groups: group I with signs of diabetic non-proliferative retinopathy (NPDR), and group II with signs of diabetic proliferative retinopathy (P/PDR). After collection of the general medical history and analysis of medical data, patients underwent vascular and muscle perfusion examination of the lower limbs.

RESULTS

In the P/PDR group, disturbances of lower-limb perfusion were more frequent than in the NPDR group. Analysis of the blood flow and results of lower-limb muscle perfusion for the two groups showed a significant relationship with the severity of microvascular complications observed in examination of the fundus.

CONCLUSIONS

Ophthalmological assessment of the progression of diabetic retinopathy in patients with type 2 diabetes is a reliable indicator of the changes in peripheral vessel systems and perfusion defects in the lower limbs.

Diabetes and coronary heart disease as risk factors for mortality in older adults

BACKGROUND

Type 2 diabetes has been described as a coronary heart disease (CHD) "risk equivalent." We tested whether cardiovascular and all-cause mortality rates were similar between participants with prevalent CHD vs diabetes in an older adult population in whom both glucose disorders and preexisting atherosclerosis are common.

METHODS

The Cardiovascular Health Study is a longitudinal study of men and women (n=5784) aged > or =65 years at baseline who were followed from baseline (1989/1992-1993) through 2005 for mortality. Diabetes was defined by fasting plasma glucose > or =7.0 mmol/L or use of diabetes control medications. Prevalent CHD was determined by confirmed history of myocardial infarction, angina, or coronary revascularization.

RESULTS

Following multivariable adjustment for other cardiovascular disease risk factors and subclinical atherosclerosis, CHD mortality risk was similar between participants with CHD alone vs diabetes alone (hazard ratio [HR] 1.04, 95% confidence interval [CI], 0.83-1.30). The proportion of mortality attributable to prevalent diabetes (population-attributable risk percent=8.4%) and prevalent CHD (6.7%) was similar in women, but the proportion of mortality attributable to CHD (16.5%) as compared with diabetes (6.4%) was markedly higher in men. Patterns were similar for cardiovascular disease mortality. By contrast, the adjusted relative hazard of total mortality was lower among participants with CHD alone (HR 0.85, 95% CI, 0.75-0.96) as compared with those who had diabetes alone.

CONCLUSIONS

Among older adults, diabetes alone confers a risk for cardiovascular mortality similar to that from established clinical CHD. The public health burden of both diabetes and CHD is substantial, particularly among women.

Risk prediction models for the development of diabetes in Mauritian Indians

AIMS

To develop risk prediction models of future diabetes in Mauritian Indians.

METHODS

Three thousand and ninety-four Mauritian Indians (1141 men, aged 20-65 years) without diabetes in 1987 or 1992 were followed up to 1992 or 1998. Subjects underwent repeated oral glucose tolerance tests and diabetes was diagnosed according to 2006 World Health Organization/International Diabetes Federation criteria. Cox regression models for interval censored data were performed using data from 1544 randomly selected participants. Predicted probabilities for diabetes were calculated and validated in the remaining 1550 subjects.

RESULTS

Over 11 years of follow-up, there were 511 cases of diabetes. Among variables tested, family history of diabetes, obesity (body mass index, waist circumference) and glucose were significant predictors of diabetes. Predicted probabilities derived from a simple model fitted with sex, family history of diabetes and obesity ranged from 0.05 to 0.64 in men and 0.03 to 0.49 in women. To predict the onset of diabetes, area under the receiver operating characteristic (ROC) curve (AROC) of predicted probabilities was 0.62 (95% confidence interval, 0.56-0.68) in men and 0.64 (0.59-0.69) in women. At a cut-off point of 0.12, the sensitivity and specificity were 0.72 (0.71-0.74) and 0.47 (0.45-0.49) in men and 0.77 (0.75-0.78) and 0.50 (0.48-0.52) in women, respectively. Addition of fasting plasma glucose (FPG) to the model improved the prediction slightly [AROC curve 0.70 (0.65-0.76) in men, 0.71 (0.67-0.76) in women].

CONCLUSIONS

A diabetes prediction model based on obesity and family history yielded moderate discrimination in Mauritian Indians, which was slightly inferior to the model with the FPG but may be useful in low-income countries to promote identification of people at high risk of diabetes.

Glucose challenge test screening for prediabetes and undiagnosed diabetes

AIMS/HYPOTHESIS

Diabetes prevention and care are limited by lack of screening. We hypothesised that screening could be done with a strategy similar to that used near-universally for gestational diabetes, i.e. a 50 g oral glucose challenge test (GCT) performed at any time of day, regardless of meal status, with one 1 h sample.

METHODS

At a first visit, participants had random plasma and capillary glucose measured, followed by the GCT with plasma and capillary glucose (GCTplasma and GCTcap, respectively). At a second visit, participants had HbA(1c) measured and a diagnostic 75 g OGTT.

RESULTS

The 1,573 participants had mean age of 48 years, BMI 30.3 kg/m(2) and 58% were women and 58% were black. Diabetes (defined by WHO) was present in 4.6% and prediabetes (defined as impaired glucose tolerance [2 h glucose 7.8-11.1 (140-199 mg/dl) with fasting glucose

CONCLUSIONS/INTERPRETATION

GCT screening for prediabetes and previously unrecognised diabetes would be accurate, convenient and inexpensive. Widespread use of GCT screening could help improve disease management by permitting early initiation of therapy aimed at preventing or delaying the development of diabetes and its complications.

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Key Words Collapse

MESH Headings

• Adolescent
• Adult
• Black People
• Blood Glucose/analysis
• Costs and Cost Analysis
• Diabetes Mellitus/blood
• Diabetes Mellitus/diagnosis
• Diabetes, Gestational/blood
• Diabetes, Gestational/diagnosis
• Female
• Georgia
• Glucose Intolerance/blood
• Glucose Intolerance/diagnosis
• Glucose Tolerance Test
• Glycated Hemoglobin/analysis
• Humans
• Male
• Mass Screening/economics
• Mass Screening/methods
• Middle Aged
• Prediabetic State/blood
• Prediabetic State/diagnosis
• Pregnancy
• White People
• Young Adult
• Black or African American

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Grants

• DK062668 NIDDK NIH HHS
• DK066204 NIDDK NIH HHS
• DK07298 NIDDK NIH HHS
• RR00039 NCRR NIH HHS
• RR017643 NCRR NIH HHS
• RR025008 NCRR NIH HHS

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Affiliation(s)

L S Phillips Division of Endocrinology and Metabolism, Emory University School of Medicine, 101 Woodruff Circle, WMRB Room 1027, Atlanta, GA 30322, USA.
D C Ziemer
P Kolm
W S Weintraub
V Vaccarino
M K Rhee
R Chatterjee
K M V Narayan
D D Koch

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High prevalence of obesity, central obesity and abnormal glucose tolerance in the middle-aged Finnish population

Background

There is a worldwide increase in the prevalence of obesity and disturbances in glucose metabolism. The aim of this study was to assess the current prevalence of obesity, central obesity and abnormal glucose tolerance in Finnish population, and to investigate the associations between body mass index (BMI), waist circumference and abnormal glucose tolerance.

Methods

A cross-sectional population-based survey was conducted in Finland during October 2004 and January 2005. A total of 4500 randomly selected individuals aged 45–74 years were invited to a health examination that included an oral glucose tolerance test. The participation rate was 62% in men and 67% in women.

Results

The prevalence of obesity was 23.5% (95% Confidence Interval (CI) 21.1–25.9) in men, and 28.0% (95% CI 25.5–30.5) in women. The overall prevalence of abnormal glucose tolerance (including type 2 diabetes, impaired glucose tolerance, or impaired fasting glucose) was 42.0% (95% CI 39.2–44.8) in men and 33.4% (95% CI 30.9–36.0) in women. The prevalence of previously unknown, screen-detected type 2 diabetes was 9.3% (95% CI 7.7–11.0) in men and 7.3% (95% CI 5.9–8.7) in women. Central obesity was associated with abnormal glucose tolerance within each of the three BMI categories normal (< 25 kg/m²), overweight (25–29 kg/m²), and obese (≥ 30 kg/m²).

Conclusion

In a population-based random sample of Finnish population, prevalences of obesity, central obesity and abnormal glucose tolerance were found to be high. A remarkably high number of previously undetected cases of type 2 diabetes was detected. Waist circumference is a predictor of abnormal glucose tolerance in all categories of obesity.

Metabolic syndrome risk for cardiovascular disease and diabetes in the ARIC study

OBJECTIVE

The metabolic syndrome is associated with increased risk for cardiovascular disease and diabetes. Several analyses from the Atherosclerosis Risk in Communities (ARIC) study have been performed to examine the role of the metabolic syndrome and its components in predicting risk for cardiovascular disease and diabetes.

DESIGN AND SUBJECTS

The large, biracial, population-based ARIC study enrolled 15792 middle-aged Americans in four communities in the United States and has followed them for the development of cardiovascular disease and diabetes.

MEASUREMENTS

Outcome parameters included prevalence of the metabolic syndrome and its individual components, carotid intima-media thickness, incident coronary heart disease, incident ischemic stroke and incident diabetes.

RESULTS AND CONCLUSION

Several analyses from the ARIC study have shown that the metabolic syndrome, as well as individual metabolic syndrome components, is predictive of the prevalence and incidence of coronary heart disease, ischemic stroke, carotid artery disease and diabetes.

Tool to assess likelihood of fasting glucose impairment (TAG-IT)

PURPOSE

Fifty-four million people in the United States have impaired fasting glucose (IFG); if it is identified, they may benefit from prevention strategies that can minimize progression to diabetes, morbidity, and mortality. We created a tool to identify those likely to have undetected hyperglycemia.

METHODS

We undertook a cross-sectional analysis of existing data from the National Health and Nutrition Examination Survey (NHANES) 1999-2004 of 4,045 US adults aged 20 to 64 years who did not have a diagnosis of diabetes who had a measured fasting plasma glucose. Using characteristics that are self-reported or measured without laboratory data, we developed a logistic regression model predicting IFG and undiagnosed diabetes. Based on this model, we created TAG-IT (the Tool to Assess likelihood of fasting Glucose ImpairmenT), validated it using NHANES III, examined race and ethnicity subsets, and compared it with body mass index (BMI) alone.

RESULTS

Predictors in the final tool were age, sex, BMI, family history of diabetes, resting heart rate, and history of hypertension (or measured high blood pressure), which yielded an area under the curve (AUC) of 0.740, significantly better than BMI alone (AUC = 0.644).

CONCLUSIONS

The TAG-IT efficiently identifies those most likely to have abnormal fasting glucose and can be used as a decision aid for screening in clinical and population settings, or as a prescreening tool to help identify potential participants for research. The TAG-IT represents an improvement over BMI alone or a list of risk factors in both its utility in younger adult populations and its ability to provide clinicians and researchers with a strategy to assess the risks of combinations of factors.

The "metabolic syndrome" is less useful than random plasma glucose to screen for glucose intolerance

AIMS

To compare the utility of metabolic syndrome (MetS) to random plasma glucose (RPG) in identifying people with diabetes or prediabetes.

METHODS

RPG was measured and an OGTT was performed in 1155 adults. Test performance was measured by area under the receiver-operating-characteristic curve (AROC).

RESULTS

Diabetes was found in 5.1% and prediabetes in 20.0%. AROC for MetS with fasting plasma glucose (FPG) was 0.80 to detect diabetes, and 0.76 for diabetes or prediabetes--similar to RPG alone (0.82 and 0.72). However, the AROC for MetS excluding fasting plasma glucose was lower: 0.69 for diabetes (p<0.01 vs. both RPG and MetS with FPG), and 0.69 for diabetes or prediabetes. AROCs for MetS with FPG and RPG were comparable and higher for recognizing diabetes in blacks vs. whites, and females vs. males. MetS with FPG was superior to RPG for identifying diabetes only in subjects with age <40 or BMI <25.

CONCLUSIONS

MetS features can be used to identify risk of diabetes, but predictive usefulness is driven largely by FPG. Overall, to identify diabetes or prediabetes in blacks and whites with varying age and BMI, MetS is no better than RPG--a more convenient and less expensive test.

Progression from newly acquired impaired fasting glusose to type 2 diabetes

OBJECTIVE

We sought to estimate the rate of progression from newly acquired (incident) impaired fasting glucose (IFG) to diabetes under the old and new IFG criteria and to identify predictors of progression to diabetes.

RESEARCH DESIGN AND METHODS

We identified 5,452 members of an HMO with no prior history of diabetes, with at least two elevated fasting glucose tests (100-125 mg/dl) measured between 1 January 1994 and 31 December 2003, and with a normal fasting glucose test before the two elevated tests. All data were obtained from electronic records of routine clinical care. Subjects were followed until they developed diabetes, died, left the health plan, or until 31 December 2005.

RESULTS

Overall, 8.1% of subjects whose initial abnormal fasting glucose was 100-109 mg/dl (added IFG subjects) and 24.3% of subjects whose initial abnormal fasting glucose was 110-125 mg/dl (original IFG subjects) developed diabetes (P < 0.0001). Added IFG subjects who progressed to diabetes did so within a mean of 41.4 months, a rate of 1.34% per year. Original IFG subjects converted at a rate of 5.56% per year after an average of 29.0 months. A steeper rate of increasing fasting glucose; higher BMI, blood pressure, and triglycerides; and lower HDL cholesterol predicted diabetes development.

CONCLUSIONS

To our knowledge, these are the first estimates of diabetes incidence from a clinical care setting when the date of IFG onset is approximately known under the new criterion for IFG. The older criterion was more predictive of diabetes development. Many newly identified IFG patients progress to diabetes in <3 years, which is the currently recommended screening interval.

Sequential screening for diabetes—evaluation of a campaign in Swiss community pharmacies

OBJECTIVE

For early detection of persons at risk for type 2 diabetes, a combination of risk factor assessment and glucose measurement could be a promising approach and an opportunity for health promotion. The object of this study was to develop a sequential screening concept and to evaluate it in a national pharmacy based screening campaign.

METHOD

Community pharmacies of the German speaking part of Switzerland participating in the national Self Care campaign "Stop diabetes--test now" offered a free of charge "sequential screening" with (a) diabetes risk assessment, (b) consecutive capillary blood glucose measurement and (c) assessment of the motivation for lifestyle change based on the Transtheoretical Model (TTM) of behaviour change. A 35 items data sheet served as a structured screening protocol and enabled quick and reliable documentation of all relevant data. Outcomes measures were: age, sex, cigarette smoking, total score of the ADA diabetes risk-factor questionnaire, family history of diabetes, body mass index, insufficient physical activity, blood pressure, capillary blood glucose, motivation for lifestyle change, counselling activities and triage decisions of the pharmacy team.

RESULTS

During the 5 weeks of spring 2002, 530 pharmacies screened a total of 93,258 persons (33.1% male, mean age 60.9 years +/- 14.1 (SD)). Risk profile: family history of diabetes 26.4%; BMI > or = 25 kg/m(2) 49.3%; low physical activity 27.2%; elevated blood pressure 45.7%. Stratification into risk groups: < 2 risk factors 21.6%; > or = 2 risk factors 71.5%; borderline glycaemia (FG 5.3-6.1 mmol/l, confirmed in a second measurement) 2.5% and hyperglycaemia (FG > or = 6.1 mmol/1 or NFG > or = 11.1 mmol/1) 4.4%. Of all persons screened, 6.4% were referred to a physician and 73.7% got targeted advice with respect to physical activity and/or nutrition based on their specific risk profile.

CONCLUSION

The screening campaign attracted an important part of Swiss German speaking adults (2.4%). The sequential screening could successfully be implemented into pharmacy practice. Of the generally elderly persons screened, 6.9% were detected with suspicion for diabetes type 2 and 71.5% had at least two risk factors. This provided an opportunity to initiate targeted counselling regarding therapeutic lifestyle change.

Erectile Dysfunction—An Observable Marker of Diabetes Mellitus? A Large National Epidemiological Study

PURPOSE

We examined whether men with erectile dysfunction are more likely to have diabetes mellitus than men without erectile dysfunction, and whether erectile dysfunction can be used as an observable early marker of diabetes mellitus.

MATERIALS AND METHODS

Using a nationally representative managed care claims database from 51 health plans and 28 million members in the United States, we conducted a retrospective cohort study to compare the prevalence rates of diabetes mellitus between men with erectile dysfunction (285,436) and men without erectile dysfunction (1,584,230) during 1995 to 2001. Logistic regression models were used to isolate the effect of erectile dysfunction on the likelihood of having diabetes mellitus with adjustment for age, region and 7 concurrent diseases.

RESULTS

The diabetes mellitus prevalence rates were 20.0% in men with erectile dysfunction and 7.5% in men without erectile dysfunction. With adjustment for age, region and concurrent diseases, the odds ratio of having diabetes mellitus between men with erectile dysfunction and without erectile dysfunction was 1.60 (p <0.0001). With adjustment for regions and concurrent diseases, the age specific odds ratios ranged from 2.94 (p <0.0001, age 26 to 35) to 1.05 (p = 0.1717, age 76 to 85).

CONCLUSIONS

Men with erectile dysfunction were more than twice as likely to have diabetes mellitus as men without erectile dysfunction. Erectile dysfunction is an observable marker of diabetes mellitus, strongly so for men 45 years old or younger and likely for men 46 to 65 years old, but it is not a marker for men older than 66 years.

Increased cardiovascular risk associated with diabetes in Dallas County

BACKGROUND

Diabetes mellitus is a major public health problem in the United States. We assess the prevalence of diabetes in Dallas County, quantify the association between diabetes and subclinical cardiovascular disease, and assess the use of evidence-based cardiovascular disease risk-modifying therapies.

METHODS

This study uses data from 3392 participants aged 30 to 65 years from the Dallas Heart Study, a probability-based, multiethnic sample of residents living in Dallas County, Texas. Three primary outcomes were examined: (1) diabetes prevalence, (2) adjusted odds ratios for detectable coronary calcium stratified by diabetes diagnosis status, and (3) rates of use of evidence-based cardiovascular disease risk-modifying therapies among subjects with diabetes stratified by diabetes diagnosis status.

RESULTS

The estimated prevalence of diabetes in Dallas County was 7.8%, with >40% of diabetic patients undiagnosed before participation in the Dallas Heart Study. Both previously diagnosed and previously undiagnosed diabetes were independently associated with the presence of coronary artery calcium (diagnosed: OR 3.55, 95% CI 1.56-8.05) (undiagnosed: OR 2.98, 95% CI 1.39-6.39). The rates of use of aspirin, angiotensin-converting enzyme inhibitors, and statins were suboptimal, and blood pressure and low-density lipoprotein cholesterol targets were rarely met, especially among subjects with previously undiagnosed diabetes.

CONCLUSIONS

Diabetes is prevalent and is associated with subclinical cardiovascular disease; this association is present even at the time of diagnosis. Despite the cardiovascular risk associated with diabetes, evidence-based risk-modifying therapies continue to be underused, and therapeutic targets remain unmet, especially among people unaware of their diabetes diagnosis.

The influence of ethnicity on health-related quality of life in diabetes mellitus: a population-based, multiethnic study

OBJECTIVES

The aims of this study were to evaluate the influence of ethnicity on health-related quality of life (HRQoL) in diabetic participants using both profile [the Short-Form 36 (SF-36)] and single-index (the SF-6D) instruments and to evaluate the usefulness of the SF-6D as a summary measure for the SF-36.

RESEARCH DESIGN AND METHODS

Using data from a cross-sectional, population-based survey of Chinese, Malay, and Indians in Singapore, we analyzed the influence of ethnicity and other variables on each SF-36 scale and SF-6D scores using linear regression models to adjust for the influence of known determinants of HRQoL.

RESULTS

Data from 309 diabetic respondents were analyzed. Compared with other ethnicities, Indians were most likely to report impaired HRQoL. The unadjusted influence of ethnicity on HRQoL exceeded the minimum clinically important difference (MCID) for all SF-36 scales (MCID: 5 points) and the SF-6D (MCID: 0.033 points). After adjusting for gender, age, and education, the influence of Chinese ethnicity exceeded the MCID for all SF-36 scales, except vitality (VT) and mental health (MH), as well as for the SF-6D. The influence of Malay ethnicity exceeded the MCID only for the SF-36 MH scale and the SF-6D. The influence of ethnicity on HRQoL persisted after adjusting further for other determinants of HRQoL. The SF-6D reflected the ethnic trends for some but not all SF-36 scales.

CONCLUSIONS

After adjusting for demographic, socioeconomic, and other factors known to influence HRQoL, ethnicity remained an important factor influencing HRQoL in this population-based multiethnic sample of diabetic Asians. Further studies to identify modifiable factors explaining the ethnic disparities in HRQoL among diabetic participants are needed. The SF-6D may be a useful summary measure for the SF-36.

Use of the diabetes risk score for opportunistic screening of undiagnosed diabetes and impaired glucose tolerance: the IGLOO (Impaired Glucose Tolerance and Long-Term Outcomes Observational) study

OBJECTIVE

To evaluate an opportunistic screening strategy addressed to individuals with one or more cardiovascular risk factor, based on the Diabetes Risk Score (DRS) as the initial instrument, for the identification of individuals with type 2 diabetes or impaired glucose tolerance (IGT).

RESEARCH DESIGN AND METHODS

The DRS, a simple self-administered questionnaire, was completed by individuals identified by general practitioners and presenting with one or more cardiovascular risk factor. All patients underwent a 2-h oral glucose tolerance test (OGTT). The optimal DRS cutoff was calculated by applying the receiver-operating characteristic curve.

RESULTS

Overall, 1,377 individuals aged between 55 and 75 years received an OGTT and completed the DRS. Mean DRS values showed a marked variation according to glucose metabolism categories, as follows: 8.7 +/- 3.0 in normoglycemic individuals, 9.5 +/- 3.1 in individuals with impaired fasting glucose, 9.9 +/- 3.3 in individuals with IGT, and 12.0 +/- 3.5 in individuals with type 2 diabetes. The receiver-operating characteristic curve showed that, with a cutoff of 9, the sensitivity of DRS in detecting individuals with glucose abnormalities (type 2 diabetes or IGT) was 77% and the specificity 45%. The use of the DRS as an initial screening instrument, followed by the measurement of fasting blood glucose in individuals with a score > or =9 and by the OGTT in individuals with a fasting blood glucose between 5.6 and 6.9 mmol/l, would lead to the identification of 83% of the case subjects with type 2 diabetes and 57% of the case subjects with IGT, at a cost of an OGTT in 38% of the sample and a fasting blood glucose in 64%.

CONCLUSIONS

The DRS can represent a valid inexpensive instrument for opportunistic screening and a useful alternative to indiscriminate fasting blood glucose measurement, not readily available in general practice.

Physical activity and diabetes risk in postmenopausal women

BACKGROUND

To evaluate the hypothesis that physical activity independently predicts type 2 diabetes risk in postmenopausal African-American, Hispanic, Asian, and Caucasian women.

METHODS

We prospectively evaluated the relationship between incident type 2 diabetes, walking, and total physical activity at baseline in the Women's Health Initiative Observational Study. Baseline data were collected between September 1994 and December 1998; incident diabetes was identified through August 2002. Hazard ratios for self-reported diabetes adjusted for body mass index (BMI) and other variables were evaluated across categories of physical activity in Caucasian, African-American, Hispanic, and Asian/Pacific Islander women.

RESULTS

Incident diabetes was reported by 2.2% of Caucasian, 6.2% of African-American, 4.5% of Hispanic, 3% of Asian, and 5.7% of American Indian women (p <0.0001 across ethnic groups) during 458,018 woman-years of follow-up. Among Caucasian women, walking (multivariate-adjusted hazard ratios 1.00, 0.85, 0.87, 0.75, 0.74; p <0.001 for trend across exercise quintiles) and total physical activity score (hazard ratios 1.00, 0.88, 0.74, 0.80, 0.67; p =0.002) demonstrated a strong inverse relationship with diabetes risk. In BMI-adjusted models, African-American women in higher physical activity categories were less likely to develop diabetes than women in the lowest physical activity category. After adjusting for age and multiple risk factors, however, no significant association between physical activity and diabetes risk was apparent for African-American, Hispanic, or Asian women.

CONCLUSIONS

These findings suggest a stronger and more independent association of physical inactivity with development of diabetes in Caucasian women than in minority women, but could also be explained by less precise risk estimates in minority women or the role of chance.

Insulin secretion capacity in the development from normal glucose tolerance to type 2 diabetes

We have examined the contribution of insulin secretion and insulin resistance to glucose intolerance in Japanese. Some indices of insulin secretion and insulin sensitivity based on the results of OGTT were used. The decline of insulin secretion capacity was significant throughout the development of glucose intolerance from NGT via IGT to DM. Decreased insulinogenic indices were conspicuous when it is compared with other types of diabetes. Slight impairment of insulin secretion has begun in subjects with NGT. The progression from NGT via isolated IGT to isolated post-challenge hyperglycemia was considered mostly due to the deterioration of early-phase insulin secretion. It is summarized that decreased insulin secretion capacity takes a definite role in the development from NGT to type 2 diabetes in Japan.

Prevention of type 2 diabetes: issues and strategies for identifying persons for interventions

Because of the ongoing worldwide diabetes epidemic and new evidence that type 2 diabetes can be prevented or delayed, we are compelled to implement prevention efforts. Health policy makers need to bridge the evidence gap left by prevention trials that did not include all groups at risk for developing diabetes. Intensive interventions may be appropriate for groups with similar risk as those studied in clinical trials, while less intense efforts may be considered for those groups that have not been studied. Factors such as structure of the health care system and individual social and economic situations may influence the implementation of prevention efforts. Currently, no universally validated and well-tested method exists to identify all people at high risk for developing diabetes. However, groups that will be targeted for prevention efforts can be identified through several reasonable strategies.

Using metabolic syndrome traits for efficient detection of impaired glucose tolerance

OBJECTIVE

Efficient detection of impaired glucose tolerance (IGT) is needed to implement type 2 diabetes prevention interventions.

RESEARCH DESIGN AND METHODS

We assessed the capacity of the metabolic syndrome (MetS) to identify IGT in a cross-sectional analysis of 3,326 Caucasian Framingham Offspring Study (FOS), 1,168 Caucasian and 1,812 Mexican-American San Antonio Heart Study (SAHS), 1,983 Mexico City Diabetes Study (MCDS), and 452 Caucasian, 407 Mexican-American, and 290 African-American Insulin Resistance Atherosclerosis Study (IRAS) men and women aged 30-79 years who had a clinical examination and an oral glucose tolerance test (OGTT) during 1987-1996. Those with diabetes treatment or fasting plasma glucose > or =7.0 mmol/l were excluded (MetS was defined by Third Report of the National Cholesterol Education Program's Adult Treatment Panel criteria and IGT as 2-h postchallenge glucose [2hPG] > or =7.8 mmol/l). We calculated positive (PPV) and negative predictive values (NPV), population attributable risk percentages (PAR%), age- and sex-adjusted odds ratios (ORs), and areas under the receiver operating characteristic curve (AROCs) associated with MetS traits.

RESULTS

Among FOS, SAHS, and MCDS subjects, 24-43% had MetS and 15-23% had IGT (including 2-5% with 2hPG > or =11.1 mmol/l). Among those with MetS, OR for IGT were 3-4, PPV were 0.24-0.41, NPV were 0.84-0.91, and PAR% were 30-40%. Among subjects with MetS defined by impaired fasting glucose (IFG) and any two other traits, OR for IGT were 9-24, PPV were 0.62-0.89, NPV were 0.78-0.87, and PAR% were 3-12%. Among IRAS subjects, 24-34% had MetS and 37-41% had IGT. Among those with MetS, ORs for IGT were 3-6, PPVs were 0.57-0.73, and NPVs were 0.67-0.72. In logistic regression models, IFG, large waist, and high triglycerides were independently associated with IGT (AROC 0.71-0.83) in all study populations.

CONCLUSIONS

The MetS, especially defined by IFG, large waist, and high triglycerides, efficiently identifies subjects likely to have IGT on OGTT and thus be eligible for diabetes prevention interventions.