The UK Prospective Diabetes Study. UK Prospective Diabetes Study Group

Epidemiology of Poor Glycaemic Control among Patients with Type 2 Diabetes Mellitus in Terengganu State of Malaysia

Background: Type 2 diabetes mellitus (T2DM) is among the most common non-communicable diseases worldwide and Malaysia. Poor glycaemic control among T2DM patients lead to serious life-long complications. Therefore, it is imperative to study the prevalence of poor glycaemic control and its risk factors to facilitate public health physicians and clinicians in developing the best strategies to optimize glycaemic control among T2DM patients. Materials and Methods: A comparative cross-sectional study between groups of good glycaemic control and poor glycaemic control was conducted among type 2 diabetes mellitus (T2DM) patients who fulfilled study criteria in Terengganu state of Malaysia. Eligible samples in the National Diabetes Registry registered from 1st January 2021 until 31st December 2021 were included into the study. Descriptive statistics, simple and multiple logistic regressions were employed for data analysis. Result: A total of 17,165 samples were recruited in the descriptive part of the study. The prevalence of patients with poor glycaemic control in Terengganu state was 65.3% (95% CI: 0.62, 0.67). In the inferential part of the study, a total 3,700 samples were randomly selected. Multivariable analysis using multiple logistic regression revealed age, duration of diabetes, body mass index, cigarette smoking, presence of retinopathy and presence of hypertension were the significant factors associated with poor glycaemic control among T2DM patients in Terengganu state with an adjusted odds ratio (AOR) of 0.95 (95%CI:0.94, 0.96); p<0.001), AOR 1.15 (95%CI:1.13, 1.17; p<0.001), AOR 1.03 (95%CI:1.01, 1.04; p<0.001), AOR 1.45 (95%CI:1.01, 2.10; p=0.047), AOR 1.32 (95%CI:1.01, 1.73; p=0.043) and AOR 1.39 (95%CI:1.16, 1.67; p<0.001) respectively. Conclusion: Strategies focusing on the identified risk factors may improve diabetes mellitus management and avert life-long diabetic complications.

Statistical Methods for Cardiovascular Researchers

RATIONALE

Biostatistics continues to play an essential role in contemporary cardiovascular investigations, but successful implementation of biostatistical methods can be complex.

OBJECTIVE

To present the rationale behind statistical applications and to review useful tools for cardiology research.

METHODS AND RESULTS

Prospective declaration of the research question, clear methodology, and study execution that adheres to the protocol together and serve as the critical foundation of a research endeavor. Both parametric and distribution-free measures of central tendency and dispersion are presented. T testing, ANOVA, and regression analyses are reviewed. Survival analysis, logistic regression, and interim monitoring are also discussed. Finally, common weaknesses in statistical analyses are considered.

CONCLUSIONS

Biostatistics can be productively applied to cardiovascular research if investigators (1) develop and rely on a well-written protocol and analysis plan, (2) consult with a biostatistician when necessary, and (3) write results clearly, differentiating confirmatory from exploratory findings.

The Prominent Role of P38 Mitogen-Activated Protein Kinase in Insulin-Mediated Enhancement of VCAM-1 Expression in Endothelial Cells

Insulin levels are a marker for cardiovascular events, but the link between hyperinsulinemia and atherosclerosis is poorly understood. We previously showed that insulin increases monocyte-endothelial interactions and the endothelial expression of the pro-atherogenic vascular cell adhesion molecule-1 (VCAM-1). The aim of this study is to examine molecular mechanisms involved in the effect of insulin on VCAM-1 expression. Human umbilical vein endothelial cells (HUVEC) were incubated with insulin (0–24 h) ± inhibitors of signaling pathways potentially involved. At pathophysiological concentrations (10−9-10−7 M), insulin selectively induced VCAM-1 expression. The p38mitogen activated protein(MAP) kinase inhibitors SB203580 and SB202190, and partially the c-Jun NH2-terminal kinase (JNK) inhibitor SP600127, decreased insulin effect on VCAM-1. Gene silencing by small interfering RNA significantly reduced the expression of p38MAP kinase, and this was accompanied by suppression of insulin-stimulated VCAM-1 expression. Treatment with insulin also led to the activation of NF-κB and induction of IκB-α phosphorylation, thus accounting for NF-κB translocation into the nucleus. Co-treatment of HUVEC with insulin and SB202190 strongly reverted the stimulatory effect of insulin on NF-κB activation, thus establishing a link between NF-κB activation and p38MAPkinase-mediated induction of VCAM-1 by insulin. In conclusion, pathophysiological insulin concentrations increase VCAM-1 expression and activate NF-κB. This mostly occurs through stimulation of p38MAP kinase.

Realization of a service for the long-term risk assessment of diabetes-related complications

AIM

We present a computerized system for the assessment of the long-term risk of developing diabetes-related complications.

METHODS

The core of the system consists of a set of predictive models, developed through a data-mining/machine-learning approach, which are able to evaluate individual patient profiles and provide personalized risk assessments. Missing data is a common issue in (electronic) patient records, thus the models are paired with a module for the intelligent management of missing information.

RESULTS

The system has been deployed and made publicly available as Web service, and it has been fully integrated within the diabetes-management platform developed by the European project REACTION. Preliminary usability tests showed that the clinicians judged the models useful for risk assessment and for communicating the risk to the patient. Furthermore, the system performs as well as the United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine when both systems are tested on an independent cohort of UK diabetes patients.

CONCLUSIONS

Our work provides a working example of risk-stratification tool that is (a) specific for diabetes patients, (b) able to handle several different diabetes related complications, (c) performing as well as the widely known UKPDS Risk Engine on an external validation cohort.

Blood pressure level and risk of major cardiovascular events and all-cause of mortality in patients with type 2 diabetes and renal impairment: an observational study from the Swedish National Diabetes Register

AIMS/HYPOTHESIS

We assessed the relationship between BP and risk of cardiovascular events (CVEs) and all-cause mortality in patients with type 2 diabetes and renal impairment (estimated GFR < 60 ml min(-1) 1.73 m(-2)) treated in clinical practice.

METHODS

A total of 33,356 patients (aged 75 ± 9 years, diabetes duration of 10 ± 8 years) with at least one serum creatinine and BP value available in the Swedish National Diabetes Register between 2005 and 2007 were followed up until 2011 or death. The relationships between mean BPs, CVEs and all-cause mortality were examined using time-dependent Cox models to estimate HRs, adjusting for cardiovascular risk factors and ongoing medications.

RESULTS

During the follow-up period (mean 5.3 years), 11,317 CVEs and 10,738 deaths occurred. The lowest risks of CVEs and all-cause mortality were observed with a systolic BP (SBP) of 135-139 and a diastolic BP (DBP) of 72-74 mmHg, and the highest risks were observed for those with SBP intervals 80-120 (CVE HR 2.3 [95% CI 2.0, 2.6] and all-cause mortality HR 2.4, [95% CI 2.1, 2.7]) and 160-230 mmHg (CVE HR 3.0 [95% CI 2.6, 3.3] and all-cause mortality HR 2.0 [95% CI 1.8-2.3]) and DBP intervals 40-63 mmHg (CVE HR 2.0 [95% CI 1.8, 2.2], all-cause mortality HR 2.0 [95% CI 1.8, 2.2]) and 83-125 mmHg (CVE HR 2.3 [95% CI 2.0, 2.5], all-cause mortality HR 2.3 [95% CI 2.0, 2.6]).

CONCLUSIONS/INTERPRETATION

In this nationwide cohort of patients with type 2 diabetes and renal impairment, the risk of CVEs and all-cause mortality increased significantly with both high and low BPs, while an SBP of 135-139 mmHg and DBP of 72-74 mmHg were associated with the lowest risks of CVEs and death.

Development and validation of risk assessment models for diabetes-related complications based on the DCCT/EDIC data

AIM

To derive and validate a set of computational models able to assess the risk of developing complications and experiencing adverse events for patients with diabetes. The models are developed on data from the Diabetes Control and Complications Trial (DCCT) and the Epidemiology of Diabetes Interventions and Complications (EDIC) studies, and are validated on an external, retrospectively collected cohort.

METHODS

We selected fifty-one clinical parameters measured at baseline during the DCCT as potential risk factors for the following adverse outcomes: Cardiovascular Diseases (CVD), Hypoglycemia, Ketoacidosis, Microalbuminuria, Proteinuria, Neuropathy and Retinopathy. For each outcome we applied a data-mining analysis protocol in order to identify the best-performing signature, i.e., the smallest set of clinical parameters that, considered jointly, are maximally predictive for the selected outcome. The predictive models built on the selected signatures underwent both an interval validation on the DCCT/EDIC data and an external validation on a retrospective cohort of 393 diabetes patients (49 Type I and 344 Type II) from the Chorleywood Medical Center, UK.

RESULTS

The selected predictive signatures contain five to fifteen risk factors, depending on the specific outcome. Internal validation performances, as measured by the Concordance Index (CI), range from 0.62 to 0.83, indicating good predictive power. The models achieved comparable performances for the Type I and, quite surprisingly, Type II external cohort.

CONCLUSIONS

Data-mining analyses of the DCCT/EDIC data allow the identification of accurate predictive models for diabetes-related complications. We also present initial evidences that these models can be applied on a more recent, European population.

Predictors of adherence with self-care guidelines among persons with type 2 diabetes: results from a logistic regression tree analysis

Type 2 diabetes is known to contribute to health disparities in the U.S. and failure to adhere to recommended self-care behaviors is a contributing factor. Intervention programs face difficulties as a result of patient diversity and limited resources. With data from the 2005 Behavioral Risk Factor Surveillance System, this study employs a logistic regression tree algorithm to identify characteristics of sub-populations with type 2 diabetes according to their reported frequency of adherence to four recommended diabetes self-care behaviors including blood glucose monitoring, foot examination, eye examination and HbA1c testing. Using Andersen's health behavior model, need factors appear to dominate the definition of which sub-groups were at greatest risk for low as well as high adherence. Findings demonstrate the utility of easily interpreted tree diagrams to design specific culturally appropriate intervention programs targeting sub-populations of diabetes patients who need to improve their self-care behaviors. Limitations and contributions of the study are discussed.

Glucagon-like peptide analogues for type 2 diabetes mellitus

BACKGROUND

Glucagon-like peptide analogues are a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone glucagon-like peptide 1 (GLP-1). GLP-1 is an incretin, a gastrointestinal hormone that is released into the circulation in response to ingested nutrients. GLP-1 regulates glucose levels by stimulating glucose-dependent insulin secretion and biosynthesis, and by suppressing glucagon secretion, delayed gastric emptying and promoting satiety.

OBJECTIVES

To assess the effects of glucagon-like peptide analogues in patients with type 2 diabetes mellitus.

SEARCH STRATEGY

Studies were obtained from electronic searches of The Cochrane Library (last search issue 1, 2011), MEDLINE (last search March 2011), EMBASE (last search March 2011), Web of Science (last search March 2011) and databases of ongoing trials.

SELECTION CRITERIA

Studies were included if they were randomised controlled trials of a minimum duration of eight weeks comparing a GLP-1 analogue with placebo, insulin, an oral anti-diabetic agent, or another GLP-1 analogue in people with type 2 diabetes.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment of studies were done by one reviewer and checked by a second. Data were analysed by type of GLP-1 agonist and comparison treatment. Where appropriate, data were summarised in a meta-analysis (mean differences and risk ratios summarised using a random-effects model).

MAIN RESULTS

Seventeen randomised controlled trials including relevant analyses for 6899 participants were included in the analysis. Studies were mostly of short duration, usually 26 weeks.In comparison with placebo, all GLP-1 agonists reduced glycosylated haemoglobin A1c (HbA1c) levels by about 1%. Exenatide 2 mg once weekly and liraglutide 1.8 mg reduced it by 0.20% and 0.24% respectively more than insulin glargine. Exenatide 2 mg once weekly reduced HbA1c more than exenatide 10 μg twice daily, sitagliptin and pioglitazone. Liraglutide 1.8 mg reduced HbA1c by 0.33% more than exenatide 10 μg twice daily. Liraglutide led to similar improvements in HbA1c compared to sulphonylureas but reduced it more than sitagliptin and rosiglitazone.Both exenatide and liraglutide led to greater weight loss than most active comparators, including in participants not experiencing nausea. Hypoglycaemia occurred more frequently in participants taking concomitant sulphonylurea. GLP-1 agonists caused gastrointestinal adverse effects, mainly nausea. These adverse events were strongest at the beginning and then subsided. Beta-cell function was improved with GLP-1 agonists but the effect did not persist after cessation of treatment.None of the studies was long enough to assess long-term positive or negative effects.

AUTHORS' CONCLUSIONS

GLP-1 agonists are effective in improving glycaemic control.

Long-term benefits of insulin therapy and glycemic control in overweight and obese adults with type 2 diabetes

PROBLEM

Obesity and type 2 diabetes have reached epidemic proportions in the United States. Obese patients are at especially high risk for the development of metabolic syndrome, a clustering of metabolic abnormalities associated with insulin resistance that usually precede the development of cardiovascular disease. Overweight or obesity, along with insulin resistance, is frequently present in people with type 2 diabetes.

METHODS

A literature search of the PubMed and MEDLINE databases, using the terms diabetes, obesity, metabolic syndrome, glycemic control, antidiabetic therapy, and insulin, was performed. Articles published between 1985 and 2006 that examined diabetes management in the obese population were selected and reviewed.

RESULTS

There is new evidence suggesting that tight glycemic control and earlier initiation of insulin therapy can improve outcomes in obese patients with type 2 diabetes, thereby reducing the risk for the development of both macrovascular and microvascular complications of the disease. Insulin also appears to exhibit anti-inflammatory effects, which may provide additional protection against the development of atherosclerosis. Despite the benefits of insulin therapy, many patients and physicians remain reluctant to start insulin due to concerns about weight gain.

CONCLUSION

Newer insulin formulations can effectively improve glycemic control without significant effects on patient weight and, therefore, may be particularly useful in patients who are overweight or obese. Implementation of comprehensive treatment regimens that emphasize dietary modification, physical activity, and exercise, and aggressive use of pharmacological agents to achieve tight glycemic control through physiological regimens offer the most promise for reducing long-term complications in obese patients with type 2 diabetes.

Dipeptidyl peptidase-4 as a new target of action for type 2 diabetes mellitus: a systematic review

Type 2 diabetes mellitus is a metabolic disease leading to microvascular and macrovascular complications including coronary artery disease and stroke. Management of diabetes has been challenging, particularly in the presence of the enormous prevalence of obesity. In recent years, various inhibitors of the enzyme dipeptidyl peptidase (DPP)-4 have been developed to treat diabetes. The enzyme DPP-4 cleaves incretins, which, among other functions, stimulate insulin and suppresses glucagon. Inhibition of this enzyme results in an increase in the half-life and the sustained physiologic action of incretins, leading to an improvement in hyperglycemia. One such agent, namely sitagliptin (MK-04,310), has been introduced into the United States market, and another agent, vildagliptin (LAF237), is being used in Europe and elsewhere. This article is intended to evaluate the effectiveness of DPP-4 inhibitors as a therapeutic modality for managing type 2 diabetes. The authors conducted a literature search of various databases to identify the clinical trials involving the DPP inhibitors and concluded that the DPP-4 inhibitors, for example, sitagliptin and vildagliptin, are efficacious for managing diabetes as monotherapy or combination therapy.

Current strategies for evaluating, monitoring, and treating type 2 diabetes mellitus

Diabetes mellitus is a chronic progressive disease that has profound consequences for individuals, families, and society. Despite clear glycemic control targets articulated by the major medical societies, patients and physicians still struggle to meet and maintain these goals, leading to shortfalls in delivery of care. Recent advances in the treatment of type 2 diabetes seek to address these shortfalls: Modern oral hypoglycemic agents may be used with or in place of traditional therapies. Analogue insulins, whose pharmacokinetic and pharmacodynamic properties allow patients improved lifestyle flexibility compared with regular insulins, have done much to improve glycemic control. Using these new classes of therapy, physicians should strive to help patients understand and reach the targets for control that we know to be beneficial for the majority of individuals. Such targets include those for glycosylated hemoglobin (HbA1c), but increasingly we also realize the central importance of maintaining postprandial glucose levels within recommended limits, and it is likely that the recent introduction of a serum marker for this purpose, 1,5-anhydroglucitol, will help improve patient outcomes. By intensifying therapy early during the course of the disease process, using the most effective and acceptable therapies available, and maintaining the lowest and safest HbA1c levels for as long as possible, we will be serving our patients well and living up to our responsibilities as diabetes care physicians.

Bayesians in clinical trials: Asleep at the switch

The refreshing Bayes perspective has much to offer biostatistics. Yet, from its 225-year-old roots sprung difficulties that blocked its growth at the beginning of the 20th century. Computational obstacles in concert with an inability to identify the best indifferent prior revealed a weakness on which frequentists capitalized. It took Bayesians 40 years to recover, allowing the infant field of biostatistics to fall firmly in the hands of the frequentists. Recent disillusionment with the frequentist perspective, and its hegemony of p-values, has produced a second opportunity for the Bayesian philosophy to make solid contributions to clinical trials.However, difficulty with the applicability of the likelihood principle, problems with prevalent prior 'disinformation' in clinical medicine, in concert with the complexity of truly representative loss functions threaten again to thwart the Bayesian march into biostatistics. Seven suggestions are offered to the Bayesians to help them adapt to the rigors of clinical research.

Differential effects of oral hypoglycemic agents on glucose control and cardiovascular risk

Cardiovascular disease (CVD) burden remains the predominant cause of mortality and morbidity in the United States and in most of the developed world. The ongoing twin epidemics of obesity and type 2 diabetes mellitus provide a groundswell source for sustaining this trend for the foreseeable future (increasing the prevalence of CVD by 2-4 times), unless radical changes are made in public health policy. Oral hypoglycemic agents (OHAs) remain a mainstay for management of type 2 diabetes in most practice settings. Although these agents are primarily prescribed to achieve better glycemic control, it is important to evaluate what effects they have on cardiovascular risk and whether there are significant differences in effects among the different OHAs. This review presents the available data on the effects of the various OHAs on cardiovascular risk surrogates and actual events in retrospective and prospective study design settings.

Use of chromium picolinate and biotin in the management of type 2 diabetes: an economic analysis

This paper addresses the potential economic benefits of chromium picolinate plus biotin (Diachrome) use in people with Type 2 diabetes (T2DM). The economic model was developed to estimate the impact on health care systems' costs by improved HbA1C levels with chromium picolinate plus biotin (Diachrome). Lifetimes cost savings were estimated by adjusting a benchmark from the literature, using a price index to adjust for inflation. The cost of diabetes is highly dependent on the HbA1C level with higher initial levels and higher annual increments increasing the cost. Improvement in glycemic control has proven to be cost-effective in delaying the onset and progression of T2DM, reducing the risk for diabetes-associated complications and lowering utilization and cost of care. Chromium picolinate plus biotin (Diachrome) showed greater improvement of glycemic control in poorly controlled T2DM patients (HbA(1C) > or = 10%) compared to their better controlled counterparts (HbA(1C) < 10%). This improvement was additive to that achieved by oral hypoglycemic medications and correlates to calculated levels of cost savings. Average 3-year cost savings for chromium picolinate plus biotin (Diachrome) use could range from 1,636 dollars for a poorly controlled patient with diabetes without heart diseases or hypertension, to 5,435 dollars for a poorly controlled patient with diabetes, heart disease, and hypertension. Average 3-year cost savings was estimated to be between 3.9 billion dollars and 52.9 billion dollars for the 16.3 million existing patients with diabetes. Chromium picolinate plus biotin (Diachrome) use among the 1.17 million newly diagnosed patients with T2DM each year could deliver lifetime cost savings of 42 billion dollars, or 36,000 dollars per T2DM patient. Affordable, safe, and convenient, chromium picolinate plus biotin (Diachrome) could prove to be a cost-effective complement to existing pharmacological therapies for controlling T2DM.

Insulin and lipid metabolism: new developments in drug therapy

Current treatments for non-insulin-dependent diabetes mellitus (NIDDM) remain far from ideal. The presence of both hyperinsulinaemia and resistance to insulin action in NIDDM challenges the rationale of treatments which primarily boost insulin secretion. Novel therapeutic strategies focus mainly on increasing peripheral sensitivity to endogenous insulin, an approach which has the potential not only to treat, but also to prevent NIDDM in high-risk individuals. The most promising new agents are the thiazolidinedione derivatives, in particular troglitazone. Thiazolidinediones are ligands for a specific subtype of the peroxisome proliferator activated receptor (PPAR), and decrease plasma glucose levels in both obesity and NIDDM, while at the same time reducing circulating insulin and free fatty acid levels. The current development status of these agents is reviewed, along with an assessment of their potential in the prevention and treatment of diverse pathophysiological states characterised by insulin resistance, including atherosclerosis and polycystic ovarian disease. Reference is made to the current status of other experimental agents including hydantoin derivatives, (3)-adrenoceptor agonists, and inhibitors of lipolysis.

New strategies for basal insulin treatment in type 2 diabetes mellitus

BACKGROUND

The clinical progression of type 2 diabetes mellitus (DM) is well understood. Glycemic control gradually deteriorates, and progression of DM eventually leads to an increased risk for microvascular and macrovascular complications. Reassessment of current insulin treatment strategies leading to restoration of glycemic control is essential to prevent or stop the progression of type 2 DM and its complications.

OBJECTIVE

The purpose of this article was to review the importance of instituting a strategy of basal insulin therapy in patients with type 2 DM.

METHODS

Relevant articles were obtained through an online search of PubMed and MEDLINE for literature published from 1990 to 2003. The search terms used were insulin therapy, combination oral therapy, treatment failure, glycemic control, insulin analogues, insulin glargine, basal insulin, and microvascular complications.

RESULTS

Large-scale intervention trials, such as the United Kingdom Prospective Diabetes Study (UKPDS), have reported that patients with type 2 DM treated with oral combination therapy are unable to maintain glycemic control. These observations have led to a reassessment of the role of insulin therapy in type 2 DM. The importance of tight glycemic control through the aggressive use of insulin early in the course of the disease is apparent from the UKPDS, Diabetes Control and Complications Trial, and other, smaller studies. Considerable evidence indicates that initiating a basal insulin-replacement strategy with an existing oral regimen can result in regaining glycemic control. Evidence emerging from recent studies indicates that use of intensive insulin therapy early in the course of the disease may have a positive clinical impact on outcome and slow the progression of complications. The availability of basal insulin analogues has expanded treatment options and improved the efficacy of therapeutic regimens for type 2 DM.

CONCLUSIONS

The available data suggest using an earlier transition from monotherapy to combination therapy to minimize disease-associated morbidity. The availability of new insulin analogues has expanded therapeutic options and offers the potential to enhance the efficacy of therapeutic regimens for type 2 DM as well as improve the ease and safety of treatment when glycosylated hemoglobin cannot be maintained <7% on > or =1 oral antidiabetic agent.

Functional status and health outcomes in older americans with diabetes mellitus

OBJECTIVES

To determine how baseline functional status affects health outcomes in older adults with diabetes mellitus (DM).

DESIGN

Nationally representative cross-sectional and longitudinal health interview survey.

SETTING

Waves I (1993) and II (1995) of the Assets and Health Dynamics of the Oldest Old Survey (AHEAD) in the United States.

PARTICIPANTS

AHEAD respondents aged 70 and older (n = 7,447, including 995 with DM).

MEASUREMENTS

At baseline, the entire sample was divided into three groups: high-functioning group, defined as having no physical limitations or instrumental activities of daily living/activities of daily living (IADL/ADL) disabilities (39%); low-functioning group, having three or more limitations or IADL/ADL disabilities (24%); and intermediate-functioning group, those in the middle (36%). Older adults with and without DM, within each of the functioning groups, were compared at 2-year follow-up with respect to demographic characteristics, weight/body mass index, baseline and incident chronic diseases and conditions, and follow-up functioning.

RESULTS

Of people aged 70 and older, 28% with DM and 41% without were high functioning; 38% with DM and 22% without were low functioning (both P <.001). High-functioning people with DM remained high functioning at 2 years but had a significantly higher incidence of heart disease and mortality than high-functioning people without DM. Low-functioning people with DM were significantly more likely to have vascular comorbidities at baseline than low-functioning people without DM, but their 2-year outcomes were similar. The intermediate-functioning group showed the most differences between those with and without DM; those with DM were significantly (P <.01) more likely to have baseline vascular disease, low cognitive performance, increased incident vascular disease, and significantly worse 2-year functioning and to have experienced falls (P <.001).

CONCLUSION

Differences in baseline functional status in older adults with DM were associated with outcome differences. High-functioning older people with DM tended to remain high functioning but demonstrated significantly higher incidence of heart disease and mortality than those without DM, whereas low-functioning people with and without DM had similar outcomes. However, intermediate-functioning older diabetics had worse health and functioning outcomes than a similarly impaired group without DM. DM management adjusted to functional status can potentially address the most-relevant outcomes in the heterogeneous older population with DM.

Glycemic control and cardiovascular disease in type 2 diabetes: a review

Cardiovascular disease is the major cause of morbidity and mortality in people with Type 2 diabetes, and risk of atherosclerotic disease is markedly increased in people with diabetes compared to people with normal glucose tolerance. The excess risk can not be completely explained by increased prevalence of other cardiovascular disease risk factors such as hypertension and hyperlipidaemia in people with diabetes. This review examines the role of hyperglycemia and glycemic control in cardiovascular disease in people with Type 2 diabetes. The results of prospective observational studies and randomized controlled trials are summarized. We conclude that control of hypertension and hyperlipidemia are important to reduce risk of cardiovascular disease in people with diabetes and may be more easily achieved than tight glycemic control.