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Chua S, Todd A, Reeve E, Smith SM, Fox J, Elsisi Z, Hughes S, Husband A, Langford A, Merriman N, Harris JR, Devine B, Gray SL. Deprescribing interventions in older adults: An overview of systematic reviews. PLoS One 2024; 19:e0305215. [PMID: 38885276 PMCID: PMC11182547 DOI: 10.1371/journal.pone.0305215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/25/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE The growing deprescribing field is challenged by a lack of consensus around evidence and knowledge gaps. The objective of this overview of systematic reviews was to summarize the review evidence for deprescribing interventions in older adults. METHODS 11 databases were searched from 1st January 2005 to 16th March 2023 to identify systematic reviews. We summarized and synthesized the results in two steps. Step 1 summarized results reported by the included reviews (including meta-analyses). Step 2 involved a narrative synthesis of review results by outcome. Outcomes included medication-related outcomes (e.g., medication reduction, medication appropriateness) or twelve other outcomes (e.g., mortality, adverse events). We summarized outcomes according to subgroups (patient characteristics, intervention type and setting) when direct comparisons were available within the reviews. The quality of included reviews was assessed using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2). RESULTS We retrieved 3,228 unique citations and assessed 135 full-text articles for eligibility. Forty-eight reviews (encompassing 17 meta-analyses) were included. Thirty-one of the 48 reviews had a general deprescribing focus, 16 focused on specific medication classes or therapeutic categories and one included both. Twelve of 17 reviews meta-analyzed medication-related outcomes (33 outcomes: 25 favored the intervention, 7 found no difference, 1 favored the comparison). The narrative synthesis indicated that most interventions resulted in some evidence of medication reduction while for other outcomes we found primarily no evidence of an effect. Results were mixed for adverse events and few reviews reported adverse drug withdrawal events. Limited information was available for people with dementia, frailty and multimorbidity. All but one review scored low or critically low on quality assessment. CONCLUSION Deprescribing interventions likely resulted in medication reduction but evidence on other outcomes, in particular relating to adverse events, or in vulnerable subgroups or settings was limited. Future research should focus on designing studies powered to examine harms, patient-reported outcomes, and effects on vulnerable subgroups. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020178860.
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Affiliation(s)
- Shiyun Chua
- School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Adam Todd
- Newcastle University, School of Pharmacy, Newcastle-upon-Tyne, United Kingdom
- NIHR Patient Safety Research Collaborative, Newcastle-upon-Tyne, United Kingdom
| | - Emily Reeve
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Susan M. Smith
- Discipline of Public Health and Primary Care, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Julia Fox
- School of Pharmacy, University of Washington, Seattle, Washington, United States of America
| | - Zizi Elsisi
- School of Pharmacy, University of Washington, Seattle, Washington, United States of America
| | - Stephen Hughes
- School of Pharmacy, University of Sydney, Sydney, Australia
| | - Andrew Husband
- Newcastle University, School of Pharmacy, Newcastle-upon-Tyne, United Kingdom
- NIHR Patient Safety Research Collaborative, Newcastle-upon-Tyne, United Kingdom
| | - Aili Langford
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Niamh Merriman
- Discipline of Public Health and Primary Care, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Jeffrey R. Harris
- School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Beth Devine
- School of Pharmacy, University of Washington, Seattle, Washington, United States of America
| | - Shelly L. Gray
- School of Pharmacy, University of Washington, Seattle, Washington, United States of America
- Plein Center for Geriatric Pharmacy Research, Education and Outreach, School of Pharmacy, University of Washington, Seattle, Washington, United States of America
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Gungabissoon U, Broadbent M, Perera G, Ashworth M, Galwey N, Stewart R. The Impact of Dementia on Diabetes Control: An Evaluation of HbA 1c Trajectories and Care Outcomes in Linked Primary and Specialist Care Data. J Am Med Dir Assoc 2022; 23:1555-1563.e4. [PMID: 35661655 DOI: 10.1016/j.jamda.2022.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/25/2022] [Accepted: 04/30/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Diabetes self-care may become increasingly challenging as cognition declines. We sought to characterize glycated hemoglobin A1c (HbA1c) trajectories, markers of diabetes-related management, health care utilization, and mortality in people with preexisting type 2 diabetes (T2D) with and without dementia and based on the extent of cognitive impairment at the time of dementia diagnosis. DESIGN Retrospective matched cohort study. SETTING AND PARTICIPANTS Using a linkage between a primary care (Lambeth DataNet) and a secondary mental healthcare database, up to 5 individuals aged ≥65 y with preexisting T2D without dementia were matched to each individual with dementia based on age, sex, and general practice. METHODS Comparisons were made for HbA1c trajectories (linear mixed effects models), markers of diabetes-related management and severity at dementia diagnosis (logistic regression), mortality (Cox regression), and health care utilization (multilevel mixed effects binomial regression). RESULTS In 725 incident dementia and 3154 matched comparators, HbA1c trajectories differed by dementia status; HbA1c increased over time for mild dementia and non-dementia, but the increase was greater in the mild dementia group; for those with moderate-severe dementia, HbA1c decreased over time. Despite individuals with dementia having increased health care utilization around the time of dementia diagnosis, they were less likely to have had routine diabetes-related management. Patients with dementia had a higher prevalence of macrovascular complications and diabetes foot morbidity at dementia diagnosis and a higher mortality risk than those without dementia; these relationships were most marked in those with moderate-severe dementia. CONCLUSIONS AND IMPLICATIONS Our study has highlighted important differences in the monitoring, management, and control of diabetes in people with dementia. The effects of frailty and the extent of cognitive impairment on the ability to self-manage diabetes and on glycemic control may need to be considered in treatment guidelines and by primary care.
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Affiliation(s)
- Usha Gungabissoon
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom; Epidemiology, Value, Evidence and Outcomes, Global Medical, GlaxoSmithKline (GSK) R&D, London, United Kingdom.
| | - Matthew Broadbent
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Gayan Perera
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | | | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom
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Callahan KE. The future of frailty: Opportunity is knocking. J Am Geriatr Soc 2022; 70:78-80. [PMID: 34694001 PMCID: PMC8742769 DOI: 10.1111/jgs.17510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 09/29/2021] [Indexed: 01/03/2023]
Abstract
This editorial comments on the article by Cooper et al. in this issue.
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Affiliation(s)
- Kathryn E. Callahan
- Department of Internal Medicine: Division on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, 27157
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, NC, 27157
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Callahan KE, Lenoir KM, Usoh CO, Williamson JD, Brown LY, Moses AW, Hinely M, Neuwirth Z, Pajewski NM. Using an Electronic Health Record and Deficit Accumulation to Pragmatically Identify Candidates for Optimal Prescribing in Patients With Type 2 Diabetes. Diabetes Spectr 2022; 35:344-350. [PMID: 36082014 PMCID: PMC9396712 DOI: 10.2337/ds21-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Despite guidelines recommending less stringent glycemic goals for older adults with type 2 diabetes, overtreatment is prevalent. Pragmatic approaches for prioritizing patients for optimal prescribing are lacking. We describe glycemic control and medication patterns for older adults with type 2 diabetes in a contemporary cohort, exploring variability by frailty status. RESEARCH DESIGN AND METHODS This was a cross-sectional observational study based on electronic health record (EHR) data, within an accountable care organization (ACO) affiliated with an academic medical center/health system. Participants were ACO-enrolled adults with type 2 diabetes who were ≥65 years of age as of 1 November 2020. Frailty status was determined by an automated EHR-based frailty index (eFI). Diabetes management was described by the most recent A1C in the past 2 years and use of higher-risk medications (insulin and/or sulfonylurea). RESULTS Among 16,973 older adults with type 2 diabetes (mean age 75.2 years, 9,154 women [53.9%], 77.8% White), 9,134 (53.8%) and 6,218 (36.6%) were classified as pre-frail (0.10 < eFI ≤0.21) or frail (eFI >0.21), respectively. The median A1C level was 6.7% (50 mmol/mol) with an interquartile range of 6.2-7.5%, and 74.1 and 38.3% of patients had an A1C <7.5% (58 mmol/mol) and <6.5% (48 mmol/mol), respectively. Frailty status was not associated with level of glycemic control (P = 0.08). A majority of frail patients had an A1C <7.5% (58 mmol/mol) (n = 4,544, 73.1%), and among these patients, 1,755 (38.6%) were taking insulin and/or a sulfonylurea. CONCLUSION Treatment with insulin and/or a sulfonylurea to an A1C levels <7.5% is common in frail older adults. Tools such as the eFI may offer a scalable approach to targeting optimal prescribing interventions.
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Affiliation(s)
- Kathryn E. Callahan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, NC
- Corresponding author: Kathryn E. Callahan,
| | - Kristin M. Lenoir
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Chinenye O. Usoh
- Section on Endocrinology and Metabolism, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Jeff D. Williamson
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, NC
| | - LaShanda Y. Brown
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, NC
| | - Adam W. Moses
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Molly Hinely
- Department of Pharmacy, Wake Forest Baptist Health, Winston-Salem, NC
| | | | - Nicholas M. Pajewski
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
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Raffield LM, Howard AG, Graff M, Lin D, Cheng S, Demerath E, Ndumele C, Palta P, Rebholz CM, Seidelmann S, Yu B, Gordon‐Larsen P, North KE, Avery CL. Obesity Duration, Severity, and Distribution Trajectories and Cardiovascular Disease Risk in the Atherosclerosis Risk in Communities Study. J Am Heart Assoc 2021; 10:e019946. [PMID: 34889111 PMCID: PMC9075238 DOI: 10.1161/jaha.121.019946] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 10/22/2021] [Indexed: 12/14/2022]
Abstract
Background Research examining the role of obesity in cardiovascular disease (CVD) often fails to adequately consider heterogeneity in obesity severity, distribution, and duration. Methods and Results We here use multivariate latent class mixed models in the biracial Atherosclerosis Risk in Communities study (N=14 514; mean age=54 years; 55% female) to associate obesity subclasses (derived from body mass index, waist circumference, self-reported weight at age 25, tricep skinfold, and calf circumference across up to four triennial visits) with total mortality, incident CVD, and CVD risk factors. We identified four obesity subclasses, summarized by their body mass index and waist circumference slope as decline (4.1%), stable/slow decline (67.8%), moderate increase (24.6%), and rapid increase (3.6%) subclasses. Compared with participants in the stable/slow decline subclass, the decline subclass was associated with elevated mortality (hazard ratio [HR] 1.45, 95% CI 1.31, 1.60, P<0.0001) and with heart failure (HR 1.41, 95% CI 1.22, 1.63, P<0.0001), stroke (HR 1.53, 95% CI 1.22, 1.92, P=0.0002), and coronary heart disease (HR 1.36, 95% CI 1.14, 1.63, P=0.0008), adjusting for baseline body mass index and CVD risk factor profile. The moderate increase latent class was not associated with any significant differences in CVD risk as compared to the stable/slow decline latent class and was associated with a lower overall risk of mortality (HR 0.85, 95% CI 0.80, 0.90, P<0.0001), despite higher body mass index at baseline. The rapid increase latent class was associated with a higher risk of heart failure versus the stable/slow decline latent class (HR 1.34, 95% CI 1.10, 1.62, P=0.004). Conclusions Consideration of heterogeneity and longitudinal changes in obesity measures is needed in clinical care for a more precision-oriented view of CVD risk.
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Affiliation(s)
| | - Annie Green Howard
- Department of BiostatisticsGillings School of Global Public HealthUniversity of North CarolinaChapel HillNC
| | - Misa Graff
- Department of EpidemiologyGillings School of Global Public HealthUniversity of North CarolinaChapel HillNC
| | - Dan‐Yu Lin
- Department of BiostatisticsGillings School of Global Public HealthUniversity of North CarolinaChapel HillNC
| | - Susan Cheng
- Smidt Heart InstituteCedars‐Sinai Medical CenterLos AngelesCA
| | - Ellen Demerath
- Division of Epidemiology and Community HealthSchool of Public HealthUniversity of MinnesotaMinneapolisMN
| | - Chiadi Ndumele
- Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseJohns Hopkins University School of MedicineBaltimoreMD
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Priya Palta
- Departments of Medicine and EpidemiologyColumbia University Medical CenterNew YorkNY
| | - Casey M. Rebholz
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
- Welch Center for Prevention, Epidemiology and Clinical ResearchJohns Hopkins UniversityBaltimoreMD
| | - Sara Seidelmann
- Cardiovascular DivisionBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
| | - Bing Yu
- Department of Epidemiology, Human Genetics and Environmental SciencesSchool of Public HealthUniversity of Texas Health Science Center at HoustonTX
| | - Penny Gordon‐Larsen
- Department of NutritionGillings School of Global Public Health and School of MedicineUniversity of North CarolinaChapel HillNC
| | - Kari E. North
- Department of EpidemiologyGillings School of Global Public HealthUniversity of North CarolinaChapel HillNC
- Carolina Center of Genome SciencesUniversity of North Carolina at Chapel HillChapel HillNC
| | - Christy L. Avery
- Department of EpidemiologyGillings School of Global Public HealthUniversity of North CarolinaChapel HillNC
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Farzad M, MitraMoodi, Sharifi F, Amirabadizadeh H, Amirabadizadeh A, Kazemi T, Javadi A, Nasiri M. Prevalence and factors connected with chronic diseases in the elderly residents of Birjand: a community - based study in Birjand, South Khorasan Province, Iran. J Diabetes Metab Disord 2021; 20:1655-1662. [PMID: 34900817 PMCID: PMC8630296 DOI: 10.1007/s40200-021-00918-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The rapid rise of non-communicable diseases (NCDs) across the elderly has attracted much attention in Iran due to the high rate of population aging in the country. The current survey intended to evaluate the prevalence of and factors associated with five NCDs in the elderly residents of Birjand, a metropolis of South Khorasan, Iran. METHODS Following an observational design, 1820 elderly dwellers of Birjand aged ≥ 60 years residing in urban or rural areas were explored. Data on the target NCDS and socio-demographic features, health behavioral factors, and objective assessment of height and weight were collected using interviews. RESULTS The prevalence of hypertension, diabetes mellitus, chronic obstructive pulmonary disease (COPD), stroke, and cancer was 55.2% (1004/1819), 25.5% (463/1819), 1.0% (18/1807), 4.4% (80/1810), and 1.8% (33/1816), respectively. There was no gender difference concerning the prevalence of COPD, whereas the prevalence of hypertension, diabetes mellitus, and cancer was higher in women than men. Stroke was conversely higher in males than females. The common correlations of the five main NCDs were locality of residence and low body mass index (BMI). Rural residents had higher odds of diabetes mellitus and hypertension and lower odds of stroke. Diabetes mellitus, hypertension, and stroke were associated with a low BMI. Gender, age, and occupation were found to be associated with some of the NCDs. Retired and housewives had more chance to have hypertension and diabetes mellitus than the unemployed elderly. CONCLUSION The findings demonstrated that hypertension, diabetes mellitus, and stroke are the three prevalent NCDs among elders in the area and warrant a specific focus on reducing the burden of diseases and aligning healthcare services to prepare the whole needs of this population.
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Affiliation(s)
- Marjan Farzad
- Cardiovascular Diseases Research Center, School of Nursing and Midwifery, Birjand University of Medical Sciences, Birjand, Iran
| | - MitraMoodi
- Social Determinants of Health Research Center, School of Health, Birjand University of Medical Sciences, Birjand, Iran
| | - Farshad Sharifi
- Elderly Health Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hasan Amirabadizadeh
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Alireza Amirabadizadeh
- Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Toba Kazemi
- Cardiovascular Diseases Research Center, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran
- Clinical Research Development Unit of Razi Hospital, Birjand University of Medical Sciences, Birjand, Iran
| | - Abbas Javadi
- Social Determinants of Health Research Center, School of Health, Birjand University of Medical Sciences, Birjand, Iran
| | - Maziar Nasiri
- Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran
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Khuc AHT, Doan VT, Le TT, Ngo TT, Dinh NT, Tran TP, Nguyen PH. Determinants of Frailty among Patients with Type 2 Diabetes In Urban Hospital. Hosp Top 2021; 101:215-222. [PMID: 34812701 DOI: 10.1080/00185868.2021.2005501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objectives: Frailty and diabetes are on the rise due to the aging population. This study was conducted to examine frailty conditions among patients with Type 2 diabetes (T2DM) in Hanoi, Vietnam, as well as determine its associated factors. Methods: A cross-sectional study on T2DM patients at an urban hospital. This study assessed the frailty status using the FRAIL questionnaire. Socio-demographic, clinical, and paraclinical characteristics were obtained. Multivariate regression models were performed to detect factors associated with frailty. Results: Of 379 patients, the FRAIL scale results showed that 8/379 patients were at the frailty level (2.1%), and 33/379 patients were at the pre-frailty level (8.7%). Patients who had above high school education and were retired were at lower risk of pre-frailty/frailty than those with high school education or below, and self-employed, respectively. Conversely, patients with a higher number of comorbidities were more likely to develop pre-frailty and frailty. Conclusion: This study showed a low prevalence of pre-frailty and frailty among T2DM patients. It is necessary to manage diabetes carefully and strictly control the comorbidities in this population. Interventions should focus on higher risk populations, such as those with low education levels and self-employment.
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Affiliation(s)
| | - Van Thi Doan
- Nursing Faculty, Hanoi Medical College, Hanoi, Vietnam
| | - Thuy Thi Le
- Nursing Faculty, Hanoi Medical College, Hanoi, Vietnam
| | - Tam Thi Ngo
- Faculty of Health Sciences, Thang Long University, Hanoi, Vietnam
| | - Nham Thi Dinh
- Nursing Faculty, Hanoi Medical College, Hanoi, Vietnam
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The relationship between frailty and diabetes: An investigation of self-rated health, depression symptoms and quality of life in the Study of Health Aging and Retirement in Europe. Arch Gerontol Geriatr 2021; 96:104448. [PMID: 34144317 DOI: 10.1016/j.archger.2021.104448] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/17/2021] [Accepted: 05/22/2021] [Indexed: 12/30/2022]
Abstract
AIMS To assess the impact of diabetes and frailty on self-rated health, depressive symptoms and quality of life (QoL). METHODS Data were pooled for participants aged ≥50 years from five waves of the Survey of Health, Ageing and Retirement in Europe. Measures included diabetes (self-reported), physical frailty (≥3/5 criteria), low self-rated health (SRH; "poor" or "fair"), depression (screened using the EURO-D ≥4) and low QoL (CASP-12 <35). Logistic regression was used to adjust for confounding. RESULTS Participants with diabetes (n=11,661/97,691) were more likely to be older (68 vs. 64 years, p<0.001), male (50% vs. 45%, p<0.001) and frail (21% vs. 8%, p<0.001). Age, sex, diabetes and frailty were all independently associated with low SRH, depression and low QoL. Frailty had the highest adjusted odds ratios for low SRH (9.43; 95% CI:8.89-10.02), depression (6.39; 95% CI:6.07-6.71) and low QoL (9.65; 95% CI:9.17-10.16). For diabetes, the adjusted odds ratios were 2.82 (2.70-2.95), 1.49 (1.42-1.56) and 1.67 (1.60-1.74), respectively. Participants with both diabetes and frailty reported the worst self-rated health, the most depression symptoms and the lowest QoL. CONCLUSIONS Frailty was prevalent in older people with diabetes and independently associated with low self-rated health, depressive symptoms and low QoL. Prompt identification and management of frailty should be a key consideration in diabetes care.
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Nakamura I, Maegawa H, Tobe K, Uno S. Safety and Effectiveness of Ipragliflozin in Elderly Versus Non-elderly Japanese Patients with Type 2 Diabetes: Subgroup Analysis of STELLA-LONG TERM. Diabetes Ther 2021; 12:1359-1378. [PMID: 33730336 PMCID: PMC8099957 DOI: 10.1007/s13300-021-01042-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/26/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION STELLA-LONG TERM is a post-marketing surveillance study evaluating the safety and effectiveness of ipragliflozin in Japanese patients with type 2 diabetes mellitus. METHODS Patients were classified by age at ipragliflozin initiation (< 65 and ≥ 65 years), and elderly patients were subclassified by baseline body mass index (BMI) < 25.0 or ≥ 25.0 kg/m2. Incidence of adverse drug reactions (ADRs) and effectiveness were evaluated over 3 years. RESULTS Among 11,051 patients, 7894 (71.4%) were aged < 65 years and 3157 (28.6%) ≥ 65 years. The 3-year ADR incidence was similar in patients aged ≥ 65 (19.04%) and < 65 years (19.36%; P = 0.701). Serious ADRs were more frequent in the subgroup ≥ 65 years (2.79% vs 1.55%; P < 0.001). In terms of ADRs of special interest, a significantly greater proportion of elderly patients had skin complications (2.22% vs 1.62%, P = 0.033), renal disorders (2.28% vs 1.51%, P = 0.005), hypoglycemia (0.73% vs 0.43%, P = 0.048), or malignant tumors (1.01% vs 0.24%, P < 0.001), while the incidence of polyuria/pollakiuria (5.97% vs 4.47%, P = 0.002) and hepatic disorders (1.39% vs 0.73%, P = 0.004) was significantly higher in non-elderly than elderly patients. In patients aged ≥ 65 years, the incidence of ADRs was higher when baseline BMI was ≥ 25 kg/m2 versus < 25 kg/m2 (24.40% vs 17.68%; P < 0.001). Glycosylated hemoglobin, fasting blood glucose, and body weight significantly decreased from baseline in both age groups at each evaluation up to 3 years (all P < 0.001). CONCLUSIONS Ipragliflozin was well tolerated and effective for 3 years in routine clinical use in elderly and non-elderly patients, although elderly patients had a higher rate of serious ADRs. No new safety concerns were identified. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02479399.
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Affiliation(s)
- Ichiro Nakamura
- Operational Excellence, Medical Affairs Japan, Astellas Pharma Inc., Tokyo, Japan.
| | - Hiroshi Maegawa
- Department of Medicine, Shiga University of Medical Science, Shiga, Japan
| | - Kazuyuki Tobe
- First Department of Internal Medicine, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Toyama, Japan
| | - Satoshi Uno
- Data Science, Development, Astellas Pharma Inc., Tokyo, Japan
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Sinclair AJ, Heller SR, Pratley RE, Duan R, Heine RJ, Festa A, Kiljański J. Evaluating glucose-lowering treatment in older people with diabetes: Lessons from the IMPERIUM trial. Diabetes Obes Metab 2020; 22:1231-1242. [PMID: 32100382 PMCID: PMC7383926 DOI: 10.1111/dom.14013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/11/2020] [Accepted: 02/20/2020] [Indexed: 01/24/2023]
Abstract
Understanding the benefits and risks of treatments to be used by older individuals (≥65 years old) is critical for informed therapeutic decisions. Glucose-lowering therapy for older patients with diabetes should be tailored to suit their clinical condition, comorbidities and impaired functional status, including varying degrees of frailty. However, despite the rapidly growing population of older adults with diabetes, there are few dedicated clinical trials evaluating glucose-lowering treatment in older people. Conducting clinical trials in the older population poses multiple significant challenges. Despite the general agreement that individualizing treatment goals and avoiding hypoglycaemia is paramount for the therapy of older people with diabetes, there are conflicting perspectives on specific glycaemic targets that should be adopted and on use of specific drugs and treatment strategies. Assessment of functional status, frailty and comorbidities is not routinely performed in diabetes trials, contributing to insufficient characterization of older study participants. Moreover, significant operational barriers and problems make successful enrolment and completion of such studies difficult. In this review paper, we summarize the current guidelines and literature on conducting such trials, as well as the learnings from our own clinical trial (IMPERIUM) that assessed different glucose-lowering strategies in older people with type 2 diabetes. We discuss the importance of strategies to improve study design, enrolment and attrition. Apart from summarizing some practical advice to facilitate the successful conduct of studies, we highlight key gaps and needs that warrant further research.
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Affiliation(s)
- Alan J. Sinclair
- Foundation for Diabetes Research in Older PeopleDiabetes Frail LimitedWorcestershireUK
- King's CollegeLondonUK
| | - Simon R. Heller
- Department of Oncology & Metabolism, University of SheffieldSheffieldUK
| | - Richard E. Pratley
- AdventHealth Translational Research Institute for Metabolism and DiabetesOrlandoFloridaUSA
| | - Ran Duan
- Eli Lilly and CompanyIndianapolisIndianaUSA
| | | | - Andreas Festa
- 1st Medical DepartmentLK StockerauNiederösterreichAustria
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11
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Baskaran D, Aparicio-Ugarriza R, Ferri-Guerra J, Milyani R, Florez H, Ruiz JG. Is There an Association Between Metformin Exposure and Frailty? Gerontol Geriatr Med 2020; 6:2333721420924956. [PMID: 32596419 PMCID: PMC7297486 DOI: 10.1177/2333721420924956] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 03/19/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022] Open
Abstract
Frailty is a state of vulnerability to stressors resulting in higher morbidity, mortality, and utilization in older adults. Frailty and type 2 diabetes mellitus share similar pathophysiological mechanisms which metformin may target. The purpose of this study was to determine whether exposure to metformin is associated with frailty in veterans. This is a cross-sectional study of veterans 65 years and older with type 2 diabetes who were screened for frailty between January 2016 and August 2017. We constructed a 44-item Frailty Index including multiple variables using a deficit accumulation framework. After adjustment for covariates, the association was calculated using binomial logistic regression models with frailty status as the outcome variable, and metformin exposure as the independent variable. Patients were 98.3% male and 56.7% White with a mean age of 72.9 (SD = 6.8) years. The proportion of robust, prefrail and frail patients was 2.9% (n = 22), 46.7 % (n = 356) and 50.5% (n = 385), respectively. In binomial logistic regression, exposure to metformin was associated with lower risk for frailty, adjusted odds ratio (OR) = .55 (95% confidence interval [CI] = .39–.77), p ≤ .001. This study shows that exposure to metformin was associated with lower risk for frailty in community-dwelling veterans.
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Affiliation(s)
- Dhanya Baskaran
- Miami VAHS Geriatric Research Education and Clinical Center (GRECC), FL, USA
| | - Raquel Aparicio-Ugarriza
- Miami VAHS Geriatric Research Education and Clinical Center (GRECC), FL, USA.,Miller School of Medicine, University of Miami, FL, USA
| | - Juliana Ferri-Guerra
- Miami VAHS Geriatric Research Education and Clinical Center (GRECC), FL, USA.,Miller School of Medicine, University of Miami, FL, USA
| | | | - Hermes Florez
- Miami VAHS Geriatric Research Education and Clinical Center (GRECC), FL, USA.,Miller School of Medicine, University of Miami, FL, USA
| | - Jorge G Ruiz
- Miami VAHS Geriatric Research Education and Clinical Center (GRECC), FL, USA.,Miller School of Medicine, University of Miami, FL, USA
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12
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Srikanth V, Sinclair AJ, Hill-Briggs F, Moran C, Biessels GJ. Type 2 diabetes and cognitive dysfunction-towards effective management of both comorbidities. Lancet Diabetes Endocrinol 2020; 8:535-545. [PMID: 32445740 DOI: 10.1016/s2213-8587(20)30118-2] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/03/2020] [Accepted: 03/25/2020] [Indexed: 12/25/2022]
Abstract
Type 2 diabetes and cognitive dysfunction are highly prevalent disorders worldwide. Although type 2 diabetes is associated with an increased risk of dementia, awareness of the link between the two conditions is poor, and few recommendations are available to guide clinicians about how to approach cognitive dysfunction in people with diabetes. Clinical guidelines in diabetes have only recently begun to emphasise the importance of cognitive impairment in diabetes and its management. This Series paper aims to synthesise knowledge about the link between diabetes and cognitive dysfunction, issues pertaining to screening and diagnosis of cognitive impairment and dementia in those with type 2 diabetes, management of diabetes in people with cognitive dysfunction (accounting for age and frailty), and emerging therapies for prevention. A conceptual framework for approaching screening and diagnosis is included, and future research directions to guide the field forward are suggested.
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Affiliation(s)
- Velandai Srikanth
- Department of Geriatric Medicine, Peninsula Health, Peninsula Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Alan J Sinclair
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Felicia Hill-Briggs
- Johns Hopkins School of Medicine, Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, MD, USA
| | - Chris Moran
- Department of Geriatric Medicine, Peninsula Health, Peninsula Clinical School, Monash University, Melbourne, VIC, Australia
| | - Geert Jan Biessels
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center, Utrecht, Netherlands
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13
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Seidu S, Kunutsor SK, Topsever P, Hambling CE, Cos FX, Khunti K. Deintensification in older patients with type 2 diabetes: A systematic review of approaches, rates and outcomes. Diabetes Obes Metab 2019; 21:1668-1679. [PMID: 30938038 DOI: 10.1111/dom.13724] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/19/2019] [Accepted: 03/27/2019] [Indexed: 02/06/2023]
Abstract
AIM To assess deintensification approaches and rates and evaluate the harm and benefits of deintensification with antidiabetic medication and other therapies among older people (≥ 65 years) with type 2 diabetes with or without cardiometabolic conditions. METHODS We identified relevant studies in a literature search of MEDLINE, Embase, Web of Science and Cochrane databases to 30 October 2018. Data were extracted on baseline characteristics, details on deintensification and outcomes, and was synthesized using a narrative approach. RESULTS Ten studies (observational cohorts and interventional studies) with data on 26 558 patients with comorbidities were eligible. Deintensification approaches included complete withdrawal, discontinuation, reducing dosage, conversion, or substitution of at least one medication, but the majority of studies were based on complete withdrawal or discontinuation of antihyperglycaemic medication. Rates of deintensification approaches ranged from 13.4%-75%. The majority of studies reported no deterioration in HbA1c levels, hypoglycaemic episodes, falls or hospitalizations on deintensification. On adverse events and mortality, no significant differences were observed among the comparison groups in the majority of studies. CONCLUSION Available but limited evidence suggests that the benefits of deintensification outweigh the harm in older people with type 2 diabetes with or without comorbidities. Given the heterogeneity of patients with diabetes, further research is warranted on which deintensification approaches are appropriate and beneficial for each specific patient population.
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Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, Diabetes & Metabolic Medicine, University of Leicester, Leicester, UK
| | - Setor K Kunutsor
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, NHS Foundation, National Institute for Health Research Bristol, Biomedical Research Centre, University Hospitals Bristol Trust and University of Bristol, Bristol, UK
| | - Pinar Topsever
- Department of Family Medicine, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Clare E Hambling
- Department of Public Health and Primary Care, School of Clinical Medicine, Cambridge, UK
| | - Francesc X Cos
- Diabetes & Metabolic Medicine, Jordi Gol Institute for Research in Primary Care, The Foundation University Institute for Primary Health, Barcelona, Spain
| | - Kamlesh Khunti
- Diabetes Research Centre, Diabetes & Metabolic Medicine, University of Leicester, Leicester, UK
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14
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Jacob KJ, Chevalier S, Lamarche M, Morais JA. Leucine Supplementation Does Not Alter Insulin Sensitivity in Prefrail and Frail Older Women following a Resistance Training Protocol. J Nutr 2019; 149:959-967. [PMID: 31149709 DOI: 10.1093/jn/nxz038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 11/12/2018] [Accepted: 02/20/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Frailty is a clinical condition associated with loss of muscle mass and strength (sarcopenia). Although sarcopenia has multifactorial causes, it might be partly attributed to a blunted response to anabolic stimuli. Leucine acutely increases muscle protein synthesis, and resistance training (RT) is the strongest stimuli to counteract sarcopenia and was recently shown to improve insulin sensitivity (IS) in frail older women. Discrepancies exist regarding whether chronic supplementation of leucine in conjunction with RT can improve muscle mass and IS. OBJECTIVE The aim of this double-blinded placebo-controlled study was to determine the effects of leucine supplementation and RT on IS in prefrail and frail older women. METHODS Using the Fried criteria, 19 nondiabetic prefrail (1-2 criteria) and frail (≥3 criteria) older women (77.5 ± 1.3 y; body mass index (kg/m2): 25.1 ± 0.9) underwent a 3-mo intervention of RT 3 times/wk with protein-optimized diet of 1.2 g·kg-1·d-1 and 7.5 g·d-1 of l-leucine supplementation compared with placebo l-alanine. Pre-/postintervention primary outcomes were fasting plasma glucose, serum insulin, and 4-h responses to a standard meal of complete liquid formula. Secondary outcomes of resting energy expenditure using indirect calorimetry and body composition using dual-energy X-ray absorptiometry were obtained. Paired t tests analyzed pooled data, and 2-factor repeated-measures ANOVA determined supplementation, training, and interaction effects. RESULTS No significant time, group, or interaction effects were observed for postprandial areas under the curve of serum insulin or plasma glucose or for resting energy expenditure in l-leucine compared with l-alanine. Total lean body mass increased and percentage body fat decreased significantly for both groups postintervention (0.76 ± 0.13 and -0.92 ± 0.33 kg, respectively; time effect: P < 0.01). CONCLUSIONS IS was not affected by RT and leucine supplementation in nondiabetic prefrail and frail older women. Therefore, leucine supplementation does not appear to influence IS under these conditions. This trial was registered at clinicaltrials.gov as NCT01922167.
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Affiliation(s)
- Kathryn J Jacob
- Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Stéphanie Chevalier
- Research Institute of the McGill University Health Centre, Montreal, Canada.,Division of Geriatric Medicine, McGill University, MUHC-Montreal General Hospital, Montreal, Canada.,School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, Canada
| | - Marie Lamarche
- Research Institute of the McGill University Health Centre, Montreal, Canada
| | - José A Morais
- Research Institute of the McGill University Health Centre, Montreal, Canada.,Division of Geriatric Medicine, McGill University, MUHC-Montreal General Hospital, Montreal, Canada.,School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, Canada
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15
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Smith L, Chakraborty D, Bhattacharya P, Sarmah D, Koch S, Dave KR. Exposure to hypoglycemia and risk of stroke. Ann N Y Acad Sci 2018; 1431:25-34. [PMID: 29917249 DOI: 10.1111/nyas.13872] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 04/23/2018] [Accepted: 05/08/2018] [Indexed: 12/25/2022]
Abstract
In the treatment of both type 1 and type 2 diabetes mellitus, maintaining a euglycemic state represents one of the key challenges. Improper dosing and administration of glucose-lowering drugs is associated with an increased risk of recurrent hypoglycemia episodes. In addition, the risk of adverse cardiovascular events in diabetic patients, particularly myocardial infarctions and strokes, is well established. Current research indicates a potential link between the baseline risk of cardio/cerebrovascular events in diabetic patients and exposure to hypoglycemia. In this review of the literature, we aim to determine if a relationship exists between recurrent hypoglycemia and adverse neurovascular events.
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Affiliation(s)
- Logan Smith
- Cerebral Vascular Disease Research Laboratories, University of Miami, Miami, Florida.,Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - Diya Chakraborty
- Cerebral Vascular Disease Research Laboratories, University of Miami, Miami, Florida.,Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - Pallab Bhattacharya
- National Institute of Pharmaceutical Education and Research, Ahmedabad, Gujarat, India.,Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepaneeta Sarmah
- National Institute of Pharmaceutical Education and Research, Ahmedabad, Gujarat, India
| | - Sebastian Koch
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - Kunjan R Dave
- Cerebral Vascular Disease Research Laboratories, University of Miami, Miami, Florida.,Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida.,Neuroscience Program, University of Miami Miller School of Medicine, Miami, Florida
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16
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Ohara N, Minami I, Bouchi R, Izumiyama H, Hashimoto K, Yoshimoto T, Ogawa Y. Loss of skeletal muscle mass and its predictors in type 2 diabetes patients under a multifaceted treatment approach. Diabetol Int 2017; 8:366-374. [PMID: 30603342 DOI: 10.1007/s13340-017-0325-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/12/2017] [Indexed: 12/25/2022]
Abstract
Background Weight loss, which is an effective method for reducing visceral fat, may cause a concomitant loss of skeletal muscle mass. The aim of this study was to elucidate the changes in visceral fat and skeletal muscle mass in response to diabetes treatment including weight control. Methods For 6 months we observed the changes in the body compositions of 72 Japanese patients with type 2 diabetes who underwent multifaceted treatment including educational hospitalization. Visceral fat area (VFA) and appendicular skeletal muscle mass (ASM) were measured using a bioelectrical impedance method and dual-energy X-ray absorptiometry, respectively. Results During the follow-up period, VFA reduced significantly whereas the average ASM did not change. Changes in ASM were strongly positively associated with changes in body weight (r = 0.50). Additionally, in an analysis of covariance, an above-median BMI (27 kg/m2) and above-median VFA (110 cm2) at baseline were found to be independent predictors of ASM reduction prevention. Of the 55 patients who lost weight, those who had a baseline VFA of ≥110 cm2 had significantly greater reductions in VFA than those with a baseline VFA of <110 cm2 (p < 0.01). ASM reduced significantly in patients with a VFA of <110 cm2 (p < 0.01), but not in those with a VFA of ≥110 cm2 (p = 0.98). Conclusions Baseline accumulation of visceral fat may predict a preferential reduction of visceral fat rather than skeletal muscle during weight control programs in type 2 diabetes patients.
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Affiliation(s)
- Norihiko Ohara
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
| | - Isao Minami
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
| | - Ryotaro Bouchi
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
| | - Hajime Izumiyama
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
| | - Koshi Hashimoto
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
| | - Takanobu Yoshimoto
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
| | - Yoshihiro Ogawa
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan
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17
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Welcome to volume 3 of Future Science OA. Future Sci OA 2017; 3:FSO156. [PMID: 28344821 PMCID: PMC5351705 DOI: 10.4155/fsoa-2016-0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 10/11/2016] [Indexed: 11/17/2022] Open
Abstract
Happy New Year to all of our readers! Welcome to volume 3 of Future Science OA. 2016 was another excellent year, with us receiving some superb content for publication, and our becoming indexed on both Chemical Abstracts and the Emerging Sources Citation Index, meaning our content now appears on Web of Science. We thank our readers, reviewers, authors and Editorial Board members for their continued support, and look forward to working with everyone in 2017.
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