Lifestyle interventions for diabetes mellitus type 2 prevention

BACKGROUND AND AIMS

Transferring the results from clinical trials on type 2 diabetes prevention is the objective of the Diabetes in Europe-Prevention using Lifestyle, Physical Activity and Nutritional intervention (DE-PLAN) project in Catalonia, whose cost-effectiveness analysis is now presented.

PATIENTS AND METHODS

A prospective cohort study was performed in primary care involving individuals without diagnosed diabetes aged 45-75 years (n=2054) screened using the questionnaire Finnish Diabetes Risk Score (FINDRISC) and a subsequent oral glucose tolerance test. Where feasible, high-risk individuals who were identified (n=552) were allocated sequentially to standard care (n=219), a group-based (n=230) or an individual-level (n=103) intensive (structured programme of six hours using specific teaching techniques) lifestyle intervention (n=333). The primary outcome was the development of diabetes (WHO). We evaluated the cost of resources used with comparison of standard care and the intervention groups in terms of effectiveness and quality of life (15D questionnaire).

RESULTS

After 4.2-year median follow-up, the cumulative incidences were 18.3% (14.3-22.9%) in the intensive intervention group and 28.8% (22.9-35.3%) in the standard care group (36.5% relative-risk-reduction). The corresponding 4-year HR was 0.64 (0.47-0.87; P<.004). The incremental cost induced by intensive intervention compared with the standard was 106€ per participant in the individual level and 10€ in the group-based intervention representing 746€ and 108€ per averted case of diabetes, respectively. The estimated incremental cost-utility ratio was 3243€ per quality-adjusted life-years gained.

CONCLUSION

The intensive lifestyle intervention delayed the development of diabetes and was efficient in economic analysis.

Delaying progression to type 2 diabetes among high-risk Spanish individuals is feasible in real-life primary healthcare settings using intensive lifestyle intervention

AIMS/HYPOTHESIS

To assess the feasibility and effectiveness of an active real-life primary care lifestyle intervention in preventing type 2 diabetes within a high-risk Mediterranean population.

METHODS

A prospective cohort study was performed in the setting of Spanish primary care. White-European individuals without diabetes aged 45-75 years (n = 2,054) were screened using the Finnish Diabetes Risk Score (FINDRISC) and a subsequent 2 h OGTT. Where feasible, high-risk individuals who were identified were allocated sequentially to standard care, a group-based or an individual level intervention (intensive reinforced DE-PLAN [Diabetes in Europe-Prevention using Lifestyle, Physical Activity and Nutritional] intervention). The primary outcome was the development of diabetes according to WHO criteria. Analyses after 4-year follow-up were performed based on the intention-to-treat principle with comparison of standard care and the combined intervention groups.

RESULTS

The standard care (n = 219) and intensive intervention (n = 333) groups were comparable in age (62.0/62.2 years), sex (64.4/68.2% women), BMI (31.3/31.2 kg/m(2)), FINDRISC score (16.2/15.8 points), fasting (5.3/5.2 mmol/l), 2 h plasma glucose (7.1/6.9 mmol/l) and self-reported interest to make lifestyle changes at baseline. Diabetes was diagnosed in 124 individuals: 63 (28.8%) in the standard care group and 61 (18.3%) in the intensive intervention group. During a 4.2-year median follow-up, the incidences of diabetes were 7.2 and 4.6 cases per 100 person-years, respectively (36.5% relative risk reduction, p < 0.005). The number of participants needed to be treated by intensive intervention for 4 years to reduce one case of diabetes was 9.5.

CONCLUSIONS/INTERPRETATION

Intensive lifestyle intervention is feasible in a primary care setting and substantially reduces diabetes incidence among high-risk individuals.

CLINICAL TRIAL REGISTRATION

ClinicalTrial.gov NCT01519505.

FUNDING

Commission of the European Communities, Institute of Health Carlos III, Spanish Ministry of Health and Department of Health, Generalitat de Catalunya.

Shifting from glucose diagnostic criteria to the new HbA(1c) criteria would have a profound impact on prevalence of diabetes among a high-risk Spanish population

AIM

To investigate changes in the prevalence of diabetes and pre-diabetes by shifting from 2-h plasma glucose and/or fasting plasma glucose diagnostic criteria to the proposed new HbA(1c) -based criteria when applied to a Mediterranean population detected to have a high risk of Type 2 diabetes.

METHODS

Individuals without diabetes aged 45-75 years (n = 2287) were screened using the Finnish Diabetes Risk Score questionnaire, a 2-h oral glucose tolerance test plus HbA(1c) test. Prevalence and degree of diagnostic overlap between three sets of criteria (2-h plasma glucose, fasting plasma glucose and HbA(1c) ) and three diagnostic categories (normal, pre-diabetes and diabetes) were calculated.

RESULTS

Defining diabetes by a single HbA(1c) measurement resulted in a dramatic decrease in prevalence (1.3%), particularly in comparison with diabetes defined by 2-h plasma glucose (8.6%), but was also significant with regard to fasting plasma glucose (2.8%). A total of 201 screened subjects (8.8%) were classified as having diabetes and 1023 (44.7%) as having pre-diabetes based on at least one of these criteria; among these, the presence of all three criteria simultaneously classified only 21 and 110 individuals respectively, about ten percent of each group. The single overlap index between subjects diagnosed as having diabetes by 2-h plasma glucose/fasting plasma glucose vs. HbA(1c) was 13.9/28%. Similarly, the single overlap index regarding pre-diabetes was 19.2/27.1%.

CONCLUSIONS

A shift from the glucose-based diagnosis to the HbA(1c) -based diagnosis for diabetes will reduce diabetes prevalence with a low overall or single degree of overlap between diagnostic categories in this high-risk Spanish population.

[Recommendations for the management of influenza in pediatrics (2009-2010).]

Specific action plans from various institutions, governments and scientific societies have been identified and implemented to combat the A H1N1 2009 influenza virus pandemic. This document sets out the recommendations of the Spanish Association of Pediatrics for the management of influenza in children for influenza season 2009-2010. The risk factors for influenza A H1N1 2009 in pediatric patients, the clinical course, severity and complications are similar to seasonal influenza. In most cases, the diagnosis of influenza will be based on clinical suspicion, without viral subtype differentiation. In a patient with influenza virus infection, the criteria for referral and hospital admission will be based broadly on the signs of clinical severity or complications, regardless of the causative virus. Children with influenza but with no signs of clinical severity or complications do not require antiviral treatment. Physical measures of hygiene and isolation are essential to reduce the transmissibility of the disease. The influenza vaccines in infancy, for both seasonal influenza and for influenza A H1N1 2009, should be directed primarily at patients with risk factors.

Effect of different glycerol treatments on frozen-thawed dog sperm longevity and acrosomal integrity

Four different concentrations of glycerol in a Tris-fructose-citric acid extender for frozen dog semen and the effects of adding glycerol at 37 degrees C or 4 degrees C to the extender were studied by monitoring the post-thaw sperm longevity and acrosomal integrity during incubation at 39 degrees C. In the first part of this study, ejaculates from 13 dogs were pooled and divided into 4 aliquots, which were centrifuged and the sperm pellets rediluted with a Tris-fructose-citric acid extender containing 2, 4, 6 and 8% (v/v) glycerol, respectively. Progressive motility by subjective estimation, live:dead spermatozoa ratio using eosin-nigrosin staining, and acrosomal integrity using phase contrast microscopy were evaluated before processing and at 0, 0.5, 1, 2 and 4 hours post-thawing incubating the semen samples in the dark at 39 degrees C. The experiment was performed using seven replicates and it was found that sperm motility and acrosomal integrity were superior following the use of 8% glycerol in the extender. In Experiment 2, 13 ejaculates from the same dogs used in the first experiment were pooled and divided into 3 aliquots, and an 8% glycerol diluent was added at 37 degrees C and 4 degrees C after 1 h of cooling or at 4 degrees C after 2 h of cooling, respectively. After freezing and thawing the same parameters as studied in the first experiment were assessed. The experiment was performed in 7 replicates, and no difference was found between treatments.

[Renal venous thrombosis treatment in the newborn (author's transl)]

Based on the experience of 61 cases, the recommended treatment for R.V.T. in newborns and infants is described. A historical review of its management is made. Therapeutic evolution and exposition of conservative therapy, founded on the following points: Close control of the hydrosaline disorder, early peritoneal dialysis and heparinization is given. Eventually thrombectomy can be advisable when the thrombous invades the inferior vena cava. A decreasing incidence of R.V.T., after a good prophilaxis and an evident improvement of the survival of children with R.V.T. is confirmed.

[Renal venous thrombosis in infants of diabetic mothers (author's transl)]

Six cases of renal venous thrombosis in infants of diabetic mothers, out of a series of 61 infants under two months old affected of R.V.T. (9.8%), are reported. The clinical, metabolic and histopathological features of these cases are discussed, as well as the different etiological theories that exist in the literature. An etiopathogenic hypothesis that maintains a similarity with the theory that explains the origin of R.V.T. in classical cases, is suggested. Prophilactic attitudes in order to prevent R.V.T. by a control of diabetes in the pregnant and close control of the newborn in the 10 first days of life, are pointed out.