Impaired Cardiovagal Activity as a Link Between Hyperglycemia and Arterial Stiffness in Adults With Type 2 Diabetes Mellitus Among an Eastern Indian Population: A Cross-sectional Study

OBJECTIVES

Cardiac autonomic neuropathy (CAN) is one of the most common yet overlooked complications of type 2 diabetes mellitus (T2DM). Individuals with T2DM with CAN have a 5-fold higher rate of cardiovascular morbidity and mortality. The presence of CAN in T2DM could potentially lead to arterial stiffness. However, only sparse data are available suggesting any association between autonomic dysfunction and arterial stiffness in T2DM.

METHODS

We recruited 80 people with T2DM and 74 healthy controls for our study. Heart rate variability (HRV) testing was performed to assess autonomic function. Assessment of arterial stiffness was done by measuring the brachial pulse wave velocity (baPWV) and augmentation index (AI).

RESULTS

The time-domain parameters were significantly decreased (p<0.001) and frequency-domain parameters, such as total power and high-frequency band expressed as a normalized unit, were found to be significantly reduced in people with T2DM (p<0.001). Both baPWV and AI were significantly higher in people with T2DM compared with healthy controls (p<0.001). We observed a moderate correlation between standard deviation of normal to normal interval (SDNN) and baPWV (r=-0.437, p=0.002) and AI (r=-0.403, p=0.002). A multiple linear regression model showed an association between SDNN and arterial stiffness parameters, such as baPWV and AI, which were statistically significant (p<0.05) in a fully adjusted model that included the conventional risk factors for atherosclerosis.

CONCLUSIONS

Impaired cardiovagal activity is an independent risk factor for the development of arterial stiffness. Incorporation of HRV testing into the diabetes management protocol would have potential benefits for identifying individuals at high risk of developing cardiovascular events. Hence, preventive measures can be taken as early as possible to improve patient outcomes.

Beyond the Body: Using Photovoice to Explore Social Determinants of Diabetes With South Asian Adolescents in the Peel Region of Ontario, Canada

OBJECTIVES

The higher prevalence of diabetes in the South Asian (SA) population living in Canada spans across generations and is often associated with individual risk factors while undermining the social determinants of health (SDOH). There is a scarcity of studies on the perspectives of SA adolescents with a family history of type 2 diabetes mellitus (T2DM). Learning directly from these adolescents can fill a major gap by providing insight on how the SDOH contribute to disproportionate rates of T2DM in SA immigrant communities.

METHODS

In this study, we used Photovoice, which is a community-based participatory research (CBPR) method that involves the use of photography to visually capture the challenges of diabetes prevention from the perspective of those with lived experiences. A group of 15 SA youth were recruited from an adolescent diabetes education program in the Peel Region of Ontario. The youth discussed their images and accompanied written narratives during focus groups.

RESULTS

Four themes emerged from the thematic analysis of the photographs and participant narratives that influence the manifestation of T2DM in SA communities: 1) immigration and resettlement stressors; 2) food insecurity; 3) unhealthy school environments; and 4) academic pressures.

CONCLUSIONS

Findings suggest the need to address T2DM as a response to unjust conditions and environments rather than as an epidemic entrenched in genetic predisposition, culture, and poor lifestyle choices.

Working Together to Improve Type 2 Diabetes Care: A Participatory Design Project to Address Identified Needs of People With Diabetes and Their Health-care Professionals

OBJECTIVES

Diabetes care in Australia is often fragmented and provider-centred, resulting in suboptimal care. Innovative solutions are needed to bridge the evidence-practice gap, and technology can facilitate the redesign of type 2 diabetes care. We used Participatory Design to increase the chances of fulfilling stakeholders' needs. Using this method, we explored solutions aimed at redesigning diabetes care, focussing on the previously identified needs.

METHODS

The Participatory Design project was guided by stakeholders' contributions. Stakeholders of this project included people with type 2 diabetes, health-care professionals, technology developers, and researchers. Information uncovered at each step influenced the next: 1) identification of needs, 2) generation of solutions, and 3) testing of solutions. Here, we present steps 2 and 3. In step 2, we presented previously identified issues and elicited creative solutions. In step 3, we obtained stakeholders' feedback on the solutions from step 2, presented as care pathways.

RESULTS

Suggested solutions included a multidisciplinary wellness centre, a mobile app, increased access to education, improved care coordination, increased support for general practitioners, and a better funding model. The revised care pathways featured accessible community resources, a tailored self-management and educational app, a care coordinator, a digital dashboard, and specialized support for primary care to deal with complex cases.

CONCLUSIONS

Using a Participatory Design, we successfully identified multiple innovative solutions with the potential to improve person-centred and integrated type 2 diabetes care in Australia. These solutions will inform the implementation and evaluation of a redesigned care model by our team.

Relationship Between Plasma Growth Differentiation Factor 15 Levels and Complications of Type 2 Diabetes Mellitus: A Cross-sectional Study

OBJECTIVE

Our aim in this study was to identify the associations between growth differentiation factor 15 (GDF15) and type 2 diabetes mellitus (T2DM) complications in a community-based population in China.

METHODS

Based on a cross-sectional study registered in the National Basic Public Health Service for disease management of Changshu in China, a total of 1,689 T2DM patients were enrolled and tested further for plasma GDF15 levels. Macrovascular (cardiovascular disease and diabetic foot) and microvascular (diabetic kidney disease [DKD], diabetic retinopathy, and neuropathy) complications were evaluated. Logistic regression models were conducted to identify the associations of GDF15 with the risk of diabetes complications, and linear regression models were used to assess relationships between GDF15 and other clinical features.

RESULTS

Overall, 459 of the 1,689 T2DM patients (27.18%) had complications. GDF15 levels were significantly higher in patients with any type of complication compared with their counterparts. With each standard deviation increase of base 10 logarithms of GDF15 (lg-GDF15), the risk of overall complications increased by 1.17-fold (95% confidence interval [CI], 1.03 to 1.32). In contrast to macrovascular complications, associations of GDF15 with microvascular complications appeared to be stronger (adjusted odds ratio [OR], 1.24; 95% CI, 1.08 to 1.43), especially for DKD (adjusted OR, 1.51; 95% CI, 1.19 to 1.93). Subgroup analyses showed that the strength of association between GDF15 and complications varied by distinct age and T2DM duration subgroups. Patients with 2 or more types of complications had higher levels of GDF15 than those with fewer types of complications. Also, linear relationships were identified between GDF15 and several liver and kidney function indices.

CONCLUSION

Higher GDF15 levels were associated with T2DM complications, especially DKD. GDF15 may serve as a biomarker for monitoring the deterioration of T2DM.

Association of Atherogenic Index of Plasma With Retinopathy and Nephropathy in Adult Patients With Type 2 Diabetes Mellitus Aged > 18 Years

OBJECTIVES

In this study we assessed the atherogenic index of plasma (AIP) in relation to retinopathy and nephropathy in patients with type 2 diabetes mellitus (T2DM).

METHODS

In this cross-sectional study there were 4,358 inpatients with T2DM. The patients were divided into 4 groups: T2DM without complications (DM group), T2DM complicated with retinopathy alone and nephropathy alone (DR-alone and DN-alone groups) and T2DM complicated with both DR and DN (DRN group). AIP was calculated by the formula of log [triglyceride / high-density lipoprotein cholesterol].

RESULTS

AIPs in the DR-alone, DN-alone and DRN groups were significantly higher than in the DM group, with the DRN group having the highest AIP level. Moreover, patients with proliferative DR had higher AIPs than patients with nonproliferative DR in the DR-alone and DRN groups, and patients with macroalbuminuria had higher AIPs than patients with microalbuminuria in DN-alone and DRN groups. The highest AIP quartile group had the highest proportion of DRN compared with the other quartile groups. The DRN group had a maximal area under the curve (AUC) for AIP on receiver operating characteristic curve analysis (AUC=0.735). In the subgroup analyses by age, the AUCs of patients <65 years of age were all greater than those of patients ≥65 years of age. Logistic regression analysis showed that AIP had the highest correlation with age <65 years in individuals with DRN, and this association remained significant after adjustment with 3 models.

CONCLUSIONS

AIP is positively associated with both occurrence and severity of diabetic microvascular complications. It can predict their presence in T2DM, especially in those <65 years of age with DRN.

Diabesity in Adults With Type 2 Diabetes Mellitus: A Cross-sectional Study Exploring Self-care and Its Determinants

OBJECTIVES

The purpose of this study was to describe self-care maintenance, self-care monitoring, self-care management and self-care self-efficacy in adults with type 2 diabetes (T2DM) and body mass index (BMI)<30 kg/m2 and adults with T2DM and BMI≥30 kg/m2 ("diabesity"), and to identify their clinical and sociodemographic determinants. Self-care is one of the main treatments for adults with T2DM. However, self-care has been poorly described in people with diabesity, and differences in clinical and sociodemographic determinants of self-care between patients with diabesity and patients with T2DM and BMI<30 kg/m2 have, to our knowledge, not been assessed.

METHODS

A secondary analysis was performed of sociodemographic and clinical data using a multicentre, observational, cross-sectional design, wherein 540 adults diagnosed with T2DM were included in a consecutive and convenience sampling procedure.

RESULTS

Self-care maintenance and management were significantly lower among patients with diabesity (p<0.001 and p=0.025, respectively). Among patients with diabesity, low income (relative risk [RR]=3.27, p=0.01) and presence of diabetic neuropathy (RR=4.16; p=0.03) were strongly associated with inadequate self-care maintenance; completion of high school (RR=0.45; p=0.01), availability of a family caregiver (RR=0.52; p=0.04) and the use of insulin as the main treatment (RR=2.09; p=0.01) decreased the likelihood of inadequate self-care monitoring.

CONCLUSIONS

The unfavourable behavioural profile of patients with diabesity could be further worsened by their lower level of confidence in performing adequate self-care.

Serum Albumin Modifies the Effect of Peripheral Blood Monocytes on Severity of Diabetic Nephropathy in an Adult Population

BACKGROUND

Our aim in this study was to characterize clinical associations between peripheral blood immune populations and diabetic kidney disease (DKD) in patients with type 2 diabetes mellitus.

METHODS

We queried hospital records from an outpatient diabetes primary care clinic between 2018 and 2019 for clinical and laboratory data, including complete blood counts with differentials, serum albumin and globulin, glycated hemoglobin (A1C) and urine albumin-to-creatinine ratio. One hundred ninety-eight patients had complete cross-sectional data with temporally proximate complete blood counts and urine albumin-to-creatinine ratios. After univariable correlation assessment, we used a forward multivariable linear regression model to test the hypothesis that higher numbers of circulating innate immune populations would be associated with DKD, while accounting for known demographic, clinical and laboratory risk factors. We defined DKD as an albumin-to-creatinine ratio of >3 mg/mmol or an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m² from the Chronic Kidney Disease Epidemiology Collaboration.

RESULTS

Adjusted analyses demonstrated significant (p<0.01) associations between higher urine albumin:creatinine ratio and peripheral circulating monocytes, independent of other established significant risk factors, including blood pressure, A1C, age and sex. We also identified serum albumin as a potentially important modifying factor of albuminuric kidney disease, which interacts with monocytes in more advanced disease. In contrast, the variable most strongly predictive of eGFR was age.

CONCLUSIONS

Circulating monocytes and serum albumin are significantly associated with albuminuria, but not eGFR in DKD. These results support the potential role of the innate immune system in diabetic microvascular end-organ damage and urinary protein loss, and may be readily translatable clinical markers to incorporate into risk-assessment models for prognostication in diabetes.

Associations Between Obesity and Kidney Disease in Chinese Men and Women With Type 2 Diabetes: A Retrospective Cohort Study

BACKGROUND

Our aim in this study was to explore the risk factors for kidney disease in Chinese men and women with type 2 diabetes (T2D) and to clarify the relationship between obesity and the risk of chronic kidney disease (CKD).

METHODS

This retrospective study included 3,194 patients with T2D. Among 2,574 T2D patients without CKD at baseline, 753 with follow-up records of at least 12 months were included in the retrospective cohort. Logistic regression and Cox regression were used to evaluate the risk for CKD in men and women. A restricted cubic spline model was used to analyze the association of body mass index (BMI) and waist circumference (WC) with CKD risk.

RESULTS

Multivariate logistic regression analysis suggested that obesity was a risk factor for T2D with CKD in men but not in women. After a median follow-up period of 2.8 years, the incidence of CKD in men with obesity was significantly higher than that in men with obesity with T2D (p=0.039), but there was no statistically significant difference between women with obesity and women without obesity with T2D (p=0.825). In the restricted cubic spline model analysis, BMI and WC were associated with CKD risk in a nonlinear fashion in males and females. The risk of CKD was higher in males with a BMI of ≥29.5 kg/m² or a WC of ≥100 cm, whereas there was no difference observed in females.

CONCLUSIONS

Obesity was strongly related to T2D with CKD in men. Male diabetes patients with obesity, especially abdominal obesity, are more likely to develop CKD.

Association of Erythropoietin Gene Polymorphisms With Type 2 Diabetic Retinopathy in Adult Patients From Northern India

OBJECTIVES

Our aim in this study was to determine the association of erythropoietin (EPO) gene polymorphisms with diabetic retinopathy in type 2 diabetes patients from northern India.

METHODS

In this case-control study, we recruited 614 participants, consisting of 302 diabetic retinopathy cases and 312 individuals with confirmed type 2 diabetes without retinopathy as controls. EPO polymorphism analysis was performed in all participants using polymerase chain reaction and direct DNA sequence analysis.

RESULTS

The genotype distribution and allele frequency of the c.246+265G>A (rs507392) polymorphism in differed significantly (p<0.05) between the retinopathy and control groups. For the -1306C>A (rs1617640) polymorphism, genotype distribution among the 2 groups analyzed differed significantly (p=0.047), but the distribution of allele frequency was not found to be statistically significant (p=0.07). For the c.∗772G>T (rs551238) variant, genotype distribution did not differ significantly when comparing the 2 groups (p=0.062), but allele frequency distribution did differ significantly (p=0.045). For the polymorphisms analyzed, namely rs507392 and rs1617640, a statistically significant association with retinopathy was observed (dominant model: adjusted odds ratio [OR], 2.23; 95% confidence interval [CI], 1.36 to 3.35; p<0.01; codominant model: adjusted OR, 1.45; 95% CI, 1.00 to 2.09; p=0.048). However, no significant association between c.∗772G>T (rs551238) polymorphism and diabetic retinopathy was found.

CONCLUSIONS

Our findings show 2 polymorphisms (c.246+265G>A [rs507392] and -1306C>A [rs1617640]) in EPO to be risk factors for type 2 diabetic retinopathy in a northern Indian cohort. To our knowledge, this is the first report from India to demonstrate an association between EPO gene polymorphisms and retinopathy.

Transition of Youth With Type 2 Diabetes: Predictors of Health-Care Utilization After Transition to Adult Care From Population-Based Administrative Data

OBJECTIVES

In this study, we aimed to compare health-care visits pre- and posttransition from pediatric to adult care between youth with type 2 and type 1 diabetes.

METHODS

We linked a clinical database with the Manitoba Population Research Data Repository to compare health-care visits 2 years before and after transition, and investigated baseline factors influencing health-care engagement.

RESULTS

Youth with type 2 diabetes (n=196) vs type 1 diabetes (n=456) were more likely to be female (61% vs 44%), older at diagnosis (13.6 vs 10.6 years), live in northern regions and to be in the lowest socioeconomic status quartile (53% vs 5.4%). Seventy-six percent of youth with type 2 diabetes attended a follow-up visit within 2 years of transition compared to 97% of youth with type 1 diabetes. Youth with type 2 diabetes had higher rates of hospitalization pretransition (19.6 vs 11.6 admissions/100 patient years) and posttransition (24.7 vs 11.7 admissions/100 patient years) and fewer medical visits (pretransition: 2.4 vs 3.0 visits/person year [p<0.01]; posttransition: 1.6 vs 2.1 visits/person year [p<0.01]). Accounting for sex, geography, age, education, socioeconomic status and diabetes type, achieving 4 visits in 2 years posttransition was predicted by the number of visits pretransition (odds ratio, 1.35; 95% confidence interval, 1.23 to 1.49) and diabetes type (type 2 diabetes: odds ratio, 0.57; 95% confidence interval, 0.34 to 0.98).

CONCLUSIONS

Youth with type 2 diabetes attend fewer medical follow-up visits pre- and posttransition to adult care compared to youth with type 1 diabetes. Focused, informed, specific transition planning is needed that addresses the unique characteristics of this population.

Comparison of Clinical and Social Characteristics of Canadian Youth Living With Type 1 and Type 2 Diabetes

OBJECTIVES

Our aim in this study was to describe the clinical and social characteristics of 2 Canadian cohorts of adolescents with diabetes.

METHODS

Participants from the Improving renal Complications in Adolescents with type 2 diabetes through REsearch (iCARE) study (n=322) and the Early Determinants of Cardio-Renal Disease in Youth With Type 1 Diabetes (n=199) study were compared.

RESULTS

Adolescents were 10 to 18 years of age (mean ± standard deviation: 14.8±2.4 years). The T2DM cohort had a shorter duration of diabetes. Both groups had glycated hemoglobin levels above target. The type 2 diabetes (T2D) cohort was comprised of predominantly Indigenous youth. The type 1 diabetes (T1D) cohort was 58.3% European/Caucasian, with a high proportion (41.7%) of visible minority groups (Afro-Caribbean, Asian/Pacific Islander, Hispanic). The prevalence of obesity, hypertension, left ventricular hypertrophy, albuminuria and hyperfiltration was higher in the T2D cohort. The T1D cohort was more socially and economically advantaged in all 4 dimensions of health inequality.

CONCLUSIONS

There are significant differences in clinical and social characteristics of adolescents with T2D and T1D in Canada. Both have inadequate glycemic control with evidence of onset and progression of diabetes-related complications.

Prospective Study of Skipping Meals to Lose Weight as a Predictor of Incident Type 2 Diabetes With Potential Modification by Cardiometabolic Risk Factors: The Canadian 1995 Nova Scotia Health Survey

BACKGROUND

Skipping meals is an increasingly common practice to lose weight among North American adults. However, the long-term effect of this practice on incident type 2 diabetes mellitus (T2DM) remains unknown. We assessed whether skipping meals to lose weight is associated with T2DM risk and whether this association is modified by cardiometabolic risk factors.

METHODS

Skipping meals to lose weight was assessed by questionnaire in 2,288 adults from the 1995 Nova Scotia Health Survey and was linked to administrative health databases to determine T2DM incidence in the following 23 years. Multivariable-adjusted Cox proportional hazards models estimated hazard ratios (aHRs) and 95% confidence intervals (CIs) for T2DM.

RESULTS

During follow up, 378 T2DM cases were diagnosed. Compared with participants who did not skip meals to lose weight, those who did (2.2%) had a 125% higher risk of T2DM (aHR, 2.25; 95% CI, 1.31 to 3.86). This association was no longer present after further adjustment for baseline body mass index (BMI) (aHR, 1.66; 95% CI, 0.96 to 2.85). Skipping meals to lose weight was associated with T2DM among participants who were men (n=1,135; aHR, 2.09; 95% CI, 1.09 to 4.02) or had a BMI <30 kg/m² (n=1,676; aHR, 2.64, 95% CI, 1.15 to 6.06), elevated cholesterol (n=1,146; aHR, 2.11; 95% CI, 1.06 to 4.22), high blood pressure (n=1,133; aHR, 2.10; 95% CI, 1.10 to 4.01) and restless sleep (n=1,186; aHR, 2.19; 95% CI, 1.13 to 4.25), but not among women, those with a BMI of ≥30 kg/m² and those without elevated cholesterol, high blood pressure or restless sleep.

CONCLUSIONS

Skipping meals to lose weight may be a predictive modifiable risk factor for developing T2DM over time, potentially working in connection with other T2DM risk factors.

Economic Evaluation of a New Polygenic Risk Score to Predict Nephropathy in Adult Patients With Type 2 Diabetes

OBJECTIVES

The current screening method for diabetic nephropathy (DN) is based on detection of albumin in the urine and decline of glomerular filtration rate. The latter usually occurs relatively late in the course of the disease. A polygenic risk score (PRS) was recently developed for early prediction of the risk for patients with type 2 diabetes (T2D) to develop DN. The aim of this study was to assess the economic impact of the implementation of the PRS for early prediction of DN in patients with T2D compared with usual screening methods in Canada.

METHODS

A cost-utility analysis was developed using a Markov model. Health states include pre-end-stage renal disease (ESRD), ESRD and death. Model efficacy parameters were based on prediction of outcome data by polygenic risk testing of the genotyped participants in the Action in Diabetes and Vascular Disease PreterAx and DiamicronN Controlled Evaluation trial. Analyses were conducted from Canadian health-care and societal perspectives. Deterministic and probabilistic sensitivity analyses were conducted to assess results robustness.

RESULTS

Over a lifetime horizon, the PRS was a dominant strategy, from both a health-care system and societal perspective. The PRS was less expensive and more efficacious in terms of quality-adjusted life-years compared with usual screening technics. Deterministic and probabilistic sensitivity analyses showed that results remained dominant in most simulations.

CONCLUSIONS

This economic evaluation demonstrates that the PRS is a dominant option compared with usual screening methods for the prevention of DN in patients with T2D. Adoption of the PRS would reduce costs saving but would also help prevent ESRD and improve patients' quality of life.

The Outcome of Structured Education in Adults With Type 2 Diabetes Mellitus and Substance Use Disorder: A Literature Review

OBJECTIVE

Structured diabetes education for patients is a cornerstone of therapy; it empowers the patients by giving them appropriate tools for the self-management of the illness. The objective of this work was to determine how substance use disorder influences the outcome of structured diabetes education in patients with type 2 diabetes mellitus, and whether patients with substance use disorder are less likely to benefit because of their addiction issues.

METHODS

Only clinical trials involving substance use, which were randomized, in the context of type 2 diabetes mellitus were included.

RESULTS

Literature was only available for alcohol use disorder, and there were no studies available on any other recreational substance use disorders and its effects on structured diabetes education. Out of 3 relevant studies, in the context of alcohol use disorder, 2 studies identified alcohol use by the patients as a limiting factor in receiving structured diabetes education. One study did not show any impact of alcohol on structured diabetes education.

CONCLUSIONS

More high-quality randomized controlled trials with better sample sizes are required to say with confidence if alcohol use affects the patient's ability to participate in structured educational programs for type 2 diabetes mellitus management.

A Systematic Review and Delphi Study to Ascertain Common Risk Factors for Type 2 Diabetes Mellitus and Dementia and Brain-Related Complications of Diabetes in Adults

OBJECTIVES

Both type 2 diabetes (T2DM) and dementia have multifactorial etiologies. Both are associated with aging and have well-recognized lifestyle, cardiovascular and psychosocial risk factors. However, uncertainty exists in the literature with regard to: 1) the potentially modifiable risk factors common to both dementia and T2DM, and 2) the risk of brain-related complications in those with established diabetes. In this study, we address this uncertainty and inform design of a survey questionnaire to assess knowledge about diabetes and brain health among at-risk groups.

METHODS

This investigation consisted of a mixed-methods approach, including a Delphi consensus study preceded by a systematic literature review. The review was conducted using MEDLINE, EMBASE and Cochrane Library databases. A 2-round online Delphi study, informed by the review, invited international experts to rate their agreement with proposed risk factors and complications.

RESULTS

Of 7,337 abstracts retrieved, 13 were included in the final review. Among 46 international experts invited to take part in the Delphi study, 14 (32%) responded. In the Delphi study, hypertension, obesity, physical inactivity and heavy alcohol consumption reached consensus as risk factors common to both T2DM and dementia. Proposed brain-related diabetes complications, depression and dementia were also identified.

CONCLUSIONS

Results revealed expert consensus and literature review agreement on a number of common modifiable risk factors for T2DM and dementia, as well as agreement on brain-related complications of diabetes. A number of other proposed shared risk factors did not reach consensus agreement, suggesting a need for more high-quality studies to add to the evidence base.

Cardiovascular Effects of Sodium-Glucose Cotransporter-2 Inhibitors in Adults With Type 2 Diabetes

Adults with type 2 diabetes mellitus can benefit from pharmacotherapies that lower their risk for cardiovascular disease. This review describes the salient findings from sodium-glucose cotransporter-2 (SGLT2) inhibitor cardiovascular outcome trials that serendipitously revealed the cardiorenal benefits of SGLT2 inhibitors in adults with type 2 diabetes mellitus who either have established cardiovascular disease or multiple cardiovascular risk factors. It also summarizes the findings from other phase 3 clinical studies that measured the cardiovascular effects of SGLT2 inhibitors and real-world evidence reports that compared the cardiovascular impact of SGLT2 inhibitors with other antihyperglycemic agents. The collective data indicate that SGLT2 inhibitors are pleiotropic agents that offer important cardiovascular, metabolic and renal benefits beyond glucose lowering with low incidences of hypoglycemia. Specifically, the placebo-controlled SGLT2 inhibitor cardiovascular outcome trials documented either fewer major adverse cardiac events (nonfatal myocardial infarction, nonfatal stroke and cardiovascular death) or a reduction in the composite endpoint of cardiovascular death or hospitalization for heart failure in participants with type 2 diabetes mellitus and established cardiovascular disease. Amongst those with type 2 diabetes mellitus who did not have established cardiovascular disease but did present with multiple risk factors, SGLT2 inhibitors lowered the combined endpoint of cardiovascular death or hospitalization for heart failure but had little impact on the occurrence of major adverse cardiac events. Ongoing clinical trials and subanalyses of the trials that have been reported should shed further light on the clinical benefits and utility of SGLT2 inhibitors.

Effectiveness of Genistein Supplementation on Metabolic Factors and Antioxidant Status in Postmenopausal Women With Type 2 Diabetes Mellitus

OBJECTIVES

The risk of type 2 diabetes mellitus (T2DM) increases in women after menopause. Genistein is known to modulate metabolic pathways. The aim of this study was to investigate the effects of genistein supplementation on metabolic parameters, oxidative stress and obesity values in postmenopausal women with T2DM.

METHODS

This randomized, double-blind, placebo-controlled clinical trial was conducted on 54 postmenopausal women 47 to 69 years of age with T2DM. The genistein group (n=28) was given 2 genistein capsules daily for 12 weeks. Each capsule contained 54 mg genistein. The placebo group (n=26) received 2 placebo capsules daily for the same period. Fasting blood samples, anthropometric measurements, dietary intakes and physical activity levels of subjects were collected at baseline and at the end of the trial. Data were analyzed by independent t test, paired t test and analysis of covariance.

RESULTS

Genistein supplementation significantly reduced serum levels of fasting blood glucose (FBS), glycated hemoglobin (A1C), serum triglyceride (TG) and malondialdehyde (MDA) and increased total antioxidant capacity (TAC) compared with the placebo group at the end of the study (p<0.05 for all). Serum high-density lipoprotein cholesterol and quantitative insulin sensitivity check index significantly increased within the genistein group. Changes in anthropometric indexes and other variables were not significant in any of the groups.

CONCLUSIONS

Genistein administration improved FBS, A1C, serum TG, TAC and MDA in postmenopausal women with T2DM and may be useful in the control of metabolic status and oxidative stress in these subjects.

Update on Cardiovascular Safety of Incretin-Based Therapy in Adults With Type 2 Diabetes Mellitus: A Meta-Analysis of Cardiovascular Outcome Trials

OBJECTIVES

The authors of 2 large randomized trials have recently published their findings related to the effects of a glucagon-like peptide 1 receptor agonist (GLP-1RA) (the HARMONY trial) and a dipeptidyl peptidase 4 (DPP-4) inhibitor (the CARMELINA trial) on cardiovascular (CV) outcomes in patients with type 2 diabetes mellitus. In light of these new data, we conducted a systematic review and meta-analysis of GLP-1RAs and DPP-4 inhibitors in CV outcome trials to assess their CV safety in patients with type 2 diabetes.

METHODS

We conducted a comprehensive literature search in the Embase and MEDLINE databases to identify trials involving GLP-1RAs and DPP-4 inhibitors with major CV-related outcomes reported, including major adverse CV events, CV death, myocardial infarction, stroke, death from any cause and hospitalization because of heart failure. A total of 9 CV outcome trials were included. Odds ratios and 95% confidence intervals were calculated based on the Mantel-Haenszel method.

RESULTS

Relative to placebo, GLP-1RAs were associated with a statistically significant reduction in the odds of major adverse CV events (13%), CV death (12%), death from any cause (11%) and stroke (13%). DPP-4 inhibitors were comparable to placebo for all outcomes. Moreover, DPP-4 inhibitors were associated with a nonsignificant 5% increase in the odds of hospitalization from heart failure compared to placebo.

CONCLUSIONS

This meta-analysis demonstrated that GLP-1RAs were associated with a significant reduction in major adverse CV events, CV death, stroke and death from any cause, while DPP-4 inhibitors were comparable to placebo for all CV outcomes, including hospitalizations for heart failure.

Combined treatment with interleukin-1 and tumor necrosis factor-alpha antagonists improve type 2 diabetes in rats

In the present study, combined treatment with etanercept and anakinra were tested in the streptozotocin-induced diabetic rats. Forty male Wistar albino rats were divided into 5 groups: healthy control (HC), diabetic control (DC), diabetic + anakinra (DAT), diabetic + etanercept (DET), and diabetic + etanercept + anakinra (DEAT). HC and DC groups received subcutaneous (s.c.) injection with a saline solution, while DAT and DET groups received anakinra (10 mg/kg per day, s.c.) or etanercept (10 mg/kg, twice a week, s.c.), and DEAT rats received both anakinra and etanercept treatments for 21 days after diabetes has developed. Anakinra and etanercept treatments significantly increased insulin and homeostatic model assessment β-cell function levels and decreased glucose levels compared to the DC group as single (DAT and DET) and combined treatments (DEAT). The thiobarbituric acid reactive substances level was significantly decreased in DAT group. The combine use of etanercept and anakinra can improve insulin and blood glucose in type 2 diabetic rats. The combined treatment of anakinra and etanercept together was more effective than single treatment and might have a potential new treatment strategy and to reduce the mortality and morbidity resulting from diabetes.

Serum Vitamin D and Its Upregulated Protein, Thioredoxin Interacting Protein, Are Associated With Beta-Cell Dysfunction in Adult Patients With Type 1 and Type 2 Diabetes

OBJECTIVES

Diabetes mellitus is characterized by either complete deficiency of insulin secretion, as in type 1 diabetes, or decompensation of the pancreatic beta cells in type 2 diabetes. Both vitamin D (vitD) and thioredoxin interacting protein (TXNIP) have been shown to be involved in beta-cell dysfunction. Therefore, this study was designed to examine vitD and TXNIP serum levels in patients with diabetes and to correlate these levels with beta-cell function markers in both types of diabetes.

METHODS

The routine biochemical parameters and the serum levels of vitD and TXNIP were measured in 20 patients with type 1 diabetes and 20 patients with type 2 diabetes. The levels were then compared to those of 15 healthy control volunteers. Insulin, C-peptide and proinsulin (PI), vitD and TXNIP were measured by ELISA. Beta-cell dysfunction was assessed by homeostatic model assessment (HOMA-beta), proinsulin-to-C-peptide (PI/C) and proinsulin-to-insulin (PI/I) ratios. Correlations among various parameters were studied.

RESULTS

Patients with type 1 diabetes had significantly lower HOMA-beta, vitD and TXNIP levels; however, they had higher PI/C levels than the control group. Meanwhile, patients with type 2 diabetes had significantly higher C-peptide, proinsulin, PI/C, HOMA-insulin resistance (HOMA-IR) and lower HOMA-beta and vitD levels, with no significant difference in TXNIP levels as compared to the control group. In addition, vitD was significantly correlated positively with HOMA-beta and TXNIP and negatively with PI, PI/C, PI/I and HOMA-IR. TXNIP correlated positively with HOMA-beta and negatively with PI/C.

CONCLUSIONS

Our data showed that vitD and TXNIP were associated with different beta-cell dysfunction markers, indicating their potential abilities to predict the beta-cell status in people with diabetes.

New-onset type 2 diabetes mellitus among patients receiving HIV care at Newlands Clinic, Harare, Zimbabwe: retrospective cohort analysis

OBJECTIVE

To assess the incidence and associated factors of Type 2 Diabetes Mellitus (T2DM) among people living with HIV (PLHIV) in Zimbabwe.

METHODS

We analysed data of all HIV-infected patients older than 16 years who attended Newlands Clinic between March 1, 2004 and April 29, 2015. The clinic considers patients whose random blood sugar is higher than 11.1 mmol/l and which is confirmed by a fasting blood sugar higher than 7.0 mmol/l to have T2DM. T2DM is also diagnosed in symptomatic patients who have a RBS >11.0 mmol/l. Risk factors for developing T2DM were identified using Cox proportional hazard models adjusted for confounding. Missing baseline BMI data were multiply imputed. Results are presented as adjusted hazard ratios (aHR) with 95% confidence intervals (95% CI).

RESULTS

Data for 4,110 participants were included: 67.2% were women; median age was 37 (IQR: 31-43) years. Median baseline CD4 count was 197 (IQR: 95-337) cells/mm3 . The proportion of participants with hypertension at baseline was 15.5% (n=638). Over a median follow-up time of 4.7 (IQR: 2.1-7.2) years, 57 patients developed T2DM; the overall incidence rate was 2.8 (95% CI: 2.1-3.6) per 1000 person-years of follow-up. Exposure to PIs was associated with T2DM (HR: 1.80, 95% CI: 1.04-3.09). In the multivariable analysis, obesity (BMI>30 kg/m2 ) (aHR=2.26, 95% CI: 1.17-4.36), age >40 years (aHR=2.16, 95% CI: 1.22-3.83) and male gender, (aHR=2.13, 95% CI: 1.22-3.72) were independently associated with the risk of T2DM. HIV-related factors (baseline CD4 cell count and baseline WHO clinical stage) were not independent risk factors for developing T2DM.

CONCLUSION

Although the incidence of T2DM in this HIV cohort was lower than that has been observed in others, our results show that risk factors for developing T2DM among HIV-infected people are similar to those of the general population. HIV-infected patients in sub-Saharan Africa need a comprehensive approach to care that includes better health services for prevention, early detection and treatment of chronic diseases especially among the elderly and obese.

Diabetes Distress, Depression and Glycemic Control in a Canadian-Based Specialty Care Setting

OBJECTIVES

The objectives of this study were to determine rates of diabetes distress and depression in patients with type 2 diabetes in a tertiary care setting, to examine the relationship among glycemic control, diabetes distress and depression, and to identify predictors of diabetes distress and depression on the basis of demographic and clinical characteristics.

METHODS

We recruited 148 adults with type 2 diabetes who were presenting to a specialty diabetes clinic in Vancouver, British Columbia, Canada. Participants completed a questionnaire measuring diabetes distress, depressive symptoms and demographic backgrounds. The Diabetes Distress Scale was used to assess overall distress as well as 4 distinct distress dimensions, including emotional burden, physician-related, regimen-related and interpersonal distress. The Personal Health Questionnaire-9 was used to assess depressive symptoms. Glycated hemoglobin (A1C) data were also collected.

RESULTS

The prevalence of diabetes distress and depression was 39% and 12% in our population, respectively. A1C levels emerged as a significant predictor of emotional burden (p=0.03) and regimen-related distress (p=0.01); higher A1C levels were associated with increased distress regarding emotional functioning and regimen adherence. A1C levels (p=0.02) and education levels (p=0.03) emerged as predictors of physician-related distress, with higher A1C levels associated with decreased distress regarding confidence in physicians.

CONCLUSIONS

Our findings reveal that the rate of diabetes distress for patients in a tertiary care setting is high. Furthermore, diabetes distress, particularly emotion- and self-care-related distress, plays a significant role in glycemic control, whereas depression does not. Routine screening for diabetes distress as part of an initial specialty clinic evaluation should be explored.

The Short Version of the Activities-Specific Balance Confidence Scale for Older Adults with Diabetes-Convergent, Discriminant and Concurrent Validity: A Pilot Study

OBJECTIVES

The short version of the Activities-Specific Balance Confidence Scale (ABC-6) is advantageous in busy clinical or research settings because it can be administered in less time than the original 16-item Activities-Specific Balance Confidence Scale (ABC-16). This pilot study examined the convergent, discriminant and concurrent validity of the ABC-6 in older adults with diabetes mellitus with and without diagnosed diabetic peripheral neuropathy (DPN).

METHODS

Thirty older adults (aged ≥65) were age- and sex-matched in 3 groups: 10 with diabetes (DM group), 10 with diagnosed DPN (DPN group) and 10 without diabetes (no-DM group). Balance confidence was quantified by the ABC-16, which includes the ABC-6. Potential correlates were evaluated in physical and psychological domains.

RESULTS

The ABC-6 and ABC-16 balance confidence scores were strongly correlated (r=0.969; p<0.001; convergent validity). The ABC-6 revealed significant differences in balance confidence between the no-DM and the DM groups (p<0.001; discriminant validity), whereas the ABC-16 did not (p>0.05). The ABC-6 was moderately, but significantly, correlated with physical activity level (r=0.528; p=0.017), mobility (r=-0.520; p=0.027), balance (r=0.633; p=0.003), and depressive symptoms (r=-0.515; p=0.020) in the DM study groups (concurrent validity).

CONCLUSIONS

The ABC-6 and ABC-16 had excellent convergent validity, and both ABC scales had similar concurrent validity. However, the ABC-6 was more sensitive in detecting subtle differences in balance confidence in older adults with diabetes without diagnosed DPN than the ABC-16. Overall, this pilot study provided evidence of the validity of the ABC-6 in older adults with diabetes. Further exploration involving a larger sample size is recommended to confirm these findings.

Assessing Whether the Association Between Sleep Apnea and Diabetes is Bidirectional

OBJECTIVES

To determine whether there is a bidirectional association between sleep apnea and diabetes mellitus.

METHODS

We conducted longitudinal analyses of a population-based cohort over 12 years using Taiwan's national universal health insurance database. In analysis I, we included 102 355 individuals without type 2 diabetes mellitus at baseline and estimated the hazard ratio of incident diagnosis of type 2 diabetes mellitus for patients with and those without sleep apnea. In analysis II, we included 258 053 participants without sleep apnea at baseline and calculated the hazard ratio of developing sleep apnea for patients with and those without type 2 diabetes.

RESULTS

In analysis I, the incidence rates of type 2 diabetes were 17.7 and 11.1 per 1000 person-years for patients with and those without sleep apnea, respectively. Patients with sleep apnea had an increased risk for diabetes (adjusted hazard ratio [aHR] = 1.33; 95% confidence interval [CI], 1.22 to 1.46). In analysis II, the risk for sleep apnea with diabetes was not statistically significant (aHR = 1.06; 95% CI, 0.98 to 1.16). These associations in both analyses did not substantively change after accounting for various latent periods.

CONCLUSIONS

Baseline sleep apnea is associated with incident type 2 diabetes; however, the presence of type 2 diabetes cannot predict the development of sleep apnea.

A Longitudinal Investigation of Anxiety and Depressive Symptomatology and Exercise Behaviour Among Adults With Type 2 Diabetes Mellitus

OBJECTIVES

Evidence suggests that symptoms of depression and anxiety predict lower exercise behaviour and, inversely, that less exercise predicts higher symptomatology. The present longitudinal study examined this reciprocal association in adults with type 2 diabetes mellitus. We predicted that symptoms of anxiety or depression would intensify over time as a consequence of lower exercise frequency and, similarly, that exercise frequency would decrease as a consequence of greater symptoms of anxiety or depression.

METHODS

We studied 1691 adults with type 2 diabetes who provided baseline measures in 2011 and 2 subsequent annual assessments (Follow-up 1 and Follow-up 2). Symptoms of depression and anxiety were measured using the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7, respectively. A single item assessed exercise frequency in the past month (in days).

RESULTS

Separate 3-wave cross-lagged path models for symptoms of anxiety and depression tested the reciprocal associations. Contrary to our hypotheses, the reciprocal associations were not supported and, by extension, the predicted secondary associations were not tested. In sum, only depressive symptoms negatively predicted subsequent exercise frequency (Follow-up 1 and Follow-up 2).

CONCLUSIONS

Symptoms of depression were prospectively associated with lower exercise frequency, which is consistent with evidence from population-based studies that identify depressive symptoms as a barrier to exercise participation.

Dietary Patterns and Type 2 Diabetes Mellitus in a First Nations Community

BACKGROUND

Type 2 diabetes mellitus is a growing concern worldwide, particularly in Indigenous communities, which have undergone a marked nutrition transition characterized by reduced intakes of traditional foods and increased intakes of market foods. Few studies have assessed the relationships between differing dietary patterns and risk for type 2 diabetes in Indigenous communities in Canada. The objective of the study was to characterize dietary patterns using factor analysis (FA) and to relate these patterns to the incidence of type 2 diabetes after 10 years of follow up in a First Nations community in Ontario, Canada.

METHODS

We conducted a prospective analysis of 492 participants in the SLHDP who did not have diabetes at baseline (1993 to 1995) and were followed for 10 years. A food-frequency questionnaire was administered, and FA was used to identify patterns of food consumption. Multivariate logistic regression analyses determined associations of food patterns with incident type 2 diabetes, adjusting for sociodemographic and lifestyle confounders.

RESULTS

At follow up, 86 participants had developed incident type 2 diabetes. FA revealed 3 prominent dietary patterns: Balanced Market Foods, Beef and Processed Foods and Traditional Foods. After adjustment for age, sex, waist circumference, interleukin-6 and adiponectin, the Beef and Processed Foods pattern was associated with increased risk for incident type 2 diabetes (OR=1.38; 95% CI 1.02, 1.86). In contrast, the Balanced Market Foods and Traditional Foods Patterns were not significantly associated with type 2 diabetes.

CONCLUSIONS

Dietary interventions should encourage reduced consumption of unhealthful market foods, in combination with improvements in local food environments so as to increase access to healthful foods and reduce food insecurity in Indigenous communities.

Efficacy and Cardiovascular Safety of Linagliptin as an Add-On to Insulin in Type 2 Diabetes: A Pooled Comprehensive Post Hoc Analysis

OBJECTIVE

With the expanding armamentarium of noninsulin therapies for type 2 diabetes mellitus, the use of insulin with various oral agents is becoming more common. In this study, we assessed the efficacy and cardiovascular (CV) safety of the dipeptidyl peptidase-4 inhibitor linagliptin as add-on to insulin in patients with type 2 diabetes.

METHODS

In this post hoc analysis, data for patients receiving basal or basal-bolus insulin were pooled from 4 randomized, double-blind, phase 3 clinical trials of linagliptin 5 mg once daily or placebo given as add-on to background glucose-lowering treatment. Changes in glycated hemoglobin (A1C) and CV risk factors were assessed from baseline to end of trial. The primary CV endpoint was a composite of CV death, nonfatal myocardial infarction, nonfatal stroke and hospitalization due to unstable angina.

RESULTS

The number of patients receiving basal or basal-bolus insulin as background therapy was 1613 (linagliptin: n=811; placebo: n=802). The placebo-adjusted mean (SE) change from baseline in A1C was -0.41 (0.05)% (95% CI -0.50, -0.32; p<0.0001). Treatment with linagliptin provided a relative weight benefit and reduced insulin requirements without affecting blood pressure, heart rate or lipids. The incidence of hypoglycemia with linagliptin was similar to that for placebo (38.7% vs. 39.4%, respectively). The hazard ratio (HR) for the primary endpoint showed that treatment with linagliptin was not associated with an increased CV risk (HR 1.07 [95% CI 0.62, 1.85]).

CONCLUSIONS

Linagliptin, when added to ongoing insulin treatment in patients with type 2 diabetes, improves glycemic control and has a neutral impact on major adverse CV events.

Influence of maternal overnutrition and gestational diabetes on the programming of metabolic health outcomes in the offspring: experimental evidence

The incidence of obesity and type 2 diabetes mellitus have risen across the world during the past few decades and has also reached an alarming level among children. In addition, women are currently more likely than ever to enter pregnancy obese. As a result, the incidence of gestational diabetes mellitus is also on the rise. While diet and lifestyle contribute to these trends, population health data show that maternal obesity and diabetes during pregnancy during critical stages of development are major factors that contribute to the development of chronic disease in adolescent and adult offspring. Fetal programming of metabolic function, through physiological and (or) epigenetic mechanisms, may also have an intergenerational effect, and as a result may perpetuate metabolic disorders in the next generation. In this review, we summarize the existing literature that characterizes how maternal obesity and gestational diabetes mellitus contribute to metabolic and cardiovascular disorders in the offspring. In particular, we focus on animal studies that investigate the molecular mechanisms that are programmed by the gestational environment and lead to disease phenotypes in the offspring. We also review interventional studies that prevent disease with a developmental origin in the offspring.

Depressive Symptoms, Family Functioning and Quality of Life in Chinese Patients with Type 2 Diabetes

OBJECTIVE

Patients with type 2 diabetes mellitus often have depression or depressive symptoms, impaired family functioning and poor quality of life. This study aimed to examine relationships among psychological variables, including depressive symptoms, family functioning and quality of life, for Chinese patients with type 2 diabetes and to explore the influencing factors on quality of life for these patients.

METHOD

In this cross-sectional study, 257 patients with type 2 diabetes and 259 nondiabetic community controls completed the Beck Depression Inventory, the Family Assessment Device, and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form.

RESULTS

Patients with type 2 diabetes reported significant family impairment in the dimension of affective involvement compared with nondiabetic community controls (p<0.05). Mean Family Assessment Device scores were negatively associated with quality of life scores among patients with type 2 diabetes. Age, depressive symptoms, duration of diabetes, communication, affective involvement and behavioural control were associated with quality of life in patients with type 2 diabetes.

CONCLUSIONS

The results indicate that having type 2 diabetes was associated with some difficulties with family functioning and that poor family functioning was associated with a poorer quality of life. Additional factors, including older age, depressive symptoms, duration of diabetes, and some dimensions of family functioning, were found to be associated with quality of life in Chinese individuals with type 2 diabetes.

Use of Diabetes Registry Data for Comparing Indices of Diabetes Management: A Comparison of 2 Urban Sites in Canada and Colombia

OBJECTIVES

To demonstrate the use of a multinational diabetes registry for comparing indices of diabetes management among countries with differing levels of income, healthcare systems and ethnic backgrounds.

METHODS

A cross-sectional study was conducted among 1742 people with type 2 diabetes attending diabetes clinics in London, Ontario, Canada, and Bogota, Colombia. The data were extracted from the Global Registry and Surveillance System for Diabetes (GRAND).

RESULTS

Canadian patients were diagnosed with diabetes at significantly younger ages than Colombian patients (49 years and 53 years, respectively) and were heavier (body mass indices of 33 and 28, respectively). The Colombian patient population had significantly higher mean glycated hemoglobin (A1C) levels (9.4% vs. 8.6%) and fewer patients (22% vs. 26%) at the glycemic target (A1C <7.0%) than Canadian patients. In Colombia, 1 or more diabetes-related complications were present in 51% of the study population compared with 37% in Canada. Newly diagnosed Colombians had higher mean A1C levels (9.1% vs. 8.7%) and low-density lipoprotein-C levels (3.3 mmol/L vs. 2.5 mmol/L) than did newly diagnosed Canadians.

CONCLUSIONS

A multination diabetes registry collecting standardized data facilitates transnational comparison of diabetes clinical parameters for the purpose of identifying potential gaps in care.

Effectiveness of angiotensin II receptor antagonists in a cohort of Dutch patients with type 2 diabetes mellitus (ZODIAC-14)

OBJECTIVE

There is limited evidence with respect to the between-group effects of various angiotensin receptor blockers (ARBs) on blood pressure and albuminuria in patients with type 2 diabetes mellitus. Therefore, we aimed to investigate the effects of differing ARBs on systolic blood pressure (SBP) and the albumin-creatinine ratio after 1 year in a large cohort of patients with type 2 diabetes mellitus.

METHODS

In 2007, 24 940 primary care patients with type 2 diabetes mellitus participated in the Zwolle Outpatient Diabetes project Integrating Available Care (ZODIAC) study, a prospective observational cohort study. Patients were included in the current study if they were prescribed an ARB in 2007 and if 1-year follow-up data were available. The final study population comprised 3610 patients. Multivariate mixed-model analyses were performed to estimate effects of the various ARBs on SBP and albuminuria. Stratified subgroup analyses were performed according to baseline hypertension and albuminuria.

RESULTS

SBP decreased in all groups, the largest decrease being observed in the group receiving telmisartan. No significant or relevant changes over time were observed among groups for SBP and albuminuria. In the subgroup (n=1225) of normotensive patients, telmisartan was associated with a larger decrease in SBP after 1 year compared to other ARBs, without different effects on the albumin-creatinine ratio.

CONCLUSIONS

We observed no differences in effects on SBP and the albumin-creatinine ratio among differing ARBs in patients with type 2 diabetes mellitus.

Cardiovascular complications of type 2 diabetes in youth

The prevalence of type 2 diabetes mellitus (T2DM) in youth has increased dramatically over the past decades. The literature also suggests that the progression from an impaired glucose tolerance state to established T2DM is more rapid in youth, compared to adults. The presence of significant cardiovascular complications in youth with T2DM, including cardiac, macrovascular, and microvascular remodeling, is another major issue in this younger cohort and poses a significant threat to the healthcare system. However, this issue is only now emerging as a major public health concern, with few data to support optimal treatment targets and strategies to reduce cardiovascular disease (CVD) risk in youth with T2DM. Accordingly, the purpose of this minireview is to better understand the cardiovascular complications in youth with T2DM. We briefly describe the pathophysiology from youth studies, including oxidative stress, inflammation, renin-angiotensin aldosterone system, and epigenetics, which link T2DM and CVD. We also describe the literature concerning the early signs of CVD in youth and potential treatment options to reduce cardiovascular risk.

Berberine as a therapy for type 2 diabetes and its complications: From mechanism of action to clinical studies

The incidence of type 2 diabetes is increasing rapidly worldwide, and the development of novel anti-diabetic drugs is emerging. However, most anti-diabetic drugs cannot be used in patients with hepatic dysfunction, renal disease, and heart disease, which makes pharmacological therapy of type 2 diabetes complicated. Despite continued introduction of novel agents, the search for an ideal drug that is useful as both a hypoglycemic agent and to reduce diabetes-related complications remains elusive. Berberine is an isoquinoline alkaloid extract that has shown promise as a hypoglycemic agent in the management of diabetes in animal and human studies. Mechanistic studies have revealed beneficial effects of berberine on diabetes-related complications. Although there have been few clinical reports of the anti-diabetic effects of berberine, little documentation of adverse effects in humans positions it as a potential candidate drug to treat type 2 diabetes. In the present review, the anti-diabetic mechanism of berberine, its effect on diabetes-related complications, and its recent use in human clinical studies is highlighted. In addition, we summarize the different treatments for type 2 diabetes in adults and children.

Visfatin -948G/T and resistin -420C/G polymorphisms in Egyptian type 2 diabetic patients with and without cardiovascular diseases

Diabetes mellitus is one of the main threats to human health in the 21st century. Visfatin/Nampt and resistin are novel adipokines that have been implicated in the pathogenesis of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) complication. Several genetic studies have shown inconsistent results regarding association of visfatin/Nampt gene (NAMPT) and resistin gene (RETN) polymorphisms with T2DM and CVD complications. Here, we investigate whether NAMPT -948G/T and RETN -420C/G polymorphisms are associated with T2DM, its CVD complications, and serum adipokines levels in 90 Egyptian diabetic patients (44 without CVD and 46 with CVD) along with 60 healthy control subjects. Higher frequencies of NAMPT -948G/G and RETN -420G/G were observed among T2DM patients compared with controls. Furthermore, the frequencies of these genotypes were significantly higher in T2DM patients with CVD than those without CVD. Both NAMPT -948G/G and RETN -420G/G genotypes and G alleles were significantly associated with T2DM and CVD in Egyptian diabetic patients. Moreover, serum visfatin/Nampt and resistin levels were markedly elevated in T2DM patients, with the highest values observed in G/G genotypes among T2DM patients with CVD. In addition, positive correlations were observed between plasma adipokines levels and CVD risk factors. In conclusion, our data suggests that genetic variations in NAMPT -948G/T and RETN -420C/G may contribute to the disposition for T2DM and its CVD complications in Egyptian patients. However, further studies with greater sample size should be performed to verify these results.

Benefits of modest weight loss on the management of type 2 diabetes mellitus

The epidemic of overweight and obesity is a major driver of the growing prevalence of type 2 diabetes mellitus globally. The risk of type 2 diabetes increases exponentially as body mass index rises above 25 kg/m(2). Obesity currently costs the Canadian economy approximately $7.1 billion annually whereas per capita health care cost for individuals with diabetes are 3 to 4 times that for persons without the disease. Each kilogram of weight lost through health behaviour changes in people with impaired glucose tolerance is associated with a relative diabetes risk reduction of 16%. As 80% to 90% of people with type 2 diabetes are overweight or obese, and adiposity worsens the metabolic and physiologic abnormalities associated with type 2 diabetes, weight loss is recommended as the cornerstone management measure. A modest weight loss of 5% to 10% is an achievable and realistic goal for preventing type 2 diabetes in susceptible individuals and improving glycemic and metabolic control in people with type 2 diabetes. When health behaviour modification fails to achieve glycemic and metabolic goal targets, priority should be given to antihyperglycemic agents that are associated with weight loss or weight neutrality. Every pound of body fat loss matters and every kilogram counts in the management of type 2 diabetes.