Predictors of Overweight During Childhood in Offspring of Parents With Type 1 Diabetes

OBJECTIVE

To study which perinatal factors affect the risk of childhood overweight in offspring with a first-degree relative (FDR) with type 1 diabetes and to determine whether maternal diabetes is an independent contributor to overweight risk.

RESEARCH DESIGN AND METHODS

Data on a child''s weight and height were collected at age 2, 5, and 8 years from 1,214 children participating in the prospective BABYDIAB study. All children had an FDR with type 1 diabetes, including 783 whose mothers had type 1 diabetes. Overweight was defined as BMI percentile ≥90. Data on birth size, breast-feeding, maternal age, and smoking during pregnancy were collected by questionnaires. Risk estimates were calculated by logistic regression analyses.

RESULTS

Breastfeeding duration and birth size both contributed significantly to overweight risk at all age intervals. Full breast-feeding >4 months or any breast-feeding >6 months reduced risk of overweight (aged 8 years: odds ratio 0.3 [95% CI 0.2–0.7], P = 0.004; and 0.3 [0.1–0.6], P = 0.001). Large-for-gestational-age status increased risk of overweight (aged 8 years: 2.4 [1.4–4.3], P = 0.002). Importantly, no evidence was found for an independent contribution of maternal type 1 diabetes to childhood overweight.

CONCLUSIONS

Our findings indicate that maternal type 1 diabetes is not an independent risk factor for overweight during childhood in offspring of type 1 diabetic mothers but that factors associated with maternal type 1 diabetes, such as short breast-feeding duration and high birth size, predispose children to overweight during childhood.The increasing prevalence of overweight and obesity in children is a major health problem, as obesity-related medical conditions affect almost every organ system in the body (1). Gestational and perinatal factors have been shown to influence weight in childhood. Among these, maternal diabetes during pregnancy has been associated with an increased prevalence of childhood obesity (2–6). This has led to the hypothesis that in utero exposure to increased concentrations of glucose and insulin leads to increased risk of obesity and insulin resistance later in life (2). Previous studies (3–5) have been small or retrospective in design. Moreover, it is not clear whether maternal diabetes as such, or factors such as birth size and breast-feeding, which are affected by maternal diabetes, modify obesity risk.Here, we have examined weight and BMI during childhood in a cohort of 1,214 children whose mothers or fathers have type 1 diabetes and who were followed from age ≤3 months. The aim of the analysis was to determine which gestational and perinatal factors may increase the risk of childhood obesity and whether maternal diabetes is an independent contributor to obesity risk.     

Insomnia With Objective Short Sleep Duration Is Associated With Type 2 Diabetes: A population-based study

OBJECTIVE

We examined the joint effects of insomnia and objective short sleep duration, the combination of which is associated with higher morbidity, on diabetes risk.

RESEARCH DESIGN AND METHODS

A total of 1,741 men and women randomly selected from Central Pennsylvania were studied in the sleep laboratory. Insomnia was defined by a complaint of insomnia with duration of ≥1 year, whereas poor sleep was defined as a complaint of difficulty falling asleep, staying asleep, or early final awakening. Polysomnographic sleep duration was classified into three categories: ≥6 h of sleep (top 50% of the sample); 5–6 h (approximately third quartile of the sample); and ≤5 h (approximately the bottom quartile of the sample). Diabetes was defined either based on a fasting blood glucose >126 mg/dl or use of medication. In the logistic regression model, we simultaneously adjusted for age, race, sex, BMI, smoking, alcohol use, depression, sleep-disordered breathing, and periodic limb movement.

RESULTS

Chronic insomnia but not poor sleep was associated with a higher risk for diabetes. Compared with the normal sleeping and ≥6 h sleep duration group, the highest risk of diabetes was in individuals with insomnia and ≤5 h sleep duration group (odds ratio [95% CI] 2.95 [1.2–7.0]) and in insomniacs who slept 5–6 h (2.07 [0.68–6.4]).

CONCLUSIONS

Insomnia with short sleep duration is associated with increased odds of diabetes. Objective sleep duration may predict cardiometabolic morbidity of chronic insomnia, the medical impact of which has been underestimated.Many studies have established that insomnia, the most common sleep disorder, is highly comorbid with psychiatric disorders and is a risk factor for the development of depression, anxiety, and suicide (1,2). In contrast with sleep-disordered breathing (SDB), the second most common sleep disorder, chronic insomnia has not been associated with significant medical morbidity, e.g., cardiovascular disorders (3,4).Recently, we demonstrated that insomnia with objective short sleep duration is associated with a high risk for hypertension (5). These data suggest that objective sleep measures in insomnia provide an index of the severity of the disorder and that the more severe form of insomnia is most likely associated with morbidity and possibly mortality. This hypothesis is further supported by physiological studies, which demonstrated that activation of the hypothalamic-pituitary-adrenal (HPA) axis and autonomic system, including increased heart rate, 24-h metabolic rate, and impaired heart rate variability, is present in insomniacs who meet both subjective and objective polysomnographic criteria (6–11). Given the association of the HPA axis and sympathetic system activation with the pathogenesis of metabolic disorders, including diabetes (12), we hypothesized that insomnia with objective short sleep duration will be associated with type 2 diabetes.Previous studies have shown that sleep disturbances or complaints are associated with increased incidence of type 2 diabetes (13–16). However, in these studies, the presence of sleep disturbances was based only on a subjective questionnaire and did not control for obstructive sleep apnea, a sleep disorder whose association with diabetes and insulin resistance is well established (12). Thus, it is not known whether insomnia per se is associated with an increased risk for diabetes.To test this hypothesis, we examined the joint effects of the complaints of chronic insomnia and poor sleep (a milder form of insomnia) and objective sleep duration on the prevalence of diabetes in a large cross-sectional population-based sample from Central Pennsylvania (Penn State Cohort).     

Active Care Management Supported by Home Telemonitoring in Veterans With Type 2 Diabetes: The DiaTel randomized controlled trial

OBJECTIVE

We compared the short-term efficacy of home telemonitoring coupled with active medication management by a nurse practitioner with a monthly care coordination telephone call on glycemic control in veterans with type 2 diabetes and entry A1C ≥7.5%.

RESEARCH DESIGN AND METHODS

Veterans who received primary care at the VA Pittsburgh Healthcare System from June 2004 to December 2005, who were taking oral hypoglycemic agents and/or insulin for ≥1 year, and who had A1C ≥7.5% at enrollment were randomly assigned to either active care management with home telemonitoring (ACM+HT group, n = 73) or a monthly care coordination telephone call (CC group, n = 77). Both groups received monthly calls for diabetes education and self-management review. ACM+HT group participants transmitted blood glucose, blood pressure, and weight to a nurse practitioner using the Viterion 100 TeleHealth Monitor; the nurse practitioner adjusted medications for glucose, blood pressure, and lipid control based on established American Diabetes Association targets. Measures were obtained at baseline, 3-month, and 6-month visits.

RESULTS

Baseline characteristics were similar in both groups, with mean A1C of 9.4% (CC group) and 9.6% (ACM+HT group). Compared with the CC group, the ACM+HT group demonstrated significantly larger decreases in A1C at 3 months (1.7 vs. 0.7%) and 6 months (1.7 vs. 0.8%; P < 0.001 for each), with most improvement occurring by 3 months.

CONCLUSIONS

Compared with the CC group, the ACM+HT group demonstrated significantly greater reductions in A1C by 3 and 6 months. However, both interventions improved glycemic control in primary care patients with previously inadequate control.Within the Veterans Health Administration, ∼500,000 veterans receive care for diabetes annually; diabetes is a leading cause of morbidity and mortality and a major contributor to health care cost (1,2). Sampling data from 2009 indicate that ∼28% of veterans nationally have suboptimal glycemic control with A1C ≥8% (3). Increases in A1C levels above the normal range in patients with diabetes are associated with progressive increases in morbidity and mortality due to micro- and macrovascular disease (4). Intensive glycemic control can reduce microvascular complications in both type 1 and type 2 diabetes (5,6). However, recent studies have not demonstrated that intensive glycemic control for 3–6 years with achieved A1C targets from 6.4 to 6.9% reduces macrovascular complications in patients with long-standing type 2 diabetes (7–9). In contrast, intensive glycemic control initiated early in the course of either type 1 or type 2 diabetes appears to reduce the risk of subsequent macrovascular complications significantly even when glycemic control later deteriorates (10,11).Home-based telemedicine has been examined as a tool for management of chronic diseases (12), including diabetes (13–19). This approach can obviate geographic barriers; provide automated education, feedback, and data transmission; and facilitate provider-to-patient communication (12). However, outcomes with home telemonitoring in diabetes and other chronic diseases have been variable (12). Of several randomized controlled trials (RCTs) using home telemonitoring in diabetes care (13–19), only two have reported significant improvement in A1C (17,18). Neither of these trials included active medication management by a provider in response to real-time transmission of self-monitored blood glucose (SMBG) data or have specifically targeted patients not meeting glycemic control goals in response to pharmacological therapy under conditions of usual care.The present study compared the efficacy of home telemonitoring coupled with active medication management by a nurse practitioner (ACM+HT intervention) with a lower-intensity care coordination intervention (CC intervention) consisting of monthly telephone contact with a diabetes nurse educator. Our study specifically targeted veterans with A1C levels ≥8% after ≥1 year receiving pharmacological therapy under conditions of usual care.     

Hypoglycemia Unawareness in Older Compared With Middle-Aged Patients With Type 2 Diabetes

OBJECTIVE

Older patients with type 2 diabetes are at a particularly high risk for severe hypoglycemic episodes, and experimental studies in healthy subjects hint at a reduced awareness of hypoglycemia in aged humans. However, subjective responses to hypoglycemia have rarely been assessed in older type 2 diabetic patients.

RESEARCH DESIGN AND METHODS

We tested hormonal, subjective, and cognitive responses (reaction time) to 30-min steady-state hypoglycemia at a level of 2.8 mmol/l in 13 older (≥65 years) and 13 middle-aged (39–64 years) type 2 diabetic patients.

RESULTS

Hormonal counterregulatory responses to hypoglycemia did not differ between older and middle-aged patients. In contrast, middle-aged patients showed a pronounced increase in autonomic and neuroglycopenic symptom scores at the end of the hypoglycemic plateau that was not observed in older patients (both P < 0.01). Also, seven middle-aged patients, but only one older participant, correctly estimated their blood glucose concentration to be <3.3 mmol/l during hypoglycemia (P = 0.011). A profound prolongation of reaction times induced by hypoglycemia in both groups persisted even after 30 min of subsequent euglycemia.

CONCLUSIONS

Our data indicate marked subjective unawareness of hypoglycemia in older type 2 diabetic patients that does not depend on altered neuroendocrine counterregulation and may contribute to the increased probability of severe hypoglycemia frequently reported in these patients. The joint occurrence of hypoglycemia unawareness and deteriorated cognitive function is a critical factor to be carefully considered in the treatment of older patients.Hypoglycemia is the limiting factor in the glycemic management of diabetes (1). For a long time hypoglycemia was assumed a major problem only in patients suffering from type 1 diabetes (2); however, there is increasing evidence that hypoglycemic episodes are a critical factor also in type 2 diabetes (3,4). Older subjects aged >65 years, who represent the majority of type 2 diabetic patients, appear at a particularly high risk of experiencing severe hypoglycemia (3,4). Previous studies (5–7) have shown weakened perception of hypoglycemia-related symptoms in healthy older (i.e., nondiabetic older subjects, aged 65–80 years) as compared with younger subjects (aged 24–49 years). Of note, in aged humans, the perception of hypoglycemic symptoms was found to simultaneously occur with the impairment of cognitive functions during a stepwise reduction of blood glucose levels (7), contrasting the well-known hierarchical succession of central nervous responses to hypoglycemia in younger healthy adults who normally perceive hypoglycemic symptoms at higher glucose levels than cognitive dysfunction (4). The concurrence of glycemic thresholds for the onset of symptoms and of cognitive dysfunction may be expected to increase the risk for severe hypoglycemic episodes since it likely prevents behavioral counteractions (e.g., the intake of carbohydrates) (3).To date only one study (8) has assessed subjective responses to standardized hypoglycemia in older type 2 diabetic patients (aged 72 ± 1 years), revealing an impairment in the perception of hypoglycemic symptoms that was comparable to that of age-matched healthy control subjects. Although this finding points to a decrease in hypoglycemia awareness that develops in the course of aging also in type 2 diabetic patients, this assumption has not yet been experimentally elucidated. Moreover, in the previous studies in healthy subjects (5–7), the age gap between experimental groups was rather large, raising the question as to the perception of hypoglycemia in middle-aged subjects. On this background, we examined whether older (aged ≥65 years) as compared with middle-aged (aged 39–64 years) type 2 diabetic patients differ in their subjective response to hypoglycemia and how hypoglycemia awareness in these age-groups relates to hormonal and cognitive effects of hypoglycemia.     

Pediatric Endocrinologists' Management of Children With Type 2 Diabetes

OBJECTIVE

To understand physician behaviors and attitudes in managing children with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A survey was mailed to a nationwide sample of pediatric endocrinologists (PEs).

RESULTS

A total of 40% of PEs surveyed responded (211 of 527). Concordance with current monitoring guidelines varied widely, ranging from 36% (foot care) to 93% (blood pressure monitoring). Given clinical vignettes addressing hyperlipidemia, hypertension, and microalbuminuria, only 34% of PEs were fully concordant with current treatment guidelines. Reported barriers included concerns about patient adherence, insufficient scientific evidence about treatment, and lack of familiarity with current recommendations. Providers aged ≤45 years or in clinical practice <10 years reported significantly more aggressive management behaviors and had higher concordance with guidelines.

CONCLUSIONS

Screening and management of pediatric type 2 diabetes varied widely among PEs, suggesting opportunities for quality improvement. More aggressive management of type 2 diabetes among younger providers may be related to recent training when type 2 diabetes was more common.The incidence of type 2 diabetes in children is increasing (1), and children with type 2 diabetes are at high risk to develop diabetes-related complications, including hyperlipidemia, hypertension, and microalbuminuria (2–4). Despite limited scientific evidence, several consensus statements on the assessment and management of pediatric type 2 diabetes have been developed (4–6). Current understanding of physician management of pediatric type 2 diabetes is limited (7–10). We conducted a survey to better understand pediatric endocrinologists'' (PEs'') behaviors and attitudes related to the management of pediatric type 2 diabetes.     

Physical Activity, Adiposity, and Diabetes Risk in Middle-Aged and Older Chinese Population: The Guangzhou Biobank Cohort Study

OBJECTIVE

Physical activity may modify the association of adiposity with type 2 diabetes. We investigated the independent and joint association of adiposity and physical activity with fasting plasma glucose, impaired fasting glucose, and type 2 diabetes in a Chinese population.

RESEARCH DESIGN AND METHODS

Middle-aged and older Chinese (n = 28,946, ≥50 years, 72.4%women) from the Guangzhou Biobank Cohort Study were examined in 2003–2008. Multivariable regression was used in a cross-sectional analysis.

RESULTS

BMI, waist circumference, and waist-to-hip ratio (WHR) were positively associated with type 2 diabetes after multiple adjustment, most strongly for WHR with odds ratio (OR) of 3.99 (95% CI 3.60–4.42) for highest compared with lowest tertile. Lack of moderate-to-vigorous physical activity, but not walking, was associated with diabetes with an OR of 1.29 (1.17–1.41). The association of moderate-to-vigorous activity with fasting glucose varied with WHR tertiles (P = 0.01 for interaction). Within the high WHR tertile, participants who had a lack of moderate-to-vigorous activity had an OR of 3.87 (3.22–4.65) for diabetes, whereas those who were active had an OR of 2.94 (2.41–3.59).

CONCLUSIONS

In this population, WHR was a better measure of adiposity-related diabetes risk than BMI or waist circumference. Higher moderate-to-vigorous activity was associated with lower diabetes risk, especially in abdominally obese individuals.Type 2 diabetes is a worldwide cause of morbidity and mortality. Adiposity, especially abdominal adiposity, seems to be at the core of development of hyperglycemia and type 2 diabetes (1). Increased physical activity may mitigate some of the diabetogenic impact of adiposity (2–4). Individuals who are obese but fit could even have a lower risk of mortality than those who are normal weight but unfit (5,6). However, being physically active does not completely abolish the obesity-related risk for cardiovascular disease and associated mortality (7). Adiposity is still the main risk factor for the development of type 2 diabetes (2–4,8). Although increased physical activity has been shown to be associated with reduced type 2 diabetes risk independent of adiposity, the protective effects may differ by the level of adiposity. However, the group that could benefit most from physical activity for the prevention of diabetes is still unclear (2–4,8–10).Understanding the relationship between adiposity and physical activity is important to stratify risk groups for the development of effective diabetes prevention strategies from public health and clinical perspectives. Most of the studies relate to Caucasians (2–4,8–10), whereas Asians, including Chinese and Indians, are possibly more vulnerable to insulin resistance (11). The number of Chinese adults with type 2 diabetes was estimated to be ∼28.1 million in 2000 and may double by 2030, with China being second only to India (12). The purpose of this study was to investigate the independent and joint association of adiposity and physical activity with fasting plasma glucose, impaired fasting glucose (IFG), and type 2 diabetes in 28,946 middle-aged and older Chinese participants in the Guangzhou Biobank Cohort Study.     

Childhood Size and Life Course Weight Characteristics in Association With the Risk of Incident Type 2 Diabetes

OBJECTIVE

To determine how childhood overweight, in conjunction with other life course weight characteristics, relates to the development of type 2 diabetes in adulthood.

RESEARCH DESIGN AND METHODS

Among 109,172 women in the Nurses'' Health Study II, body fatness at ages 5, 10, and 20 years was assessed by recall using 9-level pictorial diagrams (somatotypes) representing extreme thinness (category 1) to obesity (category 9). Recalled weights at age 18 years and adulthood were used to derive BMI. Self-reported cases of type 2 diabetes were confirmed by supplementary questionnaire.

RESULTS

Somatotypes at ages 5 and 10 years were positively associated with diabetes risk (P_trend < 0.0001). The adjusted relative risk (RR) of women with somatotype ≥6 (vs. 2) at age 5 years was 2.19 (95% CI 1.79–2.67) and at age 10 years was 2.57 (2.20–3.01). Increases in size by somatotype or by weight gain since age 18 were associated with increased risk. Compared with women who were never overweight at any age, women who were overweight as an adult (BMI >25 kg/m²) but not previously had an adjusted RR of 8.23 (7.41–9.15). The adjusted RR was 15.10 (13.21–17.26) for women who were also overweight at age 10 (somatotype ≥5) and 18 (BMI >25 kg/m²). Increased childhood size was not associated with risk among women who did not continue to be overweight in adulthood.

CONCLUSIONS

Increased body size starting from childhood is associated with a greater risk of diabetes in adulthood. However, women who become lean in adulthood do not have an increased risk.Large proportions of children in the U.S. are currently at risk for or are overweight. Immediate and long-term health problems have arisen because of childhood overweight, including poor lipid profile, earlier onset of type 2 diabetes, and other metabolic syndrome traits (1). Although the rise in prevalence of type 2 diabetes in the pediatric population is cause for concern in itself, the risk as these children continue into adulthood will undoubtedly be a greater public health burden.Despite strong ties between the development of insulin resistance from increased adiposity via multiple biological mechanisms, few studies have looked at the long-term consequences of childhood overweight and the risk of type 2 diabetes in adulthood and findings have been inconsistent (2–8). One study using birth and medical records data from Finland, found that BMI at ages 7–11 years in women was significantly and positively associated with future risk of diabetes (4). However, the study did not investigate the roles of adolescent and adulthood obesity in this association, and the number of type 2 diabetes cases was small (n = 185) (4). In contrast, a more recent study that accounted for life course weight, found that thinness, rather than overweight, from childhood through young adulthood was associated with increased diabetes risk (8). However, these findings were from an older cohort (born 1925–1950) of French women, with a large percentage being extremely lean in childhood, whose early nutritional status might have been affected by World War II (1939–1945). Thus, the objective of this study was to determine the longitudinal association between childhood overweight in combination with other life course weight characteristics and the risk for type 2 diabetes in a more recent birth cohort of young women.     

Increases in Waist Circumference and Weight As Predictors of Type 2 Diabetes in Individuals With Impaired Fasting Glucose: Influence of Baseline BMI: Data from the DESIR study

OBJECTIVE

To evaluate in impaired fasting glucose (IFG) the relative importance of increases in waist circumference and weight on progression to type 2 diabetes.

RESEARCH DESIGN AND METHODS

The 9-year incidence of diabetes was studied in 979 men and women with baseline IFG, from the Data from an Epidemiological Study on the Insulin Resistance Syndrome (DESIR) cohort.

RESULTS

Increases in both waist circumference and weight were significantly associated with diabetes incidence. Standardized odds ratios (95% CI) were 1.79 (1.45–2.21) and 1.86 (1.51–2.30), respectively, after controlling for baseline risk factors. The impact of waist circumference increase was greater for BMI <25 kg/m² (2.40 [1.63–3.52]) than for BMI ≥25 kg/m² (1.66 [1.28–2.16]) and persisted after adjusting for concurrent changes in either insulinemia or the homeostasis model assessment of insulin resistance index. Weight change had a similar impact in both BMI groups.

CONCLUSIONS

In individuals with IFG, it is important to monitor and prevent increases in waist circumference, in particular for those with BMI <25 kg/m².Individuals with impaired fasting glucose (IFG) are at high risk for type 2 diabetes (1,2). Although visceral adiposity and waist circumference are strong risk factors for type 2 diabetes (3), the consequence of an increase in waist circumference among individuals with IFG at baseline has not been fully investigated, in particular in those who are not overweight or obese at baseline (4,5). This report investigates the relative importance of increases in waist circumference and weight on progression to diabetes in individuals with baseline IFG, according to baseline BMI strata.     

Hypertriglyceridemic Waist Phenotype Predicts Increased Visceral Fat in Subjects With Type 2 Diabetes

OBJECTIVE

Greater accumulation of visceral fat is strongly linked to risk of cardiovascular disease. However, elevated waist circumference by itself does not always identify individuals with increased visceral fat.

RESEARCH DESIGN AND METHODS

We examined 375 subjects with type 2 diabetes from the CHICAGO cohort for presence of hypertriglyceridemic waist phenotype (waist circumference >90 cm in men or >85 cm in women, in conjunction with a plasma triglyceride concentration of ≥177 mg/dl) to determine its usefulness for identifying subjects with increased amounts of visceral fat. We divided subjects into three groups: group 1 (low waist circumference and low triglycerides; waist circumference ≤90 cm in men or ≤85 cm in women and triglyceride <177 mg/dl, n = 18), group 2 (high waist circumference and low triglycerides; waist circumference >90 cm in men or >85 cm in women and triglycerides <177 mg/dl, n = 230), and group 3 (high waist circumference and high triglycerides; waist circumference >90 cm in men or >85 cm in women and triglycerides ≥177 mg/dl, n = 127).

RESULTS

Subjects in group 3 had significantly higher visceral fat (P < 0.0001), A1C (P < 0.01), and coronary artery calcium (P < 0.05) compared with group 2, despite similar age, BMI, and waist circumference. The relationship of the phenotype to atherosclerosis, however, was attenuated by adjustment for HDL cholesterol, triglyceride-rich lipoprotein cholesterol, apolipoprotein B, or LDL particle number.

CONCLUSIONS

The presence of hypertriglyceridemic waist phenotype in subjects with type 2 diabetes identifies a subset with greater degree of visceral adiposity. This subset also has greater degree of subclinical atherosclerosis that may be related to the proatherogenic lipoprotein changes.Despite the strong association of obesity, especially abdominal obesity, to metabolic and cardiovascular disease, not all obese individuals carry the same metabolic and cardiovascular risk (1,2). The metabolic syndrome (a cluster of metabolic abnormalities that include glucose intolerance, central obesity, dyslipidemia, and hypertension) has been used to identify individuals at high risk for type 2 diabetes and cardiovascular disease (3,4). A hypertriglyceridemic waist phenotype defined as an elevated waist circumference (>90 cm in men or >85 cm in women) along with an elevated plasma triglyceride concentration (defined as a level ≥177 mg/dl) has been proposed and shown to be a stronger marker of cardiovascular risk and a better predictor of cardiovascular disease than the metabolic syndrome in nondiabetic subjects (5,6). Deposition of visceral fat may be most closely linked to the metabolic and cardiovascular risk associated with both the metabolic syndrome and the hypertriglyceridemic waist phenotype (6).The CHICAGO cohort is a well-characterized group of men and women with type 2 diabetes who had measurements of abdominal fat depots by computed tomography (CT) and coronary artery calcium (CAC) by electron-beam tomography (7–9). We evaluated the prevalence of hypertriglyceridemic waist phenotype in this cohort and report its usefulness for identifying subjects with diabetes who have higher levels of visceral fat. We further examined the metabolic and cardiovascular impact of this phenotype in subjects with type 2 diabetes.     

Peri-Conceptional A1C and Risk of Serious Adverse Pregnancy Outcome in 933 Women With Type 1 Diabetes

OBJECTIVE

To study the association between peri-conceptional A1C and serious adverse pregnancy outcome (congenital malformations and perinatal mortality).

RESEARCH DESIGN AND METHODS

Prospective data were collected in 933 singleton pregnancies complicated by type 1 diabetes.

RESULTS

The risk of serious adverse outcome at different A1C levels was compared with the background population. The risk was significantly higher when peri-conceptional A1C exceeded 6.9%, and the risk tended to increase gradually with increasing A1C. Women with A1C exceeding 10.4% had a very high risk of 16%. Congenital malformation rate increased significantly at A1C above 10.4%, whereas perinatal mortality was increased even at A1C below 6.9%.

CONCLUSIONS

These results support recent guidelines of preconceptional A1C levels <7% in women with type 1 diabetes.Recently, guidelines for management of pregnancy in women with pregestational diabetes have recommended pregestational A1C values <7.0% (1,2) and <6.1% (3). Previous studies have reported information of early A1C including 116–691 pregnancies (4–10). We aimed to study whether there is a threshold value for peri-conceptional A1C in women with type 1 diabetes below which the risk of serious adverse pregnancy outcome (congenital malformation and perinatal mortality) is not increased.     

Screening for Diabetes and Pre-Diabetes With Proposed A1C-Based Diagnostic Criteria

OBJECTIVE

An International Expert Committee (IEC) and the American Diabetes Association (ADA) proposed diagnostic criteria for diabetes and pre-diabetes based on A1C levels. We hypothesized that screening for diabetes and pre-diabetes with A1C measurements would differ from using oral glucose tolerance tests (OGTT).

RESEARCH DESIGN AND METHODS

We compared pre-diabetes, dysglycemia (diabetes or pre-diabetes), and diabetes identified by the proposed criteria (A1C ≥6.5% for diabetes and 6.0–6.4% [IEC] or 5.7–6.4% [ADA] for high risk/pre-diabetes) with standard OGTT diagnoses in three datasets. Non-Hispanic white or black adults without known diabetes who had A1C and 75-g OGTT measurements were included from the prospective Screening for Impaired Glucose Tolerance study (n = 1,581), and from the National Health and Nutrition Examination Survey (NHANES) III (n = 2014), and NHANES 2005–2006 (n = 1,111).

RESULTS

OGTTs revealed pre-diabetes in 35.8% and diabetes in 5.2% of combined study subjects. A1C provided receiver operating characteristic (ROC) curve areas for diabetes of 0.79–0.83, but ROC curve areas were ≤0.70 for dysglycemia or pre-diabetes. The proposed criteria missed 70% of individuals with diabetes, 71–84% with dysglycemia, and 82–94% with pre-diabetes. Compared with the IEC criteria, the ADA criteria for pre-diabetes resulted in fewer false-negative and more false-positive result. There were also racial differences, with false-positive results being more common in black subjects and false-negative results being more common in white subjects. With use of NHANES 2005–2006 data, ∼5.9 million non-Hispanic U.S. adults with unrecognized diabetes and 43–52 million with pre-diabetes would be missed by screening with A1C.

CONCLUSIONS

The proposed A1C diagnostic criteria are insensitive and racially discrepant for screening, missing most Americans with undiagnosed diabetes and pre-diabetes.Diabetes affects >21 million American adults (1,2), with a lifetime risk ranging from 20 to 50+%, depending on sex and race (3). Identification of diabetes and its precursor, pre-diabetes, can permit management to prevent complications or delay progression from pre-diabetes to diabetes. Because most U.S. health care systems do not have systematic screening programs, many Americans have undiagnosed diabetes and pre-diabetes, and, therefore, these individuals are not initiating programs targeted at prevention (2).An International Expert Committee (IEC) recently proposed new diagnostic criteria based on measurement of A1C, with A1C ≥6.5% for diabetes and 6.0–6.4% for “high risk” of progression to diabetes (4). The American Diabetes Association (ADA) subsequently proposed A1C ≥6.5% for the diagnosis of diabetes and 5.7–6.4% for the highest risk to progress to diabetes (5).Because A1C testing is readily available in the U.S., is relatively well standardized, exhibits low intraindividual variation, and does not require fasting or restriction to certain times of the day (6), many clinicians might wish to use A1C measurements to screen for diabetes and pre-diabetes. However, the proposed diagnostic criteria were based largely on identification of diabetic retinopathy, and use of the proposed criteria as a screening test is not understood. The IEC A1C criteria have recently been compared with testing with fasting glucose or oral glucose tolerance tests (OGTTs) in various populations to diagnose diabetes (7–13) and high-risk/pre-diabetes (10,11,13), but the ADA A1C criteria have not been studied.We hypothesized that A1C diagnostic criteria would fail to identify many subjects with unrecognized diabetes or pre-diabetes. We evaluated the proposed criteria as screening tests in three populations, compared with the OGTT as a “gold standard” used for identification of diabetes and pre-diabetes around the world (14).     

Dietary Patterns and Risk for Diabetes: The Multiethnic Cohort

OBJECTIVE

The high diabetes incidence among Japanese Americans and Native Hawaiians cannot be explained by BMI. Therefore, we examined the influence of three dietary patterns of “fat and meat,” “vegetables,” and “fruit and milk” on diabetes risk in the Hawaii component of the Multiethnic Cohort with 29,759 Caucasians, 35,244 Japanese Americans, and 10,509 Native Hawaiians.

RESEARCH DESIGN AND METHODS

Subjects aged 45–75 years completed a baseline food frequency questionnaire. After 14 years of follow-up, 8,587 subjects with incident diabetes were identified through self-reports or health plan linkages. Risk was assessed using Cox regression stratified by age and adjusted for ethnicity, BMI, physical activity, education, total energy, smoking, alcohol intake, marital status, and hypertension.

RESULTS

Fat and meat was significantly associated with diabetes risk in men (hazard ratio 1.40 [95% CI 1.23–1.60], P_trend < 0.0001) and women (1.22 [1.06–1.40], P_trend = 0.004) when extreme quintiles were compared. Except in Hawaiian women, the magnitude of the risk was similar across ethnic groups although not always significant. After stratification by BMI, fat and meat remained a predictor of disease primarily among overweight men and among overweight Japanese women. Vegetables lowered diabetes risk in men (0.86 [0.77–0.95], P_trend = 0.004) but not in women, whereas fruit and milk seemed to be more beneficial in women (0.85 [0.76–0.96], P_trend = 0.005) than in men (0.92 [0.83–1.02], P_trend = 0.04).

CONCLUSIONS

Foods high in meat and fat appear to confer a higher diabetes risk in all ethnic groups, whereas the effects of other dietary patterns vary by sex and ethnicity.Native Hawaiians have extremely high rates of obesity and diabetes, but despite their relatively low body weight, individuals with Japanese ancestry are also disproportionately affected by diabetes (1). Among the >44,000 Japanese Americans, 14,000 Native Hawaiians, and 35,000 Caucasians in the Hawaii component of the Multiethnic Cohort (MEC), a previous analysis had found diabetes incidence rates of 15.5, 12.5, and 5.8 per 1,000 person-years, respectively, that could not be explained by BMI (2). Dietary patterns have been identified as additional predictors of disease but have only rarely been investigated prospectively among non-Caucasian populations (3–5). The most commonly identified patterns are the so-called “western,” “unhealthy,” or “conservative” pattern (3–11), which is high in meat, high-fat foods, and sweets, and the “prudent” or “healthy” pattern, rich in fruit and vegetables (3–8,10,12,13). With the goal to contribute to the prevention of diabetes, we examined the effect of three dietary patterns, “fat and meat,” “vegetables,” and “fruit and milk,” which had been previously identified in the MEC, on diabetes risk (14).     

Family-Planning Practices Among Women With Diabetes and Overweight and Obese Women in the 2002 National Survey for Family Growth

OBJECTIVE

To examine contraceptive practices among diabetic women and obese women.

RESEARCH DESIGN AND METHODS

We analyzed the responses of 5,955 participants aged 20–44 years in the 2002 National Survey for Family Growth. Diabetes, BMI, desire for pregnancy, history of infertility treatment, sexual activity, parity, and demographic variables (age, race/ethnicity, education, marital status, income, insurance, and smoking history) were obtained by self-report. Lack of contraception was defined as absence of hormonal-, barrier-, or sterilization-based methods. Associations among contraception, diabetes, and BMI category were assessed in multivariable logistic regression models in nonsterile, sexually active women.

RESULTS

In unadjusted comparisons among sexually active women who were not sterilized, women with diabetes were more likely to lack contraception than women without diabetes (odds ratio [OR] 2.61 [95% CI 1.22–5.58]). Women with BMI ≥35 kg/m² were more likely to lack contraception than women with BMI <25 kg/m²(1.63 [1.16–2.28]), but associations between contraception use and lesser degrees of overweight and obesity were not significant. In multivariable models, women who were older (aged ≥30 vs. 20–29 years), were of non-Hispanic black race, were cohabitating, had a history of infertility treatment, and desired or were ambivalent about pregnancy were significantly more likely to lack contraception. The associations among diabetes, BMI, and contraception were no longer significant after these adjustments.

CONCLUSIONS

Older women with diabetes and obesity who desire pregnancy, regardless of pregnancy intention, should be targeted for preconceptive management.Diabetes and obesity increasingly affect women of reproductive age in the U.S. (1,2). Data from the National Health and Nutrition Examination Survey show that the prevalence of physician-diagnosed diabetes in women aged ≥20 years was 7.1% from 2001 to 2004 (3). Moreover, in 2003–2004, one in three women aged ≥20 years was identified as obese (BMI ≥30 kg/m²) (4). Women with diabetes and those who are obese are at increased risk for pregnancy complications, including those fromsurgical delivery, and their offspring areat riskfor congenital anomalies (5,6). Women with diabetes can improve pregnancy outcomes by delaying pregnancy until optimal glucose levels are reached (7). Obese women are also at risk for gestational diabetes mellitus and future onset of diabetes (8,9). Effective family planning, used in conjunction with glucose management for women with diabetes, as well as weight loss and diabetes screening before pregnancy, may reduce the risk to the mother and fetus associated with diabetes and obesity. In addition, family planning will reduce the risk of mistimed pregnancies (10).Between one-half and two-thirds of women with diabetes have experienced unplanned pregnancies (11–14). However, Chuang et al. (15) found that among sexually active women with diabetes, only a quarter reported no contraceptive use. Similarly, reports of contraceptive practices of obese women vary. While Chuang et al. (15) found that one-fifth of potentially fertile obese women reported no contraceptive use, other reports (16) have found much lower rates of contraception among obese women.It is also not clear to what extent diabetes or obesity are independent riskfactors for contraception nonuse. The objective of this study was to examine contraceptive nonuse and its associations with diabetes and categories of BMI using data from the 2002 National Survey for Family Growth (NSFG). We hypothesized that women with diabetes wouldreport less contraceptive use than nondiabetic women and that this difference would persist after adjustment for demographic factors and potential confounders, such as desire for pregnancy, history of infertility treatment, and obesity. We also hypothesized that overweight and obese women would report less frequent contraceptive use than healthy-weight women after adjustment for potential confounders.     

Extended Family History of Diabetes and Autoimmune Diseases in Children With and Without Type 1 Diabetes

OBJECTIVE

To determine the extended family history of diabetes or autoimmune diseases in families with and without children having type 1 diabetes.

RESEARCH DESIGN AND METHODS

Three hundred case families and 381 control families were interviewed using structured questionnaires.

RESULTS

The proportion of case children having at least one relative with type 1 diabetes outside the nuclear family was higher than that of control children (50.3 vs. 31.8%, P < 0.001). The proportions of case and control children having relatives with type 2 diabetes or gestational diabetes were similar. Other autoimmune diseases occurred more frequently among the case children (9.7 vs. 1.1%, P < 0.001), in the case nuclear families (22.0 vs. 12.9%, P = 0.002) and in relatives outside the case nuclear family (72.0 vs. 62.2%, P = 0.007).

CONCLUSIONS

Type 1 diabetes and autoimmune diseases not only cluster in the nuclear families of children with type 1 diabetes but are also overrepresented in their extended families.First degree relatives of patients with type 1 diabetes clearly have an increased disease risk (1–5), but little information is available about the occurrence of type 1 diabetes outside the nuclear family (6). It is also unclear whether type 2 diabetes and gestational diabetes are more frequently present in the families of children with type 1 diabetes (7–9). Type 1 diabetes is known to be associated with other autoimmune diseases, but there is a scarcity of data on the frequency of autoimmune diseases among other family members (10).     

Renal Hyperfiltration and Arterial Stiffness in Humans With Uncomplicated Type 1 Diabetes

OBJECTIVE

We have reported that renal hyperfiltration is associated with endothelial dysfunction in early type 1 diabetes. However, the relationship between renal hyperfiltration and arterial stiffness is unknown. Accordingly, we measured arterial stiffness in type 1 diabetic subjects with hyperfiltering (n = 20) or normofiltering (n = 18).

RESEARCH DESIGN AND METHODS

Augmentation index (AIx), aortic pulse wave velocity (PWV), renal hemodynamic function (inulin and paraaminohippurate clearances), and urinary and circulating plasma cGMP were measured in normoalbuminuric subjects with type 1 diabetes during clamped euglycemia (glucose 4–6 mmol/l) and hyperglycemia (glucose 9–11 mmol/l).

RESULTS

During clamped euglycemia, hyperfiltering subjects (glomerular filtration rate ≥135 ml/min/1.73 m²) exhibited lower AIx values (−6.1 ± 2.9 vs. 13.9 ± 2.7%, P = 0.001) and higher cGMP levels in urine and plasma compared with normofiltering subjects. These differences were maintained during clamped hyperglycemia. As expected, renal hemodynamic responses to clamped hyperglycemia were exaggerated in normofilterers, but values for AIx remained unchanged.

CONCLUSIONS

Renal hyperfiltration is associated with reduced arterial stiffness in subjects with uncomplicated type 1 diabetes.Early type 1 diabetes is associated with renal hemodynamic function changes characterized by arteriolar vasodilation and hyperfiltration (1). In addition to renal microvascular vasodilation, previous work has suggested the presence of macrovascular arterial dysfunction in diabetic subjects with renal hyperfiltration, which may reflect generalized endothelial dysfunction (2). In addition to effects on endothelial function, diabetes is associated with increased arterial stiffness, which is correlated with progression of diabetic nephropathy and increased systemic vascular risk (3–7). The relationship between arterial stiffness and renal hyperfiltration, which is the earliest preclinical manifestation of diabetic renal microvascular dysfunction, is currently unknown.Accordingly, we studied arterial stiffness in subjects based on renal filtration status to further elucidate the relationship between early renal and systemic abnormalities in diabetes (3,8). We hypothesized that arterial stiffness would be lower in hyperfiltering subjects (glomerular filtration rate [GFR] ≥135 ml/min/1.73 m²) than in individuals with normofiltration (GFR <135 ml/min/1.73 m²). Furthermore, we hypothesized that hyperfiltering subjects would exhibit higher levels of vasodilators.     

The Relative Contribution of Prepregnancy Overweight and Obesity,Gestational Weight Gain,and IADPSG-Defined Gestational Diabetes Mellitus to Fetal Overgrowth

OBJECTIVE

The International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria for diagnosis of gestational diabetes mellitus (GDM) identifies women and infants at risk for adverse outcomes, which are also strongly associated with maternal overweight, obesity, and excess gestational weight gain.

RESEARCH DESIGN AND METHODS

We conducted a retrospective study of 9,835 women who delivered at ≥20 weeks’ gestation; had a prenatal, 2-h, 75-g oral glucose tolerance test; and were not treated with diet, exercise, or antidiabetic medications during pregnancy. Women were classified as having GDM based on IADPSG criteria and were categorized into six mutually exclusive prepregnancy BMI/GDM groups: normal weight ± GDM, overweight ± GDM, and obese ± GDM.

RESULTS

Overall, 5,851 (59.5%) women were overweight or obese and 1,892 (19.2%) had GDM. Of those with GDM, 1,443 (76.3%) were overweight or obese. The prevalence of large-for-gestational-age (LGA) infants was significantly higher for overweight and obese women without GDM compared with their normal-weight counterparts. Among women without GDM, 21.6% of LGA infants were attributable to maternal overweight and obesity, and the combination of being overweight or obese and having GDM accounted for 23.3% of LGA infants. Increasing gestational weight gain was associated with a higher prevalence of LGA in all groups.

CONCLUSIONS

Prepregnancy overweight and obesity account for a high proportion of LGA, even in the absence of GDM. Interventions that focus on maternal overweight/obesity and gestational weight gain, regardless of GDM status, have the potential to reach far more women at risk for having an LGA infant.Both International Association of Diabetes in Pregnancy Study Groups (IADPSG)–defined gestational diabetes mellitus (GDM) (1,2) and maternal overweight and obesity (2–4) are associated with increased risk for adverse maternal and perinatal outcomes, such as fetal overgrowth, shoulder dystocia and birth injury, pre-eclampsia, and preterm delivery. Although most studies addressing the effects of maternal BMI on adverse outcomes include women with GDM (2–6), a few have reported these associations in overweight or obese women with normal glucose tolerance (7–9). Scant data exist that demonstrate associations between GDM and adverse outcomes in the absence of overweight or obesity (9).Although it is currently estimated that 10–25% of pregnant women develop GDM by IADPSG criteria (1,2,10), 50–60% of women are overweight or obese at the start of their pregnancies (6,7,11,12). Prepregnancy overweight and obesity are also associated with GDM development, as 65–75% of women with GDM are also overweight or obese (11,13). As such, the relative impact of prepregnancy BMI and maternal glycemia during pregnancy on adverse maternal and perinatal outcomes is difficult to tease apart. Moreover, excess gestational weight gain complicates a large number of pregnancies and is highly correlated with maternal overweight and obesity, as well as the development of GDM (14–16). Despite the fact that studies have reported increases in the risk of adverse outcomes with increasing gestational weight gain (13,15–18), many studies examining the effects of maternal obesity and/or glucose levels have not accounted for this important factor.The purpose of this study was to examine the effects of prepregnancy overweight and obesity among women with and without IADPSG-defined GDM on clinically important adverse outcomes, focusing primarily on fetal overgrowth, one of the most prevalent adverse conditions associated with maternal and neonatal morbidity. In addition to magnitude of association, we determine the proportion of large-for-gestational-age (LGA) infants attributable to each risk factor and combinations thereof. We also examine the relative contribution of increasing gestational weight gain to the development of LGA.     

Prognostic Value of Gated Myocardial Perfusion Imaging for Asymptomatic Patients With Type 2 Diabetes: The J-ACCESS 2 investigation

OBJECTIVE

Individuals with type 2 diabetes are at high risk for cardiovascular events. We evaluated the prognostic value of gated myocardial perfusion single-photon computed tomography (SPECT) for asymptomatic diabetic patients in a Japanese population.

RESEARCH DESIGN AND METHODS

Asymptomatic patients (n = 485) aged ≥50 years with either a maximal carotid artery intima-media thickness of ≥1.1 mm, or a urinary albumin ≥30 mg/g creatinine or who had at least two of the following, abdominal obesity, low HDL cholesterol, high triglyceride levels, and hypertension, were enrolled at 50 institutions. The patients were evaluated using gated SPECT with the stress-rest protocol and followed up for 3 years.

RESULTS

During the follow-up period, 62 (13%) events occurred, including 5 cardiac deaths and 57 cardiovascular events. Patients with summed stress scores (SSS) of ≥9 had a significantly higher incidence (of either death or cardiovascular events) than those with SSS scores of <9 (23 vs. 12%; P = 0.009). Multivariate Cox regression analysis showed that significant variables were SSS ≥9, a low estimated glomerular filtration rate, and being a current smoker. Univariate Cox regression analysis showed that ticlopidine and insulin use are potent medical modulators of cardiovascular events.

CONCLUSIONS

The incidences of cardiovascular events and death were significantly high in a select population of type 2 diabetic patients with SPECT abnormalities. A targeted treatment strategy is required for asymptomatic but potentially high-risk patients with type 2 diabetes.Coronary stenosis, myocardial ischemia, and baseline cardiac functions are important factors for the risk stratification of cardiac events and thus are used to predict patient prognosis. Among various clinical factors, diabetes promotes atherosclerosis, resulting in a major pathophysiological cause of cerebral and myocardial infarction (MI) (1). The risk for diabetic patients without prior MI is two- to fourfold higher than that for nondiabetic patients, and it is comparable with the risk for nondiabetic patients with prior MI (2,3). However, because atherosclerosis can progress even in asymptomatic diabetic patients, diagnosing ischemic heart diseases at an early subclinical stage is vital (4).The role of single-photon emission computed tomography (SPECT) in detecting myocardial ischemia and evaluating prognosis has been validated (1,5–7). A prognostic investigation using gated SPECT (Japanese Assessment of Cardiac Events and Survival Study by Quantitative Gated SPECT [J-ACCESS]) in a Japanese population was started in 2001, and the patients were followed up for 3 years (3). That study revealed that diabetes is the most important predictor of cardiac events in the Japanese population, as has been shown in the Finnish population (2). Therefore, we designed the J-ACCESS 2 prospective cohort study of asymptomatic patients with type 2 diabetes (8). The 1st year interim report clarified the value of gated SPECT for individuals with type 2 diabetes (9). The present final report evaluates the prognostic value of gated SPECT and includes a more detailed stratification of ischemic cardiovascular events in diabetic patients.     

Cost-Effectiveness of Bariatric Surgery for Severely Obese Adults With Diabetes

OBJECTIVE

To analyze the cost-effectiveness of bariatric surgery in severely obese (BMI ≥35 kg/m²) adults who have diabetes, using a validated diabetes cost-effectiveness model.

RESEARCH DESIGN AND METHODS

We expanded the Centers for Disease Control and Prevention–RTI Diabetes Cost-Effectiveness Model to incorporate bariatric surgery. In this simulation model, bariatric surgery may lead to diabetes remission and reductions in other risk factors, which then lead to fewer diabetes complications and increased quality of life (QoL). Surgery is also associated with perioperative mortality and subsequent complications, and patients in remission may relapse to diabetes. We separately estimate the costs, quality-adjusted life-years (QALYs), and cost-effectiveness of gastric bypass surgery relative to usual diabetes care and of gastric banding surgery relative to usual diabetes care. We examine the cost-effectiveness of each type of surgery for severely obese individuals who are newly diagnosed with diabetes and for severely obese individuals with established diabetes.

RESULTS

In all analyses, bariatric surgery increased QALYs and increased costs. Bypass surgery had cost-effectiveness ratios of $7,000/QALY and $12,000/QALY for severely obese patients with newly diagnosed and established diabetes, respectively. Banding surgery had cost-effectiveness ratios of $11,000/QALY and $13,000/QALY for the respective groups. In sensitivity analyses, the cost-effectiveness ratios were most affected by assumptions about the direct gain in QoL from BMI loss following surgery.

CONCLUSIONS

Our analysis indicates that gastric bypass and gastric banding are cost-effective methods of reducing mortality and diabetes complications in severely obese adults with diabetes.In recent years, bariatric surgery has emerged as a popular treatment to reduce body weight and improve obesity-related complications, particularly in the diabetic population. Several studies have shown that surgery can lead to significant weight loss, with excess body weight reduced by >50% (1,2). Although weight loss declines over time, the Swedish Obese Subjects (SOS) Study found significant weight loss even 10 years after surgery (3,4). In addition to sustained weight loss, bariatric surgery may provide additional benefits to people with diabetes. Among severely obese patients with diabetes, bariatric surgery often leads to diabetes remission, with remission rates that are as high as 80% in the short run (1) and that remain significant in the long run (3,4).Although the evidence suggests that bariatric surgery is a successful long-term treatment of obesity for people with diabetes, it is an expensive procedure. The average cost of surgery exceeds $13,000 (5), with additional costs possible in the months following surgery (6). This raises the question of whether bariatric surgery is cost-effective for severely obese people with diabetes.Several studies have estimated the cost-effectiveness of bariatric surgery and found that surgery is either cost-effective (7–10) or that it leads to cost savings over time (6,11–13). The existing studies tend to be relatively simple, and only two (10,13) focus on people with diabetes. The studies generally do not model the microvascular complications associated with diabetes, the effect of surgery on blood pressure and cholesterol levels, or the resulting outcomes.This study used the Centers for Disease Control and Prevention (CDC)-RTI Diabetes Cost-Effectiveness Model to analyze the cost-effectiveness of bariatric surgery in severely obese adults with diabetes. We separately estimated the cost-effectiveness of gastric bypass surgery relative to usual diabetes care and the cost-effectiveness of gastric banding surgery relative to usual diabetes care. Gastric bypass and gastric banding are the two forms of bariatric surgery most commonly studied (1). We examined the cost-effectiveness of each type of surgery for severely obese people who are newly diagnosed with diabetes (no more than 5 years after diagnosis) and for people with established diabetes (at least 10 years after diagnosis).     

Sex and Racial/Ethnic Differences in Cardiovascular Disease Risk Factor Treatment and Control Among Individuals With Diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA)

OBJECTIVE

To examine sex and racial/ethnic differences in cardiovascular risk factor treatment and control among individuals with diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA).

RESEARCH DESIGN AND METHODS

This study was an observational study examining mean levels of cardiovascular risk factors and proportion of subjects achieving treatment goals.

RESULTS

The sample included 926 individuals with diabetes. Compared with men, women were 9% less likely to achieve LDL cholesterol <130 mg/dl (adjusted prevalence ratio 0.91 [0.83–0.99]) and systolic blood pressure (SBP) <130 mmHg (adjusted prevalence ratio 0.91 [0.85–0.98]). These differences diminished over time. A lower percentage of women used aspirin (23 vs. 33%; P < 0.001). African American and Hispanic women had higher mean levels of SBP and lower prevalence of aspirin use than non-Hispanic white women.

CONCLUSIONS

Women with diabetes had unfavorable cardiovascular risk factor profiles compared with men. African American and Hispanic women had less favorable profiles than non-Hispanic white women.Population-based health survey data suggest that sex and racial/ethnic disparities are present in diabetes process of care measures and cardiovascular risk factor control (1–9). Available data also indicate that sex-specific race/ethnicity differences are present in cardiovascular risk factor control, but these data are limited to Medicare and Veterans'' Hospital patient populations (5,10–13). We therefore performed analyses of participants with diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA) to examine sex and sex-specific racial/ethnic differences in cardiovascular risk factor treatment and control.     

Effectiveness of a Computerized Insulin Order Template in General Medical Inpatients With Type 2 Diabetes: A cluster randomized trial

OBJECTIVE

To determine whether an electronic order template for basal-bolus insulin ordering improves mean blood glucose in hospitalized general medical patients with hyperglycemia and type 2 diabetes.

RESEARCH DESIGN AND METHODS

We randomly assigned internal medicine resident teams on acute general medical floors to the use of an electronic insulin order template or usual insulin ordering. We measured diabetes care parameters for 1 month on all patients with type 2 diabetes and blood glucose <60 mg/dl or >180 mg/dl treated by these physicians.

RESULTS

Intervention group patients (n = 65) had mean glucose of 195 ± 66 mg/dl. Control group patients (n = 63) had mean glucose of 224 ± 57 mg/dl (P = 0.004). In the intervention group, there was no increase in hypoglycemia.

CONCLUSIONS

Access to a computer insulin order template was associated with improved mean glucose levels without increasing hypoglycemia in patients with type 2 diabetes.Physiological, basal-bolus insulin prescribing is safe, effective (1), and the standard of care in hospitalized patients with type 2 diabetes and hyperglycemia (2). Yet only about half of such patients are prescribed basal insulin in the hospital (3). Order templates to support basal-bolus insulin prescribing (usually as part of a comprehensive inpatient diabetes quality improvement program) have been effective in improving glycemia in observational trials (4–8). Randomized trials have shown more modest effects (9,10). Knowledge of appropriate insulin ordering is a barrier to ordering basal-bolus insulin among inpatient providers (11–13).We tested the hypothesis that giving internal medicine residents access to an electronic insulin order template would be more effective than usual insulin ordering in lowering mean blood glucose in medical inpatients with type 2 diabetes.