Thirty-year trends in cardiovascular risk factor levels among US adults with diabetes: National Health and Nutrition Examination Surveys, 1971-2000

Among US adults with diabetes, using data from the National Health and Nutrition Examination Survey for 1971-1974, 1976-1980, 1988-1994, and 1999-2000, the authors describe 30-year trends in total cholesterol, blood pressure, and smoking levels. Using Bayesian models, the authors calculated mean changes per year and 95% credible intervals for age-adjusted mean total cholesterol and blood pressure levels and the prevalence of high total cholesterol (> or =5.17 mmol/liter), high blood pressure (systolic blood pressure: > or =140 mmHg and/or diastolic blood pressure: > or =90 mmHg), and smoking. Between 1971-1974 and 1999-2000, mean total cholesterol declined from 5.95 mmol/liter to 5.48 mmol/liter (-0.02 (95% credible interval: -0.03, -0.01) mmol/liter per year). The proportion with high cholesterol decreased from 72% to 55%. Mean blood pressure declined from 146/86 mmHg to 134/72 mmHg (systolic blood pressure: -0.5 (95% credible interval: -1.1, 0.5) mmHg per year; diastolic blood pressure: -0.6 (95% credible interval: -1.0, -0.03) mmHg per year). The proportion with high blood pressure decreased from 64% to 37%, and smoking prevalence decreased from 32% to 17%. Although these trends are encouraging, still one of two people with diabetes has high cholesterol, one of three has high blood pressure, and one of six is a smoker.     

Participatory Decision Making,Patient Activation,Medication Adherence,and Intermediate Clinical Outcomes in Type 2 Diabetes: A STARNet Study

PURPOSE Participatory decision making (PDM) is associated with improved diabetes control. We examine a causal model linking PDM to improved clinical outcomes that included patient activation and medication adherence.METHODS This observational study was conducted in 5 family physician offices. Diabetic patients were recruited by mail and by completing a study interest card at the conclusion of their office visit. Two survey questionnaires, administered 12 months apart, elicited patients’ ratings of their physician’s PDM style at baseline and their level of activation and medication adherence both at baseline and at follow-up. Measures of glycated hemoglobin (hemoglobin A_1c), systolic blood pressure, and low-density lipoprotein (LDL) cholesterol were abstracted from the medical record starting 12 months before the baseline survey to 12 months after the follow-up survey. A path analysis using a structural equation model was used to test hypotheses.RESULTS We mailed questionnaires to 236 participants; 166 (70%) returned the baseline questionnaire, and 141 (80%) returned the follow-up questionnaire. Hemoglobin A_1c levels, systolic blood pressure, and LDL cholesterol values all declined significantly, and patient activation and medication adherence improved. PDM at baseline was associated with patient activation at follow-up. Patient activation at follow-up was associated with medication adherence at follow-up, and medication adherence at follow-up was associated with change in hemoglobin A_1c levels and LDL cholesterol values but not with systolic blood pressure.CONCLUSIONS Participatory decision making during primary care encounters by patients with type 2 diabetes resulted in improvements in hemoglobin A_1c levels and LDL cholesterol values by improving patient activation, which in turn improved medication adherence.     

Substituting white rice with brown rice for 16 weeks does not substantially affect metabolic risk factors in middle-aged Chinese men and women with diabetes or a high risk for diabetes

Epidemiologic studies have suggested that higher consumption of white rice (WR) is associated with increased risk for type 2 diabetes mellitus. However, it is unclear whether substituting brown rice (BR) for WR can improve metabolic risk factors. A total of 202 middle-aged adults with diabetes or a high risk for diabetes were randomly assigned to a WR (n = 101) or BR group (n = 101) and consumed the rice ad libitum for 16 wk. Metabolic risk markers, including BMI, waist circumference, blood pressure, glycated hemoglobin, and serum lipid, glucose, and insulin concentrations were measured before and after the intervention. Over the course of the intervention, no between-group differences were found for any markers except the serum LDL cholesterol concentration, which decreased more in the WR group compared to the BR group (P = 0.02). However, this effect was observed only among participants with diabetes (n = 47). The reversion rate of reduced serum HDL cholesterol was marginally higher in the BR group (14.9%) than in the WR group (6.9%) (P = 0.07). Among participants with diabetes, a greater reduction in diastolic blood pressure was observed in the BR group compared to the WR group (P = 0.02). Our study suggests that incorporating BR into the daily diet for 16 wk did not substantially improve metabolic risk factors. Further studies with larger sample sizes, longer durations of follow-up, and different varieties of rice are needed to carefully examine the role of BR in the prevention and management of diabetes.     

Effects of purified eicosapentaenoic and docosahexaenoic acids on glycemic control,blood pressure,and serum lipids in type 2 diabetic patients with treated hypertension

BACKGROUND: n-3 Fatty acids lower blood pressure, improve lipids, and benefit other cardiovascular disease risk factors. Effects on glycemia in patients with type 2 diabetes are uncertain. OBJECTIVE: We determined whether purified eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have differential effects on glycemic control, including insulin sensitivity and stimulated insulin secretion; 24-h ambulatory blood pressure; and serum lipids in type 2 diabetic patients with treated hypertension. DESIGN: In a double-blind, placebo-controlled trial of parallel design, 59 subjects were randomly assigned to consume 4 g EPA, DHA, or olive oil/d for 6 wk while continuing to consume their usual diet. RESULTS: Thirty-nine men and 12 postmenopausal women with a mean (+/- SE) age of 61.2 +/- 1.2 y completed the study. In comparison with the change from baseline in fasting glucose in the olive oil group, fasting glucose in the EPA and DHA groups increased 1.40 +/- 0.29 mmol/L (P = 0.002) and 0.98 +/- 0.29 mmol/L (P = 0.002), respectively. Neither EPA nor DHA had significant effects on glycated hemoglobin, fasting insulin or C-peptide, insulin sensitivity or secretion, or blood pressure. Serum triacylglycerols in the EPA and DHA groups decreased 19% (P = 0.022) and 15% (P = 0.022), respectively. There were no significant changes in serum total, LDL, or HDL cholesterol, although HDL(2) cholesterol in the EPA and DHA groups increased 16% (P = 0.026) and 12% (P = 0.05), respectively. HDL(3) cholesterol decreased 11% (P = 0.026) with EPA supplementation. CONCLUSIONS: EPA and DHA had similar benefits on lipids but adverse effects on short-term glycemic control in hypertensive diabetic patients. The overall implications for cardiovascular disease require long-term evaluation.     

Gender Differences in Cardiovascular Risk Factors in Incident Diabetes

BackgroundCardiovascular disease is a major cause of morbidity and mortality for women and men with diabetes. Previous cross-sectional studies of prevalent diabetes have found that women are less likely to meet American Diabetes Association (ADA) and American Heart Association guidelines for control of cardiovascular risk factors (hemoglobin A1c, low-density lipoprotein [LDL] cholesterol, and blood pressure), but have not studied the critical period immediately after diagnosis.MethodsTo assess gender differences in cardiovascular risk factors at the time of diabetes diagnosis (baseline) and 1 year later (follow-up), we conducted a retrospective cohort study of 6,547 individuals with incident diabetes in an integrated care delivery system. We assessed mean cardiovascular risk factor values by gender and adjusted odds ratios of attaining ADA goals.FindingsCompared with men, at baseline women had lower hemoglobin A1c (7.9% vs. 8.2%; p < .001), higher LDL cholesterol (118.9 vs. 111.5 mg/dL; p < .001), higher systolic blood pressure (131.9 vs. 130.5 mmHg; p < .001), and lower diastolic blood pressure (79.1 vs. 79.7 mmHg; p = .006). At follow-up, the hemoglobin A1c gender gap had closed (6.9% vs. 6.9%; p = .39), and the gender gaps had decreased for blood pressure (129.8/77.0 vs. 128.9/77.6; p = .009) and LDL cholesterol (104.0 vs. 98.2 mg/dL; p < .001). These associations varied by age. Adjusted odds ratios showed similar relationships.ConclusionsIn this cohort of individuals with incident diabetes, men and women had important differences in risk factor control at the time of diabetes diagnosis. These differences varied by age and decreased over time.     

Changes in dietary intake account for seasonal changes in cardiovascular disease risk factors.

OBJECTIVES: (1) to compare dietary intake in summer and winter time; (2) to measure the change in body mass index (BMI), blood pressure and serum cholesterol between winter and summer; and (3) to determine the relationships between seasonal differences in dietary intake and BMI, blood pressure and serum cholesterol measurements. SUBJECTS AND METHODS: Ninety-four male industrial employees were screened twice in one year, in their work place, at winter and summer time. Workers were recruited from two factories and response rate was 95%. Health-related variables, including dietary intake, blood pressure and serum cholesterol were evaluated at each season and were compared. Correlation coefficients between seasonal differences in dietary intake and in BMI, blood pressure and serum cholesterol were calculated. RESULTS: From summer to winter the mean values of BMI increase from 26.1 kg/cm2 to 26.6 (P=0.038), systolic blood pressure from 119.6 to 121.6 (P=0.025), diastolic blood pressure from 75.2 to 77.2 mmHg (P=0.001), total cholesterol from 200.8 to 208.6 mg/dL (P=0.001), LDL cholesterol from 125.2 to 134.9 (P=0.001) and HDL cholesterol from 42.7 to 44.3 (P=0.0084). Triglycerides levels decrease from 174 to 145 in the winter (P=0.03). Mean dietary intake of fat increases from 99.1 to 106.0 (P=0.0016), saturated fat from 43.6 to 46.3 (P=0.0137), polyunsaturated fat from 25.1 to 28.3 (P=0.0002), cholesterol from 462.0 to 497.9 (P=0.0313), sodium from 5778.5 to 8208.2 (P=0.0035), zinc from 11.6 to 12.3 (P=0.0001), vitamin B1 from 1.4 to 1.5 (P=0.002), vitamin D from 4.3 to 4.9 (P=0.0323) and vitamin E from 11.2 to 12.7 (P=0.0073). Significant correlation was shown between the seasonal increase in saturated fat and the increase in BMI (r=0.37), total cholesterol (r=0.21) and LDL cholesterol (r=0.29). Seasonal change in dietary cholesterol intake was significantly and positively correlated with serum total cholesterol (r=0.24) and LDL cholesterol (r=0.24). Blood pressure was not associated with nutritional intake variables. CONCLUSIONS: Dietary intake in summer and winter is different as well as blood pressure, BMI and serum cholesterol. The seasonal increase in fat and cholesterol intake at winter time is associated with changes in BMI and serum cholesterol.     

Effects on diabetes management of a health-care provider mediated, remote coaching system via a PDA-type glucometer and the Internet

We conducted a randomized controlled trial for 12 weeks in patients with type 2 diabetes living in a rural part of Korea. The intervention group (n = 35) was managed by a diabetes centre which provided specialized management mediated by a primary health-care nurse who used a PDA-type blood glucometer with a bar code detector to measure the capillary glucose levels. The control group (n = 36) received usual care. Compared with baseline, HbA(1c) was significantly reduced at three-month follow-up in the intervention group (8.0% vs. 7.5%; P < 0.01), but not in the control group. Total cholesterol was significantly reduced in the intervention group (10.7 mmol/L vs. 10.4 mmol/L; P = 0.043). Fasting plasma glucose and triglyceride levels were lower at follow-up in both groups, but the difference was not significant. The new system could be implemented widely and would contribute to improving the quality of diabetes care, even in isolated rural areas.     

A successful physician training program in cholesterol screening and management

METHOD. Thirty-six resident physicians received a blood cholesterol training program which included training in blood cholesterol screening using a fingerstick method and a desktop analyzer, diet assessment and counseling, and a management protocol for follow-up diet and drug treatment. The program also included feedback to residents about their blood cholesterol screening activity, incentives, and biweekly articles in the department newsletter. RESULTS. Between 1986-1987 (baseline) and 1987-1988 (intervention), the percentage of the target patient population (ages 20-65 years, nonpregnant, not screened in the previous year) that was screened for hypercholesterolemia in this primary care practice increased from 16.2 to 23.2% [rate difference (RD) = 7.0; 95% confidence interval (CI) = 4.75-9.25]. The mean value of the screening tests decreased from 5.36 mmol/liter (207.2 mg/dl) to 5.08 mmol/liter (196.6 mg/dl; t = 2.98, P = 0.003) and the percentage of the population screened needing further evaluation decreased from 36.8 to 27.6% (RD 9.2; CI = 2.00-14.00). In the intervention year, compared with the baseline year, patients with a borderline blood cholesterol and cardiovascular risk factors were more likely to have a follow-up test (28.8% vs 11.9%, RD = 16.9; 95% CI = 0.80-33.00) and the low-density lipoprotein cholesterol test was used less for screening (8.2% vs 19.4%, P less than 0.0001). Conclusion. We conclude that this program was effectively integrated into a busy primary care practice, leading to improvement in blood cholesterol screening and management practices.     

Flavonoid-rich cocoa consumption affects multiple cardiovascular risk factors in a meta-analysis of short-term studies

A growing body of evidence suggests that the consumption of foods rich in polyphenolic compounds, particularly cocoa, may have cardioprotective effects. No review, however, has yet examined the effect of flavonoid-rich cocoa (FRC) on all major cardiovascular risk factors or has examined potential dose-response relationships for these effects. A systematic review and meta-analysis of randomized, controlled trials was performed to evaluate the effect of FRC on cardiovascular risk factors and to assess a dose-response relationship. Inclusion and exclusion criteria as well as dependent and independent variables were determined a priori. Data were collected for: blood pressure, pulse, total cholesterol, HDL cholesterol, LDL cholesterol, TG, BMI, C-reactive protein, flow-mediated vascular dilation (FMD), fasting glucose, fasting insulin, serum isoprostane, and insulin sensitivity/resistance indices. Twenty-four papers, with 1106 participants, met the criteria for final analysis. In response to FRC consumption, systolic blood pressure decreased by 1.63 mm Hg (P = 0.033), LDL cholesterol decreased by 0.077 mmol/L (P = 0.038), and HDL cholesterol increased by 0.046 mmol/L (P = 0.037), whereas total cholesterol, TG, and C-reactive protein remained the same. Moreover, insulin resistance decreased (HOMA-IR: -0.94 points; P < 0.001), whereas FMD increased (1.53%; P < 0.001). A nonlinear dose-response relationship was found between FRC and FMD (P = 0.004), with maximum effect observed at a flavonoid dose of 500 mg/d; a similar relationship may exist with HDL cholesterol levels (P = 0.06). FRC consumption significantly improves blood pressure, insulin resistance, lipid profiles, and FMD. These short-term benefits warrant larger long-term investigations into the cardioprotective role of FRC.     

广州市农村地区慢性病自我管理模式效果初探

目的评价慢性病自我管理小组活动实施6个月后的效果,探讨慢性病自我管理在农村地区实施的可行性。方法采用香港复康会慢性病自我管理模式,在广州市番禺区小谷围村和沙公堡村各成立1个慢性病自我管理小组（小谷围村组30人,沙公堡f村组21人）,每组由2名小组长按照指导手册组织开展小组活动。活动前和活动完成6个月后对参加活动的患者进行问卷调查和实验室检测,比较活动前后患者慢性病相关知识知晓率、慢性病相关危险因素和身体指标的变化情况。结果共51名患者接受问卷调查和体检,其中男性27人,女性24人,年龄34~86（65.47±11.51）岁;自我管理小组活动后6个月与活动前相比高血压、糖尿病标准知晓率分别提高了11.76%和17.64%,糖尿病标准知晓率活动前后差别有统计学意义（χ2=4.55,P〈0.05）;慢性病相关危险因素（控制体重人数、饮食咸淡适中情况、药物治疗情况）短期改善效果明显,活动前后差别均有统计学意义;活动后6个月与活动前相比患者的收缩压、空腹血糖、体重指数、血清总胆固醇分别下降了5.16 mmHg、0.22 mmol/L、0.33和0.22 mmol/L,舒张压和血清甘油三酯分别上升了1.17 mmHg和0.11 mmol/L,但各指标在活动前后差别均无统计学意义。结论该慢性病自我管理模式短期内可明显增加参与者慢性病相关知识,适当改善慢性病患者身体功能以及健康相关行为;提示慢性病自我管理模式可以在经济欠发达的农村地区推广,但要保持长期效果尚需要进一步研究     

Prevalence of vitamin D insufficiency and risk factors for type 2 diabetes and cardiovascular disease among African migrant and refugee adults in Melbourne: a pilot study

Migration to industrialised countries poses a "double whammy" for type 2 diabetes among sub-Saharan African migrant and refugee adults. This population group has been found to be at an increased risk of obesity and type 2 diabetes, which may be further aggravated by inadequate vitamin D status. Thus, this study aimed to describe the demographics of vitamin D insufficiency, obesity, and risk factors for type 2 diabetes among sub-Saharan African migrants and refugees aged 20 years or older living in Melbourne, Australia (n=49). Data were obtained by a questionnaire, medical assessment, and fasting blood samples. The mean serum 25-hydroxyvitamin D level was 27.3 nmol/L (95% CI: 22.2, 32.4 nmol/L); with 25-hydroxyvitamin D levels <50 nmol/L occurring in 88% of participants. Participants displayed a cluster of risk factors for type 2 diabetes and cardiovascular disease: 62% were overweight or obese, 47% had insulin resistance (HOMA-IR >=2), 25% had low density lipoprotein cholesterol levels >=3.5 mmol/L, 24.5% had high density lipoprotein cholesterol levels <=1.03 mmol/L, 34.6% had borderline or high levels of total cholesterol (>=5.2 mmol/L), 18.2% had borderline or high levels of triglyceride (>=1.7 mmol/L), and 16% had hypertension (systolic blood pressure >=140 mmHg or diastolic blood pressure >=90 mmHg). These findings suggest that sub-Saharan African migrants and refugees may be at risk of type 2 diabetes and atherosclerosis-related diseases such as ischemic heart disease, stroke, and peripheral vascular disease. Well-designed vitamin D interventions that incorporate lifestyle changes are urgently needed in this sub-population.     

Nutritional status in patients with diabetes and chronic kidney disease: a prospective study

BACKGROUND: A poor nutritional status reduces the life expectancy of diabetes patients undergoing hemodialysis. OBJECTIVE: The study objective was to specify the nutritional outcome in patients with chronic kidney disease (CKD) and well-controlled diabetes. DESIGN: Forty-five diabetes patients with CKD were enrolled in a cooperative-care program designed to control glucose, blood pressure, LDL cholesterol, and the albumin excretion rate (AER). Their glomerular filtration rate (GFR), body composition, serum albumin (SA), and resting energy expenditure were assessed and compared at baseline and 2 y later. RESULTS: Thirty-five patients did not start dialysis. Their glycated hemoglobin, blood pressure, LDL cholesterol, and AER improved; their GFR declined slowly (-3.3 mL x min(-1) x 1.73 m(-2) x y(-1)). Their body mass index (BMI), lean body mass, and SA increased. The GFR decline was correlated negatively with the initial BMI (r = -0.37, P < 0.05) and positively with the initial GFR (r = 0.34, P < 0.05). Ten patients started hemodialysis: except for higher total body water (P < 0.05) and extracellular volume (P < 0.01), their initial nutritional status did not differ significantly from that of 10 patients with comparable baseline severe CKD but without dialysis. At the second evaluation, patients on hemodialysis lost lean body mass, and their SA was lower than that of the patients with severe CKD (P = 0.05); lean body mass was unchanged and SA was higher (P = 0.01) in the patients with severe CKD. No significant difference was detected for resting energy expenditure. CONCLUSIONS: Nutritional status improved in CKD patients with well-controlled diabetes without dialysis, and it deteriorated in patients who started dialysis. A high initial BMI was associated with a slower decline in GFR.     

延边地区朝鲜族与汉族青少年心血管病危险因素的分布比较

[目的]比较朝鲜族与汉族青少年心血管病危险因素的分布.[方法]1997年9月,采用横断面研究方法,对延边地区朝鲜族、汉族中学生1122名的心血管病危险因素进行了调查.[结果]男性高密度脂蛋白-胆固醇水平,朝鲜族和汉族分别为1.00、1.07、mmol/L,空腹血糖分别为4.64、3.36mmol/L,重度肥胖率分别为9.4%、3.1%.女性甘油三酯水平,朝鲜族和汉族分别为0.82、0.75mmol/L,空腹血糖分别为4.86、3.36mmol/L,舒张压分别为72.9、70.5mmHg,肥胖率分别为18.3%、10.8%.朝鲜族肥胖组,甘油三酯、收缩压及舒张压均值皆高于正常体重组.汉族总胆固醇、甘油三酯、低密度脂蛋白-胆固醇、收缩压与舒张压均值肥胖组皆高于正常体重组.血糖对朝鲜族的血压的影响较大,而低密度脂蛋白-胆固醇对汉族血压的影响较大.[结论]朝鲜族和汉族青少年心血管病危险因素分布有差异,应对青少年提早进行心血管病危险因素的监测.     

Kennedy Space Center Cardiovascular Disease Risk Reduction Program evaluation

This program evaluation examined the Kennedy Space Center (KSC) Cardiovascular Disease (CVD) Risk Reduction Program which aims to identify CVD risk factors and reduce these risk factors through health education phone counseling. High risk participants (those having two or more elevated lipid values) are identified from monthly voluntary CVD screenings and counseled. Phone counseling consists of reviewing lab values with the participant, discussing dietary fat intake frequency using an intake questionnaire, and promoting the increase in exercise frequency. The participants are followed-up at two-months and five-months for relevant metrics including blood pressure, weight, body mass index (BMI), total cholesterol, high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol, triglycerides, dietary fat intake, and exercise frequency. Data for three years of the KSC CVD Program included 366 participants, average age of 49 years, 75% male, and 25% female. For those with complete two and five month follow-up data, significant baseline to two-month follow-up comparisons included decreases in systolic blood pressure (p = 0.03); diastolic blood pressure (p = 0.002); total cholesterol, LDL cholesterol and dietary fat intake (all three at p < 0.0001) as well as a significant increase in exercise frequency (p = 0.04). Significant baseline to five-month follow-up comparisons included decreases in triglycerides (p = 0.05); and total cholesterol, LDL cholesterol and dietary intake (all three at p < 0.0001). These program evaluation results indicate that providing brief phone health education counseling and information at the worksite to high risk CVD participants may impact CVD risk factors.     

Improvements in Care and Reduced Self-management Barriers Among Rural Patients With Diabetes

CONTEXT: Improved preventive care and clinical outcomes among patients with diabetes can reduce complications and costs; however, diabetes care continues to be suboptimal. Few studies have described effective strategies for improving care among rural populations with diabetes. PURPOSE: In 2000, the Park County Diabetes Project and the Montana Diabetes Control Program collaboratively implemented a countywide effort, which included health systems interventions and coordinated diabetes education, to improve the quality of diabetes care. METHODS: Clinical data from the diabetes registries in 2 primary care practices, in addition to baseline and follow-up telephone surveys, were used to evaluate improvements in care, outcomes, education, and barriers to self-management. FINDINGS: In the cohort of patients, the proportion receiving the following services increased significantly from 2000 to 2003: annual foot examination (43% to 58%), influenza (30% to 53%), and pneumoccocal immunizations (39% to 70%). The median hemoglobin A1c values decreased significantly from baseline to follow-up (7.2% to 6.8%). Mean systolic and diastolic blood pressure decreased significantly over the 2 time periods (139 mmHg to 135 mmHg, and 78 mmHg to 75 mmHg, respectively). Significant decreases were also observed in barriers to self-management, including lack of knowledge (decrease from 12% to 5%), difficulties making lifestyle changes (36% to 27%), cost of monitors and test strips (25% to 16%), cost of medications (37% to 24%), and diabetes education (22% to 4%). CONCLUSIONS: Findings suggest that system changes in primary care practices and the implementation of accessible diabetes education can improve care and reduce barriers for rural patients with diabetes.     

Diabetes risk factors, diabetes and diabetes care in a rural Australian community

OBJECTIVE: To comprehensively describe diabetes-related risk factors, quality of care and patient-perceived barriers to care in a rural community. DESIGN: Cross-sectional mail study, self-completed survey and retrospective chart review. SETTING: Community and health services in Corryong, rural Victoria, Australia. PARTICIPANTS: Ninety-seven patients with diabetes and 495 with other diseases in the mail study, 84 with diabetes in the self-completed survey and 101 diabetic patient chart reviews. MAIN OUTCOME MEASURES: Self-reported lifestyle activities, uptake of health checks, metabolic measures and uptake of medication, and self-reported barriers to diabetes care. RESULTS: Most residents without diabetes had recently had their blood pressure and cholesterol checked; 60.4% were trying to control their weight and 73.9% were exercising regularly (although only 30.7% to an adequate level). Those with diabetes reported a greater uptake of healthy living messages, and had a mean HbA1c of 7.3%, total cholesterol of 5.0 mmol L(-1); 12.9% had a diastolic blood pressure > or =85 mmHg. Foot checks were infrequent (18%). There was substantial room to increase antiplatelet, blood pressure, antihyperglycaemia and lipid-lowering therapy. Most patients reported psychological (84.5%) and educational (82.1%) barriers to care, with few perceiving physical barriers to care. CONCLUSION: Living in a rural area with predominantly GP care can be associated with comparatively good metabolic control, although psycho-educational barriers are frequently present. In the wider community, risk factors for diabetes remain common, and the majority have been screened for components of the metabolic syndrome in the previous year.     

2013年常熟市2型糖尿病患者的血糖、血脂及血压控制情况及影响因素分析

目的 评估常熟市2型糖尿病患者血糖、血压及血脂控制情况,探讨其影响因素,为优化社区糖尿病管理提供依据。方法 对2013年常熟市社区管理的10 238例2型糖尿病患者进行调查,根据中华医学会糖尿病学分会(Chinese Diabetes Society, CDS)的综合控制目标,评估血糖、血压及血脂的达标情况。结果 10 238例被调查者的糖化血红蛋白(Hemoglobin A1c,HbAlc)平均值为(7.60±1.58)%,达到控制目标(HbA1c<7.0%)的比例为40.84%。SBP平均值为(150.06±20.05)mmHg,达标率为32.01%,DBP平均值为(80.76±10.33)mmHg,达标率为46.70%,两者同时达到控制目标(<140/80 mmHg)的比例为22.33%。TG平均值为(1.96±1.60)mmol/L,达标率为56.80%, TC平均值为(5.24±1.11)mmol/L,达标率为23.82%,HDL-C平均值为(1.50±0.41)mmol/L,达标率为78.43%,LDL-C平均值为(3.13±0.90)mmol/L,达标率为25.22%。除HDL-C外,血脂其余三项指标检测平均值均超过糖尿病综合控制目标值,差异有统计学意义(均P<0.05)。多因素非条件logistic回归分析显示,地区(OR=1.351,OR95%CI:1.242~1.470 )、血脂(OR=1.257,OR95%CI:1.156~1.367)、吸烟(OR=1.297,OR95%CI:1.082~1.554)、腰围(OR=1.290,OR95%CI:1.184~1.404)、性别(OR=0.698,OR95%CI:0.638~0.763)、年龄:(OR=0.897,OR95%CI:0.854~0.941)、用药情况(OR=1.244,OR95%CI:1.208~1.282)、收缩压(OR=1.208,OR95%CI:1.104~1.322)、糖尿病病程(OR=1.517,OR95%CI:1.450~1.588)是血糖控制的独立影响因素。生活在农村、吸烟、男性、年龄50岁以下、用药不佳、糖尿病病程长,血脂、腰围、收缩压控制不良均不利于血糖的控制。结论 2013年常熟市2型糖尿病患者血糖、血压和血脂控制达标率不够理想,影响因素有地区、吸烟、性别、年龄、用药情况、糖尿病病程、血脂、腰围、收缩压等,应积极开展综合措施控制血糖和糖尿病并发症的发生。     

基线总胆固醇水平对糖尿病人群新发脑梗死事件的影响

目的探讨基线总胆固醇水平对糖尿病人群新发脑梗死事件的影响。方法采用前瞻性队列研究方法,以空腹血糖≥7.0 mmo/lL或<7.0 mmo/lL但已确诊为糖尿病,正在使用降糖药物的8 306例糖尿病人群作为观察队列,随访(48.01±3.14)个月,随访期间每半年收集一次新发脑梗死事件情况。分析基线总胆固醇水平对糖尿病人群新发脑梗死事件的影响。结果 (1)随着基线总胆固醇水平的增高,研究对象的空腹血糖、甘油三酯、收缩压和舒张压的水平逐渐增高(P<0.05)。(2)总胆固醇<4.46 mmo/lL组累积发生脑梗死事件率最低(2.2%,P<0.05)。校正年龄、性别、空腹血糖、收缩压、舒张压、甘油三酯、体重指数、吸烟和糖尿病病程因素,Cox比例风险回归分析表明,相对于总胆固醇<4.46 mmo/lL组,总胆固醇≥5.93 mmo/lL组发生脑梗死事件的相对危险(RR)增加1.90倍(95%CI 1.24～2.89,P<0.01)。结论糖尿病人群总胆固醇控制在4.46 mmo/lL以下发生脑梗死事件率最低。     

Outcomes of audit-enhanced monitoring of patients with type 2 diabetes

OBJECTIVE: To assess the outcome of diabetes care in a practice-based research network after the introduction of an audit-enhanced monitoring system (AEMS). STUDY DESIGN: An AEMS was introduced into family practices participating in the academic research network of Nijmegen University, Nijmegen, the Netherlands. One and 7 years later, a cross-sectional analysis was performed on the outcome of care in all type 2 diabetes patients under treatment by their family physicians. POPULATION: Approximately 42,000 patients in 1993 and approximately 46,000 patients in 1999 at 10 family practices participating in the university's academic research network. OUTCOMES MEASURED: Targets of care were HbA1c < 8.5% and blood pressure < 150/85 mm Hg. Targets for lipids depended on age, cardiovascular morbidity, and smoking status. RESULTS: In 1993, 540 type 2 diabetes patients were included; in 1999, 851 such patients were included, representing a prevalence of 1.3% and 2.0%, respectively. Glycemic control improved statistically significantly by the percentage of patients with HbA1c < 8.5% (87% vs 59%, P =.0001) and the mean HbA1c (7.1% vs 8.2%, P =.0001) from the first to the second cohort. Mean blood pressure and the percentage of patients above the target blood pressure did not change. The mean cholesterol (207 mg/dL vs 238 mg/dL [5.4 mmol/L vs 6.2 mmol/L], P =.0001) and the percentage of patients who met their target lipid levels (72% vs 52%, P =.001) also improved between 1993 and 1999. In addition, an increased percentage of patients attended an annual review in the past year (73% vs 84%). CONCLUSIONS: Outcomes of diabetes care in a family practice research setting using an AEMS were comparable with those reported under randomized controlled trial conditions.     

Introducing a new component of the metabolic syndrome: low cholesterol absorption

BACKGROUND: Weight reduction is the recommended treatment of obese type 2 diabetes, but the effects of weight reduction on cholesterol metabolism are poorly understood. OBJECTIVE: We investigated glucose, cholesterol, and lipoprotein metabolism at baseline and 2 y after weight reduction in obese patients with type 2 diabetes consuming an isoenergetic diet. DESIGN: Sixteen subjects were randomly chosen to consume a very-low-energy or low-energy diet for 3 mo, after which they consumed a weight-maintenance diet for up to 2 y. Cholesterol absorption and metabolism, LDL and HDL kinetics, and variables of glucose metabolism were studied at baseline and 2 y. RESULTS: Baseline serum sex hormone binding globulin (SHBG) was significantly related to cholesterol absorption efficiency, and serum glucose and insulin concentrations were associated with cholesterol synthesis. After 2 y, body weight was reduced by 6 +/- 1 kg (P < 0.01), body mass index by 6% (P < 0.05), and blood glucose by 14% (P < 0.01); the ratio of serum SHBG to insulin increased by 66% (P < 0.05). Serum and VLDL, LDL, and HDL triacylglycerol were significantly reduced by 13-24%. Despite unchanged serum concentrations of cholesterol, cholesterol absorption efficiency and the ratio of serum plant sterols to cholesterol-indicators of cholesterol absorption-increased by 28% (P < 0.01) and 20-31% (P < 0. 05 for both), respectively; the fractional removal of LDL apolipoprotein B decreased. Fecal excretion of cholesterol as neutral sterols decreased significantly by 11%. Changes in body weight were significantly negatively correlated with changes in ratios of cholesterol to serum plant sterols and cholestanol. CONCLUSIONS: Baseline cholesterol absorption and synthesis were related to respective serum SHBG, glucose, and insulin values. Weight reduction increased cholesterol absorption and improved variables of glucose metabolism. These results suggest that low cholesterol absorption and high synthesis may be part of the insulin resistance syndrome.