Prevalence of comorbidity in primary care patients with type 2 diabetes and its association with elevated HbA1c: A cross-sectional study in Croatia

Objective To the authors’ knowledge, there are few valid data that describe the prevalence of comorbidity in type 2 diabetes mellitus (T2DM) patients seen in family practice. This study aimed to investigate the prevalence of comorbidities and their association with elevated (≥?7.0%) haemoglobin A1c (HbA1c) using a large sample of T2DM patients from primary care practices. Design A cross-sectional study in which multivariate logistic regression was applied to explore the association of comorbidities with elevated HbA1c. Setting Primary care practices in Croatia. Subjects Altogether, 10 264 patients with diabetes in 449 practices. Main outcome measures Comorbidities and elevated HbA1c. Results In total 7979 (77.7%) participants had comorbidity. The mean number of comorbidities was 1.6 (SD 1.28). Diseases of the circulatory system were the most common (7157, 69.7%), followed by endocrine and metabolic diseases (3093, 30.1%), and diseases of the musculoskeletal system and connective tissue (1437, 14.0%). After adjustment for age and sex, the number of comorbidities was significantly associated with HbA1c. The higher the number of comorbidities, the lower the HbA1c. The prevalence of physicians’ inertia was statistically significantly and negatively associated with the number of comorbidities (Mann–Whitney U test, Z?=?–12.34; p?Conclusion There is a high prevalence of comorbidity among T2DM patients in primary care. A negative association of number of comorbidities and HbA1c is probably moderated by physicians’ inertia in treatment of T2DM strictly according to guidelines.

• Key points

• There is a high prevalence of comorbidity among T2DM patients in primary care.

• Patients with breast cancer, obese patients, and those with dyslipidaemia and ischaemic heart disease were more likely to have increased HbA1c.

• The higher the number of comorbidities, the lower the HbA1c.

     

2型糖尿病患者糖尿病饮食知识掌握现状及其对糖化血红蛋白的影响

目的调查2型糖尿病(T2DM)患者糖尿病饮食知识的掌握现状,并探索其饮食知识对糖化血红蛋白(HbA1c)的影响。方法采用一般资料调查表和糖尿病饮食知识问卷,调查苏州地区的205例T2DM患者糖尿病饮食知识的掌握情况及对HbA1c的影响。结果患者糖尿病饮食知识掌握不十分理想,文化程度低者尤甚,约75%的患者知识得分不达标;而高中以上学历的人群学习能力较强,得分较高,75%左右达标。糖尿病饮食知识对有药物降糖治疗患者的HbA1c产生了影响(P0.05)。结论 T2DM患者的糖尿病饮食知识水平不一,应针对不同的人群采取个性化的健康教育。     

High serum ACE activity predicts severe hypoglycaemia over time in patients with type 1 diabetes

Abstract

Aims/hypothesis. High serum angiotensin-converting enzyme (ACE) activity is associated with increased risk of severe hypoglycaemia (SH) within 1 year in type 1 diabetes. We wanted to find out whether ACE activity is stable over time and predicts SH beyond 1 year, and if gender differences exist in the association between ACE activity and risk of SH. Methods. A follow-up study of 128 adult patients with type 1 diabetes was conducted. At entry, ACE activity was measured. For 12 months, patients prospectively recorded events of severe hypoglycaemia (SH). At a median of 40 months, ACE activity was measured again and participants recalled the number of SH in the last year. Results. ACE activity is reproducible over 40 months (p < 0.00001). Patients with SH during the baseline study also had SH during follow-up (p < 0.00001). Serum ACE activity measured at baseline was positively associated with the rate of SH at follow-up (p = 0.0003) with a 3.2-fold increased rate of SH in subjects belonging to the upper ACE quartile compared to subjects in the three lowest quartiles (p < 0.00001). The association between high serum ACE activity and increased risk of SH did not differ significantly in women and men. Conclusion. In type 1 diabetes individual serum ACE activity is reproducible over time. High ACE activity predicts recurrent SH over at least 40 months with no differences between genders.     

低碳水化合物饮食对2型糖尿病患者血糖管理有效性及安全性的系统评价

目的评价低碳水化合物饮食(Low Carbohydrate Diet,LCD)方案对2型糖尿病(Type 2diabetes mellitus,T2DM)患者血糖管理的有效性及安全性。方法计算机检索多个中英文数据库,查找所有LCD干预T2DM患者的随机对照试验,按照Cochrane偏倚风险评估评判标准对文献进行质量评价,用RevMan 5.0软件进行统计处理。结果共纳入11篇文献。与其他糖尿病饮食干预相比,LCD组糖化血红蛋白(HbA1c)和HDL-C水平的变化值明显优于干预组,总胆固醇水平和LDL-C指标未发生明显变化;两组低血糖发生次数差异无统计学意义(P0.05)。资料有异质性,主要源于纳入人群的体质指数。结论 LCD方案可进一步改善T2DM患者的血糖控制,并能改善HDL-C血脂指标,且安全性与对照组差异无统计学意义(P0.05)。     

2型糖尿病患者糖化白蛋白/糖化血红蛋白比值与动态血糖参数的相关性分析

目的 探讨糖化白蛋白/糖化血红蛋白比值（GA/HbA1c）与2型糖尿病（T2DM）患者动态血糖参数间的相关性。 方法 筛选2020年1月至2021年12月期间首次就诊于复旦大学附属中山医院内分泌科的T2DM患者。收集其一般临床资料，包括患者的血压、体重指数、生化指标、空腹血糖(FBG)、空腹C肽、精氨酸激发后的C肽，HbA1c、GA等。每例患者入院后佩戴扫描式血糖监测仪，截取每例患者入院后第3到5天的72小时的血糖结果，以此计算平均血糖、平均血糖波动幅度(MAGE)、最高及最低血糖差（△BG），以及血糖在目标范围的时间（TIR）、血糖高于目标范围时间（TAR）、血糖低于目标范围时间（TBR）。采用SPSS17.0统计学软件进行数据分析。 结果 共100例T2DM患者入选，其中男58例，女42例。以GA/HbA1c比值三分位数分组。随GA/HbA1c比值升高，激发后C肽值呈逐渐降低趋势(P趋势<0.05)，MAGE、FBG、△BG呈逐步升高趋势(P趋势<0.05)。Pearson相关分析/Spearman秩相关分析显示，GA/HbA1c比值与空腹C肽、激发后C肽水和TIR平呈负相关(P<0.01)，与FBG、MAGE、△BG呈正相关(P<0.05)。与并发症个数无相关性。多元线性回归分析显示，GA/HbA1c比值与MAGE、△BG、TIR 独立相关(P<0.05)。Logistic回归分析显示，GA/HbA1c比值与TIR（OR=6.990，95% CI 2.179~22.423，P<0.01）是否达标独立相关。 结论 GA/HbA1c比值与T2DM患者的残余胰岛β细胞功能相关，与血糖波动参数MAGE、△BG、TIR独立相关。该比值是评估胰岛功能、监测血糖波动及考察血糖达标的敏感指标。     

Recognition of fasting or overall hyperglycaemia when starting insulin treatment in patients with type 2 diabetes in general practice

Background

One of the long-term effects in childhood cancer survivors (CCS) is the development of second cancers. In a cohort of CCS, this study describes how second cancers were presented, the way they were diagnosed, and the knowledge CCS had about their increased risk to develop a second cancer.

Patients and methods

Selected participants were all adult five-year CCS (n = 1275) who were treated at the University Medical Center Groningen since 1965. Of these, 84 (6.6%) had developed a second cancer, of which 27 had died. The 57 survivors were asked to participate in a telephone interview.

Results

Of the 57 CCS, 35 (61%) participated. Together they had developed 45 second cancers. Most participants (97%) were seen at the long-term follow-up clinic. Of all second cancers, 89% caused symptoms. Of all second cancers, the majority (56%) were first presented at the general practitioner''s (GP''s) office and 20% at follow-up testing. Of these CCS, only 28% were aware of their increased risk of developing a second cancer.

Conclusions

It is important to inform CCS continuously regarding their increased risk, as a relatively small percentage are aware of this. Since most of these patients first reported their symptoms to the GP, all GPs should be aware of this increased risk, in particular because this concerns cancer at a younger age than normally expected. A survivor care plan might be an effective way of communication with both CCS and GPs.Key Words: Childhood cancer survivors, general practice, general practitioner, long-term follow-up, second cancers, The Netherlands

• Childhood cancer survivors are at risk of late effects such as development of second cancers.
• Follow-up testing for late effects is advised in long-term effects clinics, but is still debated with regard to second cancers.
• Awareness is advised among GPs about the risk of second cancers as most are diagnosed by the GP.

     

Recognition of fasting or overall hyperglycaemia when starting insulin treatment in patients with type 2 diabetes in general practice

OBJECTIVE: The efficacy of various regimens of initial insulin treatment in poorly controlled type 2 diabetes was compared with regard to diurnal glucose variation. DESIGN: Randomized controlled trial. Setting. Insulin therapy initiated on hospital wards, follow-up as outpatients for 12 months. SUBJECTS: Fifty-two type 2 diabetic patients (HbA1c >7.5%, mean 9.8%) on maximal oral therapy. Interventions. Insulin only (IO), bedtime insulin with sulphonylurea (glipizide) (IS), or bedtime insulin with metformin (IM). MAIN OUTCOME MEASURES: HbA1c and body weight. RESULTS: HbA1c decreased on average by 1.8, 1.0 and 1.5 percentage points in the IO, IS, and IM groups, respectively (p always <0.025). Body weight increased, most in the IO patients (+6.2 kg), least in the IM patients (+3.4 kg). Analysing all treatment groups combined, a similar HbA1c reduction was observed in patients with overall hyperglycaemia (low fasting plasma glucose/HbA1c ratio) and in patients with fasting hyperglycaemia (high fasting plasma glucose/HbA1c ratio). Within the overall hyperglycaemia group, the IS and IM patients had smaller decreases in HbA1c (-1.5 and -1.3 percentage points, respectively) than the IO patients (-2.7 percentage points). On the other hand, within the fasting hyperglycaemia group HbA1c reductions were -1.2, -0.8 and -1.5 percentage points, in the IO, IS, and IM groups, respectively. CONCLUSION: Not all poorly controlled type 2 diabetic patients should automatically be treated with an oral agent and bedtime insulin. Two daily insulin injections is a valid choice, particularly if the patient has overall hyperglycaemia.     

HbA1c对糖调节受损和2型糖尿病的诊断价值

摘要：目的：评估糖化血红蛋白（HbA1c）不同cut off值诊断2型糖尿病（T2DM）的效能,初步探讨美国糖尿病协会（ADA）推荐的HbA1c诊断T2DM及T2DM前期标准对中国人的适用性。 方法：招募接受口服葡萄糖耐量（OGTT）试验且试验前未诊治为T2DM的志愿者338例,用高效液相色谱法检测HbA1c;以WHO标准诊断糖调节受损（IGR）、糖耐量正常和T2DM;用受试者工作特征（ROC）曲线分析不同 cut off值HbA1c诊断IGR和T2DM的效能。 结果：HbA1c在诊断T2DM时,ROC曲线下面积（AUC^ROC）为0.954,最佳cut off值为6.0%,敏感性为92.5%,特异性为86.0%;当HbA1c为6.5%时,敏感性为64.8%,特异性为96.7%;当HbA1c为5.6%时,诊断T2DM阴性预测值为100.0%;HbA1c诊断IGR的AUC^ROC为0.653。 结论: HbA1c用于IGR的诊断效能不高;HbA1c诊断T2DM最佳cut off值为6.0%,此界值诊断敏感性较FPG高,但特异性较差;ADA推荐用于T2DM诊断的cut off值6.5%主要考虑到诊断的特异性,该诊断标准适用于中国人群。     

不同比例抗阻-有氧联合训练对2型糖尿病患者降糖作用的观察

目的观察不同比例抗阻-有氧联合训练对2型糖尿病患者降糖的作用,为2型糖尿病患者训练提供最佳方案。方法将42例2型糖尿病患者平均分为高抗-有氧联合训练组16例(A组)、低抗-有氧联合训练组16例(B组)、空白对照组10例(C组)。三组患者均予相同的降糖、降脂等基础治疗,疗程均为8周。在训练前后分别进行口服葡萄糖耐量试验评价空腹血糖(FBG)、餐后两小时血糖(2h PBG)、糖化血红蛋白(Hb A1c)水平及胰岛素敏感性(ISI)等指标。结果三组患者治疗前各项指标比较差异无统计学意义(P0.05)。疗程结束后,A、B两组患者的FBG、2h PBG、Hb A1c及ISI水平较C组均出现好转,差异有统计学意义(P0.05);与A组相比,B组患者在改善FBG、2h PBG、Hb A1c及ISI水平方面更加显著(P0.05)。结论高抗-有氧联合训练及低抗-有氧联合训练都可以有效改善2型糖尿病患者的血糖水平和胰岛素敏感性的作用,但低抗-有氧联合训练对于改善胰岛素敏感性治疗效果要优于高抗-有氧联合训练。     

Improving life expectancy and decreasing the incidence of complications associated with type 2 diabetes: a modelling study of HbA1c targets

To project the long-term clinical and cost outcomes that accompany predefined improvements in glycaemic control in patients with type 2 diabetes. A peer-reviewed, validated, non-product-specific Markov model of type 2 diabetes was used to project the long-term clinical and cost outcomes associated with three HbA1c reduction scenarios (vs. no reduction): (i) decreasing mean HbA1c from 9.5% to 8.0%; (ii) from 8.0% to 7.0%; and (iii) from 7.0% to 6.5%. A typical baseline US type 2 diabetes cohort derived from National Health and Nutrition Examination Survey data was simulated over a lifetime horizon (35 years). Incidence of diabetes-related complications and costs (2005 USD) were accounted based on published data. Discount rates (3% per annum) were applied to clinical benefits and costs. Sensitivity analyses were performed. Stepwise reductions in HbA1c as an independent variable correlated with delayed time to diabetes-related complications and a reduced cumulative incidence of complications, including cardiovascular, renal and neurologic comorbidities. Related costs also decreased. Reductions in both poorly- (9.5-8.0%) and better-controlled (7.0-6.5%) patients produced incremental gains in undiscounted life expectancy (LE) [1.06 (0.31) and 0.32 (0.34) years [mean (SD)], respectively]. Similar improvement patterns were observed in quality-adjusted life expectancy (QALE). Benefits from sequential reduction scenarios, when aggregated, exhibited the most dramatic effect. Improved glycaemic control was associated with reductions in complication rates and costs, as well as increased LE and QALE among type 2 patients. These data illustrate the long-term importance of reaching normoglycaemia and support intensified HbA1c control as a cornerstone of effective long-term type 2 diabetes management.     

Forearm vascular reactivity is differentially influenced by gliclazide and glibenclamide in chronically treated type 2 diabetic patients

Sulphonylureas (SUs) act by inhibition of beta-cell K(ATP) channels after binding to the sulphonylurea receptor SUR1. K(ATP) channels are also expressed in cardiac and vascular myocytes coupled to SUR2A and SUR2B involved into adaptations of vascular tone and myocardial contractility. Different influence of SUs on vascular function is based on different binding to the SUR family. Few data on the effect of different SUs, used in patients in therapeutic doses, on vascular function are currently available. We investigated possible effects of acute and chronic treatment with glibenclamide and gliclazide on forearm postischaemic reactive hyperaemia (RH) in type 2 diabetic patients. To that purpose a double-blind, randomized, cross-over study with gliclazide (80 mg, b.i.d.) and glibenclamide (5 mg, b.i.d.) was performed in 15 type 2 diabetic patients. Forearm vascular reactivity was measured after 5 min of ischaemia by plethysmography before and after 4 weeks treatment. After acute administration of gliclazide (80 mg) or glibenclamide (5 mg) RH was not influenced. After 4 weeks of treatment, no influence of either drug was seen in the steady state before dosing. After dosing glibenclamide induced a significant (P = 0.004) reduction of RH from 26.4 +/- 6.9 to 21.9 +/- 7.6 ml min(-1)/100 ml after 4 h. Gliclazide, conversely, did not induce a reduction of RH (23.9 +/- 6.0 to 23.3 +/- 6.6 ml min(-1)/100 ml). No influence of HbA1c or actual glycaemia on RH was observed. Our results indicate that in chronically treated patients with type 2 diabetes ingestion of glibenclamide but not gliclazide results in sustained reduction of postischaemic RH. This difference is most probably based on different SUR binding.     

Insulin secretion and sensitivity as determinants of HbA1c in type 2 diabetes

BACKGROUND: Defects in insulin secretion and sensitivity, two major determinants of glycaemic control, can occur and progress or not in parallel. The present study was designed to compare the respective roles of both determinants on HbA1c, in type 2 diabetic patients, according to whether or not residual beta-cell function was stimulated with insulin secretagogues. MATERIALS AND METHODS: Insulin secretion and insulin sensitivity were both estimated using the homeostasis model assessment (HOMA). HbA1c, insulin sensitivity (HOMA2%S) and insulin secretion (HOMA2%B) were determined in 289 noninsulin-using type 2 diabetic patients who were further divided into two groups according to treatment: metformin alone (group I, n = 57) or metformin and glyburide (group II, n = 232). The patients of both groups were further divided into three subsets in order to test the dependence of HbA1c on HOMA2%B and HOMA2%S. RESULTS: In group I mean HbA1c were greater (8.4%) in patients with HOMA2%B < 50% than in the two subsets with HOMA2%B > or = 50%: 7.2 and 6.8% (P = 0.0013). In group II mean values of stimulated-insulin secretion (HOMA2%B) were lesser (40.7 and 30.1%) in the two subsets of patients with HbA1c > or = 8% than in patients with HbA1c < 8%: 55.1% (P < 0.0001). By contrast, we found no differences in both groups with HOMA2%S. A stepwise multiple regression showed that HOMA2%B contributed to HbA1c more than HOMA2%S both in groups I (33.5% vs. 23.4%) and II (22.7% vs. 8%). CONCLUSIONS: Although the role of insulin sensitivity is not negligible, insulin secretion appears to be the major determinant of diabetic control in overt type 2 diabetic patients who are treated with metformin alone or with a two-drug therapy combining metformin and glyburide.     

Potential effect of opium addiction on lipid profile and blood glucose concentration in type 2 diabetic patients in Iran

Background: Diabetes is one of the most common chronic diseases in the world. People believe that opium improves blood glucose and lipid profiles in these patients and controversial studies show the effect of consumption of opium in controlling these indices. Accordingly, this study aimed to compare the serum levels of blood indices such as fasting blood glucose (FBS), Hemoglobin A1c (HbA1c) and lipid profile in opium users and non-users in type ΙΙ diabetic patients.

Methods: In this cross-sectional study, among type II diabetic patients referred to the Diabetes Clinic of Birjand 45 opium users and 135 non-users were selected and entered the study by the convenience sampling method.

Results: The results of this study showed that the mean serum levels of FBS, HbA1c, and serum lipid profiles were not significantly different between the two groups of opium users and non-users, but the levels of triglyceride (TG) were significantly 0.18 unit higher in the opium users, compared to non-opium users.

Conclusion: According to the results, the use of opium does not affect the indices of blood glucose, HbA1c and serum lipid profiles except triglyceride in diabetic patients. The general belief that opioid use reduces biochemical indices does not seem to be correct.

Abbreviations: FBS: fasting blood sugar; HbA1c: Hemoglobin A1c; LDL: low-density lipoprotein; HDL: High-density lipoproteins; HDL-C: High-density lipoproteins-cholesterol; BMI: Body mass index; IQR: Inter quartile range; TG: triglyceride; TC: total cholesterol; NS: non-significant; S: significant; ATN: Acute tubular necrosis     

Effects of sibutramine in overweight, poorly controlled Chinese female type 2 diabetic patients: a randomised, double-blind, placebo-controlled study

To assess the efficacy of sibutramine 15 mg once daily as weight reduction in overweight and obese (body mass index > 25 kg/m2) Chinese female type 2 diabetic patients and to evaluate the influence of weight loss on diabetic control, a randomised, double-blind, placebo-control, 12-week study was conducted. Chinese female type 2 diabetic patients, poorly controlled glucose levels and HbA(1C) > 8% were randomly assigned to two groups. In addition to their hypoglycaemic agents (maximal doses of sulphonylureas and metformin), one group (n = 30) received a sibutramine 15 mg once daily for 12 weeks, and the other (n = 30) received placebo for the same period. Comparing the changes that occurred after 12 weeks in the sibutramine and placebo groups, the former showed significantly greater reduction in body weight (2.5 vs. 0.1 kg, p < 0.05), fasting plasma insulin level (28.8 vs. 2.4 pmol/l, p < 0.01), 2-h postprandial blood glucose after standard test meal (3.2 vs. 1.1 mmol/l, p < 0.01), insulin resistance (5.1 vs. 0.2, p < 0.01), HbA1C (1.7% vs. 0.2%, p < 0.05), triglyceride (0.43 vs. 0.12 mmol/l, p < 0.05) and total cholesterol (0.52 vs. 0.08 mmol/l, p < 0.05). No significant differences were found between treatment groups in blood pressure and heart rate. The addition of sibutramine to diet and oral hypoglycaemic therapy resulted in significant weight loss and improvement in metabolic parameters in the treatment group. Sibutramine should be considered for use alongside diet and oral hypoglycaemic therapy in Chinese overweight and obese women with poorly controlled type 2 diabetes.     

A follow-up study of the occurrence and consequences of HbA1c measurements in an unselected cohort of non-pharmacologically treated patients with Type 2 diabetes

Objectives

To describe the occurrence of HbA1c measurements among non-pharmacologically treated diabetes patients, and to evaluate whether poor blood glucose regulation (HbA1c >8%) prompted intensification of treatment.

Method

Data from the National Health Service Registry, the Regional Laboratory Database and the Danish National Hospital Registry were collected from 2002 to 2004 to identify and describe all Type 2 diabetic patients above 40 years of age in a background population of nearly 660 000 citizens in Aarhus County, corresponding to 12% of the total Danish population.

Results

A total of 1989 had at least one HbA1c measurement, whereas 484 (20%) had no HbA1c measurement at all in 2003. Most patients had an HbA1c of less than 8%, and for 820 (41%) HbA1c was less than 6.5%, but for 316 (16%) patients, the first HbA1c measurement in 2003 was above 8%. After 6 months, patients with HbA1c above 8% had a higher probability of initiating pharmacological treatment (M; 0.64; 95% CI 0.58–0.70) (F; 0.68; 95% CI 0.58–0.77) than patients with HbA1c below 8% (M; 0.12; 95% CI 0.10–0.14) (F; 0.11; 95% CI 0.09–0.14).

Conclusion

This study indicates that poor blood glucose regulation (HbA1c >8%) prompted a shift from non-pharmacological treatment to pharmacological treatment for most patients. However, a substantial group of patients are either not monitored on a regular basis or, if monitored, their elevated measurements of HbA1c do not prompt initiation of pharmacological treatment.     

Screening for type 2 diabetes with random finger‐prick glucose and bedside HbA1c in an Australian emergency department

Objective: To determine if screening for undiagnosed type 2 diabetes mellitus (T2DM) and pre‐diabetes is feasible in an Australian ED; to estimate the prevalence of T2DM and pre‐diabetes in the Australian ED population. Methods: Prospective cross‐sectional prevalence survey in the ED of St Vincent's Hospital, Melbourne, an adult, tertiary referral centre seeing approximately 40 000 patients annually. A convenience sample of adult patients was screened with finger‐prick random blood glucose and glycosylated haemoglobin (HbA1c); those over 6.0 mmol/L and 6.0% were referred for oral glucose tolerance test (OGTT). Diagnoses of T2DM and pre‐diabetes were made according to World Health Organization definitions. Those not attending for OGTT were contacted by phone, and interviewed about their reasons. Results: Seven hundred and twenty‐five patients were recruited; 135 (18.6%; 95% confidence intervals [CI] 15.9–21.6%) had known T2DM, leaving 590 screened, of whom 210 screened positive. Of the 192 referred for OGTT, 147 (77%) did not attend despite several telephone reminders. Of the 45 (23%) completing OGTT, pre‐diabetes was present in eight (17.8%; 95% CI 9.0–31.6%) and T2DM in six (13.3%; 95% CI 5.9–26.6%). Many people interviewed (18/86, 21%) did not attend for OGTT on the advice of their doctors. Conclusions: This inner city tertiary ED has a high prevalence of T2DM, diagnosed and undiagnosed, with as much as half our population possibly affected. Although ED screening might have a high yield, opportunistic screening is not feasible, with difficulties in staff engagement and patient follow up for diagnostic testing. Future studies might consider finger‐prick fasting blood glucose through a patient's general practitioner for diagnosis.