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1.  The Effect of Quality of Care on Cardiovascular Risk Factors in Newly Diagnosed Diabetic Patients 
In this study, we evaluated the quality of care and control of cardiovascular risk factors in newly diagnosed diabetic patients, identified during diabetes screening program, 1 year after diagnosis.
In this prospective study, 83 newly diagnosed diabetic patients identified at screening in Isfahan, were studied. Height, weight, blood pressure, plasma glucose, lipids, and hemoglobin A1c (HbA1c) of these patients were measured 2 times, first at the time of diagnosis and then 1 year later, and the results were compared between two groups, with and without regular course of treatment.
Nearly 46.99% and 53.1% of the studied patients have regular and irregular course of treatment. After 1 year, significant improvement in the mean of plasma glucose, cholesterol, triglyceride, low density lipoprotein (LDL), high density lipoprotein and HbA1c was seen in patients with regular course of treatment except for blood pressure (P < 0.05). Frequency of controlled cardiovascular risk factors including fasting plasma glucose, HbA1c, cholesterol and LDL was significantly improved in patients with regular course of treatment (P < 0.05). Mentioned changes were not seen in patients with irregular course of treatment.
The findings of the current study demonstrated that though diabetes screening program result in earlier diagnosis of patients with type 2 diabetes, but it seems that regular follow-up and proper management of newly diagnosed patients is crucial for appropriate glycemic and metabolic control and preventing its related micro and macrovascular complication.
PMCID: PMC4274550  PMID: 25538839
Cardiovascular disease; care; screening; type 2 diabetes
2.  Strategies to overcome type 1 diabetes–related social stigma in the Iranian society 
This study explored the strategies to overcome diabetes-related social stigma in Iran.
Materials and Methods:
This paper is part of an action research study which was designed in Iran in 2012 to plan and implement a program for overcoming diabetes-related stigma. Participants were people with type 1 diabetes, their family members, people without diabetes, and care providers in a diabetes center. Data collection was done through unstructured in-depth interviews, focus groups, e-mail, Short Message Service (SMS), and telephone interview. Data were analyzed using inductive content analysis approach.
Participants believed that it is impossible to overcome the stigma without community-based strategies. Community-based strategies include education, advocacy, contact, and protest.
The anti-stigma strategies obtained in the study are based on the cultural context in Iran. They are extracted from statements of a wide range of people (with and without diabetes). However, during planning for stigma reduction, it is necessary to note that the effectiveness of social strategies varies in different studies and in different stigmatizing conditions and many factors are involved. These strategies should be implemented simultaneously at different levels to produce structural and social changes. It should be accepted that research on reducing health-related stigma has shown that it is very difficult to change beliefs and behavior. Evidence suggests that individuals and their families should be involved in all aspects of the program, and plans should be made according to the local conditions.
PMCID: PMC4223961  PMID: 25400672
Anti-stigma strategies; diabetes-related stigma; Iran; qualitative research; stigma management
3.  Why 24-h Urine Albumin Excretion Rate Method Still is Used for Screening of Diabetic Nephropathy in Isfahan Laboratories? 
The first step in diagnosis of diabetic nephropathy is measurement of albumin in a spot urine sample. The aim of this study was assessment of the accuracy of urinary albumin to creatinine ratio (UACR) in random urine specimens (RUS) for microalbuminuria and macroalbuminuria screening in Iranian diabetic patients.
A total of 200 diabetic patients participated to our study. 24 h timed urine specimens followed by RUS were collected. 24-h urine albumin excretion (24-h urinary albumin excretion (UAE)) and UACR in RUS were measured. Data were analyzed by Pearson's correlation, receiver operating characteristic (ROC) curve and McNemar test.
A total of 165 patients finalized the study. Pearson's correlation of coefficient for 24-h UAE versus UACR was 0.64. The area under ROC curve for UACR was 0.83 in microalbuminuria and 0.91 in macroalbuminuria. The cutoff point of 30 mg/g in UACR method had 86% sensitivity and 60% specificity for microalbuminuria screening and cut-off point of 300 mg/g had 75% sensitivity and 99% specificity for macroalbuminuria screening respectively.
UACR in RUS showed acceptable performance as a screening test for diagnosis of both micro and macroalbuminuria in Iranian diabetic patients.
PMCID: PMC4018644  PMID: 24829719
Albuminuria; diabetic nephropathy; screening; urinary albumin to creatinine ratio
4.  Prevalence and related risk-factors of peripheral neuropathy in children with insulin-dependent diabetes mellitus 
Diabetes mellitus (DM) is a common metabolic disorder that can cause various complications including, peripheral neuropathy (PNP). Some possible risk-factors such as blood glucose level, hyperglycemia, duration of diabetes, and lipid profiles are assumed to be important in diabetic PNP incidence. The aim of this study is to evaluate the prevalence and possible risk-factors of PNP in children with insulin dependent DM.
Materials and Methods:
Among diabetic children, 146 patients (up to 18-years old) were evaluated in this cross-sectional study. All patients were examined for signs and symptoms of neuropathy and nerve conduction studies were performed. Blood level of glucose and lipid profiles were also tested. The relation between variables was compared by independent t-test and logistic regression test.
The mean age of diabetic children was 11.9 ± 3.3 years whereas mean diabetes duration was 3.8 ± 2.9 years. PNP was detected in 40 patients (27.4%) that 62.5% of them have subclinical and 37.5% have clinical neuropathy. According to logistic regression analysis, duration of diabetes was the most important factor in prevalence of PNP (5.7 ± 3.5 and 3.1 ± 2.5 years in patients with and without neuropathy respectively, P < 0.001, 95% confidence interval [1.15-1.54]).
As most of the patients had subclinical PN, neurological assessment is recommended to detect subclinical neuropathy in asymptomatic type 1 diabetic children and it seems that the best way to prevent this complication is still rigid blood glucose control and periodic evaluations.
PMCID: PMC3724374  PMID: 23914216
Diabetes mellitus; peripheral neuropathy; prevalence; risk factors; type 1
5.  The effects of oral vitamin D on insulin resistance in pre-diabetic patients 
Some epidemiological and interventional studies have shown the role of vitamin D on insulin secretion and resistance. A previous study in our center showed that intramuscular vitamin D decreases insulin sensitivity in pre-diabetic patients. We investigated the role of oral vitamin D on the insulin sensitivity index and insulin resistance in pre-diabetic patients.
Materials and Methods:
In a randomized clinical trial, we divided 45 people with pre-diabetes aged 47.4 ± 6.6 (range 33-61) years into three groups: group A subjects treated with 50,000 IU oral vitamin D and 500 mg calcium carbonate (n = 21), group B subjects treated with a single 300,000 IU intramuscular vitamin D and 500 mg calcium carbonate (n = 9), and group C subjects treated with 500 mg calcium carbonate alone (n = 15). Serum 25-hydroxyvitamin D [25(OH) D] was measured at baseline. If it was less than 75 nmol/l, 50,000 IU vitamin D was given weekly, and if serum 25(OH) D was more than that, vitamin D was administered every 2 weeks. Before and after 12 weeks of treatment, a 75-g glucose tolerance test was performed. We used paired t-test and analysis of variance (ANOVA) to analyze the data. P values less than 0.05 were considered significant.
Mean (SD) of serum vitamin D increased from 77.5 ± 39.2 to 118.8 ± 56.3 nmol/l (P = 0.009) in group A and from 80 ± 36 to 102.8 ± 43.3 nmol/l (P = 0.053) in group B, and decreased from 44.8 ± 18.3 to 34.6 ± 13.9 nmol/l (P = 0.06) in group C. Insulin sensitivity index (Matsuda) decreased from 11.4 ± 3 to 9.9 ± 3.2 (P = 0.046) in group A, but in comparison with other groups, it was not significant.
Oral vitamin D had no effect on insulin sensitivity in pre-diabetes patients in 12 weeks treatment. A randomized double-blind study with a longer duration of treatment is suggested to investigate the effect of vitamin D on insulin resistance.
PMCID: PMC3719226  PMID: 23900423
Glucose tolerance test; insulin resistance; pre-diabetes; vitamin D; vitamin D deficiency
6.  Comparison of ox-LDL Levels in Diabetic Patients with Normo-, Micro-, and Macroalbuminuria with Their First Degree Relatives and the Healthy Control Group 
Oxidized low density lipoprotein (ox-LDL) is a product of oxidative stress. In this cross-sectional study, we compared the ox-LDL concentrations in diabetic patients with normoalbuminuria (n = 28), microalbuminuria (n = 28), and macroalbuminuria (n = 28) with their first degree relatives (n = 28) and healthy control people (n = 31). They were selected by consecutive patient selection method. The ox-LDL level was assayed using ELISA. We measured blood pressure, lipid profile, fasting plasma glucose (FPG), and HbA1c in all groups. There was no significant difference in ox-LDL concentrations among normoalbuminuric, microalbuminuric, and macroalbuminuric diabetic groups. In diabetic patients with micro- and macroalbuminuria, ox-LDL concentration was higher than their first degree relatives (P = 0.04 and P = 0.03) and control group (P = 0.001 and P = 0.03, resp.). In normoalbuminuric diabetic persons, ox-LDL concentration was just higher than that of healthy people (P = 0.02). There was no statistically significant difference in ox-LDL levels between normoalbuminuric diabetic patients and their first degree relatives. In conclusion, the presence and progression of albuminuria in diabetic patients are not related to ox-LDL concentration and genetic predisposition influences the plasma OX-LDL level. Larger sample size is needed to confirm this conclusion in future studies.
PMCID: PMC3501829  PMID: 23193400
7.  Is uric acid an indicator of metabolic syndrome in the first-degree relatives of patients with type 2 diabetes? 
To determine whether uric acid levels are associated with the components of metabolic syndrome and whether uric acid is a significant factor for development of metabolic syndrome in the first-degree relatives of type 2 diabetic patients as high risk group.
Materials and Methods:
A total of 694 (182 male and 512 female, aged 30-69 years) first-degree relatives of type 2 diabetic patients during 2007-2011 were enrolled. The height, weight, waist circumference, blood pressure, fasting plasma glucose, lipid profile and uric acid concentrations were measured. Metabolic syndrome was defined by NCEP-ATP III.
Uric acid was associated with waist circumference, blood pressure, triglyceride and HDL-cholesterol level in both sexes (r = 0.1-0.3, P < 0.05). The prevalence of metabolic syndrome in the fourth quartile of uric acid (64.4% of male and 60.2% of female population) was significantly more than those in the first (25.5% of male and 31.2% of female population) and second quartiles (33.3% of male and 32.0% of female population). The mean of uric acid in people with metabolic syndrome was significantly higher than in those without (6.6 ± 1.2 mg/dL vs. 5.8 ± 1.2 mg/dL; P = 0.0001). The age-adjusted odds ratios (95% confidence interval) of uric acid for metabolic syndrome in univariate analysis were [1.60 (1.23-2.07); P = 0.008] for men and [1.61 (1.34-1.92); P = 0.0001] for women but the effect of uric acid in multivariate logistic regression was not significant.
Uric acid is associated with majority of the metabolic syndrome components. People with metabolic syndrome have higher uric acid levels. However, uric acid probably is not an independent factor to predict the metabolic syndrome.
PMCID: PMC3702079  PMID: 23833572
Cardiovascular disease; insulin resistance; metabolic syndrome; obesity; type 2 diabetes
8.  Does the intramuscular injection of vitamin D increase insulin resistance? 
Considering the physiologic roles of vitamin D on insulin regulation, the effects of vitamin D treatment on insulin sensitivity and resistance indexes and beta cell function in pre-diabetic vitamin D deficient patients were investigated.
In a randomized open clinical trial, 61 pre-diabetic vitamin D deficient patients who were the first degree relatives of type 2 diabetic patients, were enrolled and randomized into three groups (A, B and C). Group A (n = 21) were treated with intramuscular injection of 300,000 units of vitamin D at the beginning of the study and one month later. In group B (n = 20), injection of vitamin D plus 500 mg/d calcium and in group C (n = 20), just calcium was administered for two months. At baseline and two months later, oral glucose tolerance test was done. Homeostasis Model of Assessment-Insulin Resistance (HOMA-IR), insulin resistance index, Homeostasis Model of Assessment-B (HOMA-B) which is a beta cell function index, and Matsuda index, an insulin sensitivity index, were calculated and compared before and after intervention and between three groups.
In vitamin D treated groups (A + B), the mean (SD) of HOMA-IR increased from 2.46 (1.36) to 3.1 (2.3) (P = 0.02), and Matsuda index decreased from 11 (3) to 9.0 (2.3) (P = 0.001).
Injection of vitamin D increased insulin resistance and decreased insulin sensitivity indexes.
PMCID: PMC4076860  PMID: 24991591
Vitamin D; pre-diabetic state; diabetes mellitus type 2; oral glucose tolerance test
9.  Thyroid Peroxidase Gene Mutation in Patients with Congenital Hypothyroidism in Isfahan, Iran 
Background. Thyroid peroxidase gene (TPO) mutations are one of the most common causes of thyroid dyshormonogenesis in patients with congenital hypothyroidism (CH). In this study, the prevalence of TPO gene mutations in patients with thyroid dyshormonogenesis in Isfahan was investigated. Methods. In this cross-sectional study, genomic DNA of 41 patients with permanent CH due to thyroid dyshormonogenesis was extracted using the salting out method. The 17 exonic regions of the TPO gene were amplified. SSCP technique was performed for scanning of the exonic regions of the TPO gene, except exon 8. DNA sequencing was performed for those with different migration patterns in SSCP by chain termination method. Exon 8 was sequenced directly in all patients. In 4 patients, all fragments were also sequenced. Results. One missense mutation c.2669G > A (NM_000547.5) at exon 15 (14th coding exon) in one patient in homozygous form and seven different single nucleotide polymorphisms (SNPs) in exons 1, 7, 8, 11, and 15 of TPO gene. Conclusion. The TPO gene mutations among CH patients with dyshormonogenesis in Isfahan were less frequent in comparison with other similar studies. It may be due to the presence of other unknown gene mutations which could not be detected by SSCP and sequencing methods.
PMCID: PMC3419406  PMID: 22919382
10.  The impact of acute hypothyroidism on lipid levels in athyreotic patients 
We investigated the effect of acute hypothyroidism on lipid concentrations especially on high density lipoprotein (HDL-cholesterol) level in athyroatic patients.
Materials and Methods:
Thirty-one patients, with a history of differentiated thyroid carcinoma and total thyroidectomy, who were candidates of radioiodine therapy, enrolled in the study. Their lipid profiles and serum thyrotropin stimulating hormone (TSH) levels were measured before and two-to-six weeks after thyroid hormone withdrawal. The lipid concentrations were compared with the paired t test and serum TSH using the Wilcoxon singed rank test. P values < 0.05 were considered statistically significant.
The median of TSH concentration was 0.06 mU / liter on thyroid hormone suppressive therapy and 102 mU / liter at the thyroid hormone withdrawal phase (P < 0.0001). The serum concentrations of all lipids were significantly increased after withdrawal (P < 0.0001). The mean (SD) of the HDL-cholesterol concentration rose from 44 ± 9 mg / dL to 58 ± 17 mg / dL. The levels of total cholesterol, LDL-cholesterol, HDL-cholesterol, and triglyceride increased by 58, 75, 30, and 59%, respectively, during acute hypothyroidism.
The present study showed that thyroid hormone withdrawal altered the lipid concentrations significantly, in a short period of time. The levels of both atherogenic (LDL-cholesterol) and cardioprotective (HDL-cholesterol) particles increased concurrently. Their clinical importance should be investigated in future.
PMCID: PMC3687877  PMID: 23798937
Cholesterol-HDL; hypothyroidism; lipid metabolism; thyroid hormones; thyroid neoplasms
11.  Inadequate investment on management of diabetes education 
Reforming and improving the patient education process need more insight into the strengths and weaknesses of the existing education process. There is little documentation on patient education in National Diabetes Prevention and Control Program in Iran, so the present study aimed to describe patient education process in diabetes centers in one of the provinces of Iran.
Materials and Methods:
This is a qualitative content analysis. Twelve nurses who work as diabetes nurse educators (DNEs) and an internal medicine specialist participated in this study. Data was obtained through semi-structured face-to-face interviews, a focus group, existing documents, field notes, and multiple observations. Data analysis was guided by the conventional approach of qualitative content analysis.
Three main themes including unequipped trainers (insufficient knowledge and experience, lack of appropriate educational facilities, lack of time, lack of patient's interest), unstructured education (lack of educational need assessment, lack of evaluation, lack of continuing patient education), unmanaged education (lack of official planning for patient education and supervising the education process) emerged from qualitative content analysis.
Although patient education is one of the important strategies in National Diabetes Prevention and Control Program, there however has not been necessary investment and adequate space to achieve it. Patient education was not structured and based on scientific principles. Training of diabetes nurse educators (DNEs) is neglected, and there is no supervision on patient education process.
PMCID: PMC3687889  PMID: 23798949
Diabetes mellitus; education; health educator; need assessment
12.  The prevalence of hypogonadism in diabetic men in Isfahan Endocrine and Metabolism Research Center, Isfahan, Iran 
Low testosterone, with or without symptoms, reported in diabetic men in some studies. We investigated the prevalence of hypogonadism in Iranian type 2 diabetic men.
Materials and Methods:
Total testosterone (TT) and sex hormone binding globulin (SHBG) concentrations were measured in 247 diabetic men >30 years who had symptoms of androgen deficiency, according to ADAMs questionnaire. The correlation between some parameters and total, free and bioavailable testosterone levels was determined using Pearson correlation coefficient. Free and bioavailable testosterone were calculated by electronic calculator. Four patients were excluded because of high testosterone level, due to unreported androgen use. Overt hypogonadism was defined as total testosterone ≤8 nmol/l or calculated bioavailable testosterone (cBT)≤2.5 nmol/l and borderline hypogonadism was considered as TT 8-12 nmol/l or cBT 2.5-4nmol/l.
The mean and SD of age was 59 (9.3) years. The mean TT, calculated free testosterone (cFT), and cBT and SHBG levels were 4.81 (1.7) nmol/l, 0.11 (0.06) nmol/l, 2.42 (1.17) nmol/l and 36.15 (18.3) nmol/l, respectively. According to TT and cBT, overt hypogonadism observed in 7.4% and 61.6% of men, respectively, and the prevalence of borderline hypogonadism was 9.9% and 36%, respectively. cFT ≤0.16 nmol/l found in 227 diabetic men (96%). Hypogonadism (TT ≤12 nmol/l) was not correlated with obesity, smoking, age,duration of diabetes, blood pressure, and HbA1c.
Hypogonadism is highly prevalent in type 2 diabetes men.
PMCID: PMC3685773  PMID: 23798917
Hypogonadism; male; Iran; prevalence; Type 2 diabetes mellitus
13.  Hearing Impairment in Congenitally Hypothyroid Patients 
Iranian Journal of Pediatrics  2012;22(1):92-96.
Thyroid hormone is necessary for normal development of the auditory system. The aim of this study was to investigate the rate of hearing impairment in congenitally hypothyroid (CH) patients, and its relation with factors such as CH severity and age at starting treatment, during CH screening program in Isfahan.
Hearing acuity was assessed in two groups of children with (94 patients aged 4 months – 3 years) and without CH (450), between 2000-2006. Otoacostic emission (OAE) was performed by a two step method. After two tests without OAE signals bilaterally, they were referred for auditory brainstem response (ABR) test. Subjects with both OAE and ABR abnormal test results were considered to have hearing problem. Obtained data was compared in case and control group and also CH patients with and without hearing impairment.
Three (3.2%) of patients and 1 of control group (0.2%) were diagnosed with sensorineural hearing loss. The rate of hearing loss was not different significantly in two studied groups (P>0.05). There was no difference between age of starting treatment and first T4 and TSH level in CH patients with and without hearing loss (P>0.05). CH neonates with hearing impairment had thyroid dyshormonogenesis according to the follow up results.
The rate of hearing loss was low among our studied CH patients. It may be due to proper management of CH patients. In view of the fact that all CH neonates were dyshormonogentic and considering the relation between certain gene mutations and hearing impairment in CH patients, further studies with larger sample size, with regard to different etiologies of CH should be investigated to indicate the possible gene mutations related to hearing loss in CH.
PMCID: PMC3448222  PMID: 23056865
Hearing impairment; Auditory Brain Stem Response; ABR; Oto Acostic Emission; OAE
14.  Weight status of the first-degree relatives of patients with type 2 diabetes based on the glucose tolerance test 
This study aimed to compare different body mass index (BMI) categories in individuals with diabetes, prediabetes and normal glucose tolerance among the first degree relatives of type 2 diabetic patients.
Materials and Methods:
A cross-sectional study was conducted during 2005-2007 in Isfahan, Iran. It evaluated 3323 first-degree relatives of diabetic patients selected by consecutive convenient sampling method. Participants were classified as diabetic, prediabetic, and normal glucose tolerance test groups according to the results of 75 g oral glucose tolerance test (OGTT). The analysis of variance (ANOVA) was used for comparison of quantitative variables, and chi square test for comparison of categorical parameters.
The study population consisted of 3323 individuals including 306 diabetics (98 males and 208 females), 1309 prediabetics (337 males and 972 females), and 1708 normal subjects (430 males and 1278 females). Among diabetic patients, the prevalence of obesity was 48.5% in women and 27.6% in men. Among prediabetics, the corresponding figures were 45.6% and 27.3%, respectively.
Our findings suggest that men are diagnosed with T2DM at lower BMI than women. Moreover, the alarming high prevalence of overweight and obesity among females necessitates preventing and controlling this underlying problem among females.
PMCID: PMC3527046  PMID: 23267380
Diabetes Mellitus; Family History; Glucose Tolerance Test; Obesity; Prevention
15.  Challenges of training diabetes nurse educator in Iran 
The purpose of this study was to describe the first attempts and performance of health system in Iran in training specialist nurses in the field of diabetes- related care and education.
Materials and Methods:
This was a qualitative content analysis. Three diabetes management planners in the Ministry of Health and Medical Education, three provincial executive authorities of diabetes in the health system and ten nurses who worked as diabetes nurse educators (DNEs) participated in this study. Data obtained through semi-structured face-to-face interviews, a focus group, existing documents, field notes, and multiple observations. Data analysis was guided by the conventional approach of qualitative content analysis.
Three major themes and six sub-themes were emerged through data analysis. Main themes were: (a) decentralization diabetes nurse educator training without any management (stop education due to transition training responsibility to provincial health authorities and lack of supervision of managers on training); (b) try to reform nursing education infrastructures (try to train qualified educators who were candidate for teaching to DNEs, try to reform undergraduate nursing curriculum); (c) failure of DNE curriculum (lack of consistency between content and timing with the curriculum objectives and lack of attention to learn evaluation process).
The findings of this study reflected the failure and multiple challenges in educating nurses working in diabetes units. Despite the fact that important roles were defined for nurses in the action plan for preventing and controlling diabetes, any specific action was not done in preparing nurses for these roles.
PMCID: PMC3696209  PMID: 23833610
Diabetes; Iran; nursing education; qualitative research
16.  The role of ultrasonography in primary congenital hypothyroidism 
The aim of this study was to compare the usefulness of ultrasonography and scintigraphy in diagnosing the etiology of primary congenital hypothyroidism (CH).
The newborns that were examined by both thyroid scintigraphy and ultrasonography during CH screening program in Isfahan were included in this study. The ultrasonographic findings were compared with the scintigraphic findings and the sensitivity and specificity of the ultrasonography was determined.
During this study, 102 CH newborns were studied. According to the ultrasonographic results, 61.8%, 26.5%, 2.9% and 8.8% of them had normal thyroid gland, agenesia, ectopia and hypoplasia, respectively, and according to scintigraphic results, 55.9%, 35.3% and 8.8% of them had normal thyroid gland, agenesia and ectopia, respectively. Ultrasound detected sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio were 77%, 92%, 89%, 84%, 9.6 and 0.25, respectively. The sensitivity and specificity of ultrasonography compared with thyroid scintigraphy in diagnosis of thyroid gland ectopia was 33% and 100%, respectively.
Though thyroid ultrasonography failed to diagnose 67% of ectopic cases and nonfunctioning thyroid gland, it had the ability to determine the anatomy of thyroid gland. So, considering some limitations of scintigraphy, we concluded that ultrasonography is a relatively appropriate imaging tool for diagnosing CH etiologies, especially in the initial phase of CH screening.
PMCID: PMC3430036  PMID: 22973380
Congenital Hypothyroidism; Etiology; Iran; Radioisotope Scanning; Ultrasonography
17.  Adherence to Glyburide and Metformin and Associated Factors in Type 2 Diabetes in Isfahan, Iran 
The purpose of this study was to determine the adherence to oral hypoglycemic medications and associated factors in type 2 Diabetes Mellitus patients who were referred to the Isfahan Endocrinology and Metabolism Research Centre (IEMRC). Convenience sampling was used to enroll 248 patients with type 2 diabetes in a prospective study at IEMRC from January 2007 to January 2008. Patients had to be on a stable dose of oral hypoglycemic medications (glyburide and metformin) or for 3 months prior to the study and willing to participate in consultation sessions with a pharmacist. Pill count and self report methods were used to measure the adherence. Mean (SD) of patients studied was 56.6 (8.9) years and 62% were females. The mean (SD) duration of diabetes in the study patients was 10.8 (6.1) years and 81.9% of them were literate with basic education. Non-adherence rates to metformin and glyburide were recorded in 39.7% and 35.3% of the study population respectively. Lower HbA1C levels and higher education were associated with higher adherence rates. Forgetfulness, confusion, fasting, adverse effects, complexity of medication regimen and disruption of routines were most commonly reported causes of non adherence. Prevalence of adherence to these two medications did not differ significantly between pill count (62.3%) and self report (62.8%), (p >0.05). Adherence rates did not vary by pill count and self report significantly. It was concluded that good adherence to medications was associated with a lower HbA1C profile; so it seems that pill count is a useful method in the clinical practice to identify non-adherent patients. Further studies are needed to find out efficient interventions to improve the patient’s adherence.
PMCID: PMC3813068  PMID: 24250432
Adherence; Pill count; Self report; Type 2 diabetes; Hemoglobin A1C
18.  Prevalence of Vitamin D Deficiency among Adult Population of Isfahan City, Iran 
Determination of vitamin D status in different age-groups in a community and in different climates of a country is necessary and has important implications for general health. The study was conducted to determine the prevalence of vitamin D deficiency among the adult population of Isfahan, a centrally-located city in Iran. In this cross-sectional study, 1,111 healthy people—243 men and 868 women—aged 41.4 (mean 14 and range 20-80) years, who attended a single-consultation outpatient clinic, were selected. Serum 25-hydroxy vitamin D (25-OHD), parathyroid hormone (PTH), calcium and phosphorus concentrations were measured. Mild, moderate and severe vitamin D deficiencies were defined as 25-OHD values of 20-30 ng/mL, 10-20 ng/mL, and <10 ng/mL respectively. The median (range) concentrations of 25-OHD were 21 (4.0-105.0) ng/mL in males and 18 (1.5-117) ng/mL in females (p=0.05). The prevalence of mild, moderate and severe vitamin D deficiencies among the adult population was 19.6%, 23.9%, and 26.9% respectively. Vitamin D deficiency was more prevalent among women (p=0.001) and younger age-group (p=0.001). Medians of 25-OHD in spring-summer and autumn-winter were 21 ng/mL and 18 ng/mL respectively (p=0.005). The prevalence of severe vitamin D deficiency was higher in autumn-winter than in spring-summer (odds ratio=1.6, 95% confidence interval 1.2-2.2, p=0.001). The prevalence of vitamin D deficiency was high in a sunny city—Isfahan— especially among women and younger population. The high prevalence of vitamin D deficiency in this city emphasizes the necessity of vitamin D supplementation as more exposure to sun is limited due to the type of clothing required by current law.
PMCID: PMC3126987  PMID: 21608424
Adult; Cross-sectional studies; Parathyroid hormone; Seasonal variation; Vitamin D deficiency; Iran
19.  Visual acuity in an Iranian cohort of patients with type 2 diabetes: the role of nephropathy and ischemic heart disease 
The aim of this study was to investigate the risk factors of low vision in type 2 diabetic patients and the prevalence of ischemic heart diseases and nephropathy for different visual acuities.
In this cross-sectional study, data from 738 type 2 diabetic patients including evidences for nephropathy and ischemic heart disease, demographic characteristics, blood pressure and body mass index were collected, and then patients were divided into 3 groups based on their best corrected visual acuity in the better-seeing eye. Analysis of variance was used to compare basic characteristics according to different levels of visual acuity.
The prevalence of blindness and low vision was 5.5% and 13.3% respectively, and as age, duration of diabetes, systolic blood pressure and body mass index increased, the visual acuity decreased. The prevalence of hypertension and obesity in patients with visual disabilities was significantly higher than in patients with not impaired visions (p = 0.008 and p = 0.02, respectively). We also found that with greater decline in visual acuity, the prevalence of neph-ropathy and ischemic heart diseases increased.
The factors related to retinopathy play a role in affecting the degree of visual impairment in diabetic patients. Therefore, controlling risk factors can be useful in decreasing impairment of vision and blindness.
PMCID: PMC3252768  PMID: 22247728
Diabetes Mellitus; Type 2; Visual Acuity; Diabetic Retinopathy; Blindness; Diabetic Nephropathies; Cardiovascular Diseases
20.  Relationship between gamma-glutamyl transferase and glucose intolerance in first degree relatives of type 2 diabetics patients 
Considering that serum gamma-glutamyl transferase (GGT) activity could reflect several different processes relevant to diabetes pathogenesis and the increasing rate of type 2 diabetes worldwide, the aim of this study was to assess the association between serum GGT concentrations and glucose intolerance, in the first-degree relatives (FDR) of type 2 diabetic patients.
In this descriptive study, 30-80 years old, non diabetic FDRs of type 2 diabetic patients were studied. Serum GGT was measured by enzymatic photometry method in all studied population. The relationship between GGT and glucose intolerance status (normal, prediabetic and diabetics) was evaluated.
During this study 551 non-diabetic FDRs of type 2 diabetic patients were studied. Mean of GGT was 25.3 ± 12.1 IU/L. According to glucose tolerance test, 153 were normal and 217 and 181 were diabetic and prediabetic respectively. Mean of GGT in normal, prediabetic and diabetic patients was 23.5 ± 15.9 IU/L, 29.1 ± 28.1 IU/L and 30.9 ± 24.8 IU/L respectively (p = 0.000). The proportion of prediabetic and diabetic patients was higher in higher quartile of GGT and there was a significant correlation between GGT and BMI, HbA1c, FPG, cholesterol, LDL-C, and triglyceride (p < 0.05). There was a significant relation between GGT and area under the curve (AUC) of oral glucose tolerance test (p = 0.00).
Measurement of GGT in FDRs of type 2 diabetic patients may be useful in assessing the risk of diabetes; those with chronically high levels of GGT should be considered as high risk group for diabetes.
PMCID: PMC3214292  PMID: 22091220
Gamma-Glutamyltransferase; Glucose Intolerance; Diabetes Mellitus; Type 2
21.  The association of hypertriglyceridemic waist phenotype with type 2 diabetes mellitus among individuals with first relative history of diabetes 
Antropometric measures with biochemical indicators have been used as screening tools for metabolic abnormalities in adolescents and adults. A few studies have assessed the relation of EWET (Enlarge waist Elevated triglyceride) phenotype with diabetes, especially among individuals with first relative history of diabetes. This study aimed to evaluate the association of EWET phenotype with diabetes among individuals with family history of diabetes.
Antropometric and biochemical measurments were evaluated in a population – based cross – sectional study of 332 male and 991 female Isfahani adults aged 35-55 year. The EWET phenotype was defined as serum trigcylglycerol concentrations ≥ 150 mg/dl and concurrent waist circumference (WC) ≥ 88 cm in females and ≥ 102 cm in males.
The prevalence of EWET phenotype was respectively 9.6% and 23.6% among male and female. Individuals with the phenotype had significantly higher BMI and WHR (waist to hip ratio) as compared to other groups. After control for age and physical activity, male with EWET phenotype were significantly more likely to have high serum triglyceride levels (p < 0.001), cholesterol (p < 0.001). Even after additional control for BMI, the significant associations remained except for low HDL Cholestrol. Female with EWET phenotype had significantly adverse metabolic risks as compared to other groups, either before or after control for BMI (p < 0.001). Individuals with the phenotype were more likely to have diabetes (both gender) and (IGT) Impaired Glucose Tolerance (female only).
Our results showed that EWET phenotype has significantly associated with diabetes. This phenotype could be used for early identification of diabetes and IGT.
PMCID: PMC3214297  PMID: 22091225
Enlarge waist Elevated triglyceride; IGT; Obesity and Antropometric
22.  Effect of pharmacist-led patient education on glycemic control of type 2 diabetics: a randomized controlled trial 
This study was conducted to evaluate the effect of a clinical pharmacist-led patient education program for type 2 diabetic patients at Isfahan Endocrine & Metabolism Research Center (IEMRC) from April 2008 to January 2009.
In a randomized controlled clinical trial, a total of 172 patients with uncontrolled type 2 diabetes were selected and randomly allocated into control and intervention groups. After taking informed written consent, the intervention group received an educational program about oral anti-hyperglycemic medications, adherence, diabetes dairy log and pill box usage. Patient's glycemic control in the intervention group was followed for three months through either telephone or face to face interviews with the pharmacist. Fasting blood glucose and HbA1c were measured at the start and end of the pharmacistled drug education program for both intervention and control groups.
After a three months follow-up, mean fasting blood glucose and HbA1c of the patients in the intervention group decreased significantly compared to control group (p < 0.001).
This study demonstrates an improvement in diabetes management of type 2 diabetics by involving a pharmacist in the multidisciplinary teams in the outpatient clinics. The results suggest the benefits of adding adherence education to the diabetic education programs.
PMCID: PMC3063424  PMID: 21448382
Diabetes Mellitus; Adherence; Medication; Self-Care; Clinical Pharmacist; HbA1c; Educational Activities
23.  Should the first degree relatives of type 2 diabetic patients with isolated impaired fasting glucose be considered for a diabetes primary prevention program? 
The aim of this study is to investigate the need for diabetes primary prevention program in isolated impaired fasting glucose (i-IFG) of the first degree relatives of type 2 diabetics.
In a cross sectional study, 793 individuals with prediabetes [543 with i-IFG and 250 with isolated impaired glucose tolerance (i-IGT)] who were the first degree relatives of type 2 diabetic patients, were enrolled. Isolated IFG was considered as fasting plasma glucose between 100-125 mg/dl and 2 hour plasma glucose < 140 mg/dl and isolated IGT as FPG < 100 mg/dl and 2 hour plasma glucose between 140-199 mg/dl during an overnight fasting 75 g oral glucose tolerance test. Mean of the age, weight, waist circumference, body mass index, systolic and diastolic blood pressure, plasma glucose, HbA1C, and lipid profile were compared between two groups (i-IFG and i-IGT). The prevalence of cardiometabolic risk factors (BMI ≥ 25 kg/m2, hypertension, cholesterol ≥ 200 mg/dl, LDL-C ≥ 100 mg/dl, HDL-C ≤ 40 mg/dl, and triglyceride ≥ 150 mg/dl) adjusted by age, sex and BMI were compared.
The prevalence of cardiometabolic risk factors is higher in i-IFG group than i-IGT. The mean level of LDL-C is significantly higher in i-IFG than i-IGT group.
First degree relatives of T2DM with isolated impaired fasting glucose should probably be included in the primary preventive program for diabetes. However, longitudinal cohort study is required to show high progression of i-IFG to T2DM.
PMCID: PMC3082819  PMID: 21526094
Prediabetic States; Diabetes Mellitus; Type II; Oral Glucose Tolerance Test; Primary Prevention; Dyslipidemia; Risk Factor; Iran
24.  Prevalence of Goitre in Isfahan, Iran, Fifteen Years After Initiation of Universal Salt Iodization 
This cross-sectional study investigated the prevalence of goitre in Isfahan, a centrally-located city in Iran, 15 years after the initiation of universal salt iodization. In total, 2,523 Isfahani adults (1,275 males, 1,248 females) aged >20 years were selected by multi-stage cluster-sampling method. Goitre rate, serum thyroid-stimulating hormone (TSH), thyroxine (T4), thyroid peroxidase antibody (TPOAb), thyroglobulin antibody (TgAb), and urinary iodine concentration (UIC) were measured and compared between the goitrous (n=478) and the non-goitrous (n=2,045) participants. The total goitre rate was 19% (n=478) of the 2,523 adults. The rate of Grade I and II goitre was 12.4% (n=312) and 6.6% (n=166) respectively. The total goitre rate, Grade I and II goitre were more prevalent among women than among men. Hypothyroidism was observed in 6.4% (130/2,045) and 18.6% (89/478) of the non-goitrous and goitrous participants respectively [odds ratio (OR)=3.6, 95% confidence interval (CI) 2.7-4.9, p=0.001]. Hyperthyroidism was present in 0.8% (17/2,045) and 5.2% (29/478) of the non-goitrous and goitrous adults respectively (OR=9.0, 95% CI 4.9-16.6, p=0.001). Hypothyroidism was more prevalent in Grade II than in Grade I goitre and among those without goitre (31.3%, 14.1%, and 6.4% respectively) (p=0.001). Positive TPOAb was observed in 24% (n=50) of the non-goitrous and 33.5% (n=84) of the goitrous subjects (p=0.03). Positive TPOAb was observed in 24.6% (35 of 142) of the Grade I and 45% (49 of 109) of the Grade II goitrous adults (p=0.001). Positive TgAb was observed in 21.6% (n=45) of the non-goitrous and 35.9% (n=90) of the goitrous adults (p=0.001). Positive TgAb was observed in 30.3% (43 of 142) of the Grade I and 43.1% (47 of 109) of the Grade II goitrous adults (p=0.04). The median UIC was 18 μg/dL (range 1-80 μg/dL). It was 17.9 μg/dL and 19 μg/dL in the non-goitrous and goitrous adults respectively. After 15 years of successful universal salt iodization in Isfahan, goitre is still endemic, which may be due to thyroid autoimmunity. However, other environmental or genetic factors may have a role.
PMCID: PMC2965326  PMID: 20824978
Autoimmunity; Cross-sectional studies; Goitre; Hypothyroidism; Hyperthyroidism; Impact studies; Iodine; Iodine deficiency; Iran
25.  Outcome of Congenitally Hypothyroid Screening Program in Isfahan: Iran From Prevention to Treatment 
Early and proper treatment is crucial to prevent neuropsychologic deficits in congenital hypothyroidism (CH). Considering the high prevalence of CH in Isfahan, the aim of this study was to evaluate the outcome of treatment in CH patients.
In this study CH neonates diagnosed during screening program in Isfahan from May 2002 to September 2009 were studied. Frequent visits were performed to CH patients to monitor and follow their treatments. Quality of treatment was assessed by evaluating mean age of treatment initiation and mean TSH and T4 levels before and after treatment and during the first and second years according to their normal reference ranges.
Of 225,224 screened neonates, 536 were diagnosed as CH patients. The prevalence of CH was 1/420 live births. Mean age at starting treatment was 22.9 ± 13.2 days. In 93.7% of patients, treatment was begun before the 45th day of life. In the first measurement after initiating the treatment, T4 and TSH were not in their acceptable range in 3.9% and 9.8% of CH patients, respectively. Mean T4 and TSH reached to normal range during the treatment period. T4 reached the normal range earlier than TSH.
The mean age of treatment initiation was in acceptable range but the findings suggest that both early and high-dose treatments are crucial for optimal treatment, especially in patients with severe CH. Further studies are needed to determine the outcome of treatment specially regarding to different etiologies of CH.
PMCID: PMC3075477  PMID: 21566768
Congenital hypothyroidism; Treatment; Isfahan; Iran

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