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1.  Short Communication 
To compare the use, reimbursement policies and cost of self-monitoring of blood glucose (SMBG) in people with type 2 diabetes in 13 countries from Europe, North and South America, Africa, Asia and Australia.
Cross-sectional survey of SMBG International Working Group members. Application of the United Nations 2006 purchasing power parities (PPP) conversion factors from the local currency to the international dollar to facilitate inter-country glucose strip price comparison.
There were no published data for half the countries surveyed, and no country had data available at the national level. For type 2 patients using insulin, the prevalence of SMBG-use was >80 % in most countries with data, except for the Asian countries. The lowest use of SMBG was in India where there is no reimbursement and the relative cost of a strip is the highest amongst the countries surveyed. Only two countries provided free strips to patients taking oral antidiabetic drugs (OAD). These reported the highest prevalence of SMBG-use. Nevertheless, in half the countries the majority of OAD-treated patients use SMBG. The difference in frequency of strip use between countries was marked, even within the insulin-treated group Reimbursement polices differed not only by country, but by region, health insurance status, and the means of the patient.
This study finds SMBG a common practice in type 2 diabetes globally, with some exceptions, and highlights the need for more rigorous and systematic data collection across countries to ensure evidence-based use of SMBG, particularly in non-insulin-using diabetic patients.
PMCID: PMC4319544  PMID: 18995920
Self-monitoring of blood glucose; type 2 diabetes; non-insulin treated
2.  [No title available] 
PMCID: PMC3982306  PMID: 24485858
3.  Clinical and biological characteristics of diabetic patients under age 40 in Cameroon: relation to autoantibody status and comparison with Belgian patients 
We investigated the prevalence of diabetes autoantibodies (Abs) in Cameroonian patients and controls, assessed their contribution in disease classification and compared results with data from Belgium.
Abs against GAD (GADA), IA-2 (IA-2A) and zinc transporter 8 (ZnT8A) were assessed in 302 recently diagnosed Cameroonian patients with diabetes and 184 control subjects without diabetes aged below 40 years.
Only 27 (9%) Cameroonian patients were younger than 15 years. Overall, 29% of patients presented at least one diabetes-associated antibody versus 9% in healthy controls (24% versus 7% for GADA (p < 0.001), 10% versus 3% for IA-2A (p < 0.006); 4% versus 2% for ZnT8A). Ab+ patients had lower C-peptide levels (p < 0.001), were more often insulin-treated (p < 0.002) and were as frequently diagnosed with type 1 diabetes as Ab− patients. Only 43% of Ab+ patients aged 15–39 years were clinically classified as having type 1 diabetes in Cameroon vs 96% in Belgium (p < 0.001). Not one Ab+ Cameroonian patient carried HLA-DQ2/DQ8 genotype versus 23% of Belgian Ab+ patients (p < 0.001). Younger age at diagnosis and antibody positivity were independent predictors of insulin therapy. Ab+ Cameroonian patients were older (p < 0.001), had higher BMI (p < 0.001) and lower Ab titers than Belgian Ab+ patients. In ketonuric patients, prevalence of autoantibodies was similar as in non-ketonuric patients.
In Cameroonian patients with diabetes aged under 40 years, antibody-positivity is not clearly related to disease phenotype, but may help predict the need for insulin treatment.
PMCID: PMC4120294  PMID: 24332797
Autoantibodies; classification; diabetes; sub-Saharan Africa
4.  Perceptions and experiences of using automated bolus advisors amongst people with type 1 diabetes: A longitudinal qualitative investigation 
We explored people's reasons for, and experiences of, using bolus advisors to determine insulin doses; and, their likes/dislikes of this technology.
Subjects and methods
42 people with type 1 diabetes who had received instruction in use of bolus advisors during a structured education course were interviewed post-course and 6 months later. Data were analysed thematically.
Participants who considered themselves to have poor mathematical skills highlighted a gratitude for, and heavy reliance on, advisors. Others liked and chose to use advisors because they saved time and effort calculating doses and/or had a data storage facility. Follow-up interviews highlighted that, by virtue of no longer calculating their doses, participants could become deskilled and increasingly dependent on advisors. Some forgot what their mealtime ratios were; others reported a misperception that, because they were pre-programmed during courses, these parameters never needed changing. Use of data storage facilities could hinder effective review of blood glucose data and some participants reported an adverse impact on glycaemic control.
While participants liked and perceived benefits to using advisors, there may be unintended consequences to giving people access to this technology. To promote effective use, on-going input and education from trained health professionals may be necessary.
PMCID: PMC4270460  PMID: 25451897
Automated bolus advisor; Type 1 diabetes; Patient experience; Qualitative methods; Technology
5.  The ARMS-D out performs the SDSCA, but both are reliable, valid, and predict glycemic control 
The Adherence to Refills and Medications Scale (ARMS) has been associated with objective measures of adherence and may address limitations of existing self-report measures of diabetes medication adherence. We modified the ARMS to specify adherence to diabetes medicines (ARMS-D), examined its psychometric properties, and compared its predictive validity with HbA1C against the most widely used self-report measure of diabetes medication adherence, the Summary of Diabetes Self-Care Activities medications subscale (SDSCA-MS). We also examined measurement differences by age (<65 vs. ≥65 years) and insulin status.
We administered self-report measures to 314 adult outpatients prescribed medications for type 2 diabetes and collected point-of-care HbA1C.
One of the 12-item ARMS-D items was identified as less relevant to adherence to diabetes medications and removed. The 11-item ARMS-D had good internal consistency reliability (α=0.86), maintained its factor structure, and had convergent validity with the SDSCA-MS (rho=−0.52, p<0.001). Both the ARMS-D (β=0.16, p<0.01) and the SDSCA-MS (β=−0.12, p<0.05) independently predicted HbA1C after adjusting for covariates, but this association did not hold among participants ≥65 years in subgroup analyses. There were no differences in ARMS-D or SDSCA-MS scores by insulin status, but participants on insulin reported more problems with adherence on two ARMS-D items (i.e., feeling sick and medicine costs).
The ARMS-D is a reliable and valid measure of diabetes medication adherence, and is more predictive of HbA1C than the SDSCA-MS, but takes more time to administer. The ARMS-D also identifies barriers to adherence, which may be useful in research and clinical practice.
PMCID: PMC3915929  PMID: 24209600
medication adherence; glycemic control; diabetes; validity; insulin
6.  Longitudinal changes in dietary fat intake and associated changes in cardiovascular risk factors in adults with type 2 diabetes: The ACCORD trial 
To measure dietary fat intake using the Puget Sound Eating Patterns (PEP) questionnaire, a validated 19-item food questionnaire, and to quantify how reduced dietary fat intake affects cardiovascular risk factors in adults with type 2 diabetes.
Randomized controlled trial including a subsample of 1781 Action to Control Cardiovascular Risk in Diabetes (ACCORD) participants. Participants received dietary counseling to consume a reduced-fat diet. Outcome measures included HbA1c, fasting lipid profile, blood pressure, and weight. Longitudinal linear regression analyses were used to evaluate relationships between baseline and follow-up PEP scores and cardiovascular risk factors.
PEP scores decreased significantly from baseline to 12-month follow up with a mean difference of −0.09 ± 0.39, P < 0.001. All of the fat intake subscales showed significant improvement at 12 months from baseline. White race, female gender, and more hours per week of physical activity were correlated with a decline in PEP scores at 1-year. A longitudinal decrease in dietary fat intake was associated with significantly less weight gain at 12- and 36-months and lower serum triglycerides at 1 year.
Reduced fat intake as measured by a brief questionnaire was associated with significant improvement in some cardiovascular risk factors (triglycerides and weight), but not in others.
PMCID: PMC4158818  PMID: 23490598
Dietary fats; Diabetes mellitus type 2; Cardiovascular disease; Risk factors
7.  Absence of Evidence for an Association Between Resistin Gene Variants and Insulin Resistance in an Asian Population with Low and High Blood Pressure 
Although the function of resistin in human biology is unclear, some evidence suggests resistin gene variants influence insulin resistance, and insulin resistance-related hypertension. We searched for associations between common resistin gene variants and factors related to insulin resistance in Asian individuals with high or low blood pressure.
Non-diabetic Chinese or Japanese sibling pairs were included if one had extreme hypertension and the other was either hypertensive or hypotensive. Four common, non-coding single nucleotide polymorphisms (SNPs) were identified by sequencing the resistin gene in 24 hypertensive probands. Generalized estimating equations-based regressions were then performed to test for SNP associations using the entire study population (n=1556).
Of 72 tests, only one was significant at the 0.05 level; 3.5 significant tests were expected by chance alone. High variability in insulin and triglyceride levels created wide confidence intervals, thus the negative results are not conclusive for these phenotypes. However, the large sample size resulted in narrow confidence intervals for BMI, fasting and 120 minute post-load glucose, and high and low density lipoprotein cholesterol.
Factors associated with insulin resistance are not likely influenced by the resistin gene in non-diabetic Asian individuals with high and low blood pressure.
PMCID: PMC4156032  PMID: 18501464
resistin; hypertension; Asian population; insulin resistance; single nucleotide polymorphisms
8.  Impact of low-density lipoprotein cholesterol on cardiovascular outcomes in people with type 2 diabetes: a meta-analysis of prospective cohort studies 
To estimate the prospective association of low-density lipoprotein (LDL) cholesterol on cardiovascular disease (CVD) risk among individuals with type 2 diabetes.
We used extensive literature searching strategies to locate prospective cohort studies that reported LDL cholesterol levels as a risk factor for incidence of cardiovascular events. We conducted meta-analytic procedures for two outcomes: incident CVD and CVD mortality.
A total of 16 studies were included in this analysis with a mean follow-up range of 4.8–11 years. The pooled relative risk associated with a 1 mmol/L increase in LDL cholesterol among patients with type 2 diabetes was 1.30 (95% confidence interval [CI], 1.19 to 1.43) for incident CVD, and 1.50 (95% CI, 1.25 to 1.80) for CVD mortality, respectively. Subgroup analyses showed that for incident CVD, the pooled relative risk was 1.28 (95% CI, 1.17 to 1.41) for 7 studies adjusted for blood pressure and/or glucose concentration (or insulin concentration, glycated hemoglobin) and 1.40 (95% CI, 1.05 to 1.86) for 3 studies that did not adjust for these variables.
Our study demonstrates that LDL cholesterol was associated with an increased risk for cardiovascular outcomes among patients with type 2 diabetes, independently from other conventional risk factors.
PMCID: PMC4141536  PMID: 23932206
type 2 diabetes; meta-analysis; low-density lipoprotein cholesterol; cardiovascular outcomes
9.  Clinical Predictors and Significance of Postvoid Residual Volume in Women with Diabetes 
To identify women with diabetes at risk of increased postvoid residual volume (PVR) and investigate the relationship of increased PVR to urinary symptoms in women with diabetes.
PVR was measured by bladder ultrasonography in a cross-sectional cohort of 427 middle-aged and older women with diabetes. Participants completed questionnaires assessing urgency incontinence, stress incontinence, daytime frequency, nocturia, obstructive voiding, and diabetes-related end-organ complications: heart disease, stroke, neuropathy. Serum HbA1c and creatinine were recorded.
75% of participants had a PVR of 0–49, 13% had a PVR of 50–99, and 12% had a PVR ≥100 mL. Approximately 59% of women with a PVR <50 mL reported at least one lower urinary tract symptom. Women with diabetes and a PVR ≥100 mL were more likely to report urgency incontinence (OR 2.18, CI 1.08–4.41) and obstructive voiding symptoms (OR 2.47, CI 1.18–5.17) than women with PVR <50 mL. In multivariable models, poorer glycemic control was associated with an increased likelihood of PVR ≥100 mL (OR 1.30, CI 1.06–1.59 per 1.0-unit increase in HbA1c).
PVR volumes ≥100 mL may indicate increased risk of urgency incontinence and obstructive voiding. Glycemic control may play a role in preventing increased PVR in women with diabetes.
PMCID: PMC3742560  PMID: 23773505
10.  The utility of hemoglobin A1c at diagnosis for prediction of future glycemic control in children with type 1 diabetes 
We evaluated the relationships of hemoglobin A1c (A1c) at diagnosis of type 1 diabetes (T1DM) to future glycemic control and to a series of clinical variables in children with T1DM.
Materials and methods
Patients <18 years old diagnosed with T1DM during a one year period who had an A1c at diagnosis and at least one follow-up visit at our center were eligible for inclusion. Baseline variables examined included age, race, gender, symptom duration, admission acuity, anthropometrics, bicarbonate, and A1c. Annual anthropometric and A1c data were also obtained from clinic visits through 4 years after diagnosis.
We identified 120 children (53 males). Mean age at diagnosis was 7.6 ± 3.9 years. Mean A1c at diagnosis was 10.9 ± 1.9%. A1c at diagnosis correlated with age at diagnosis, symptom duration, and A1c at 3-years, with trends towards correlations at 6 weeks and 4 years. A1c at 1 year correlated highly with A1c at subsequent visits. No other baseline variables correlated with subsequent glycemic control.
In children with newly diagnosed diabetes, A1cs at diagnosis and one year post diagnosis are related to subsequent glycemic control. Children with high A1cs particularly at one year post diagnosis may benefit from targeted intensification of resources.
PMCID: PMC4070008  PMID: 21272951
Type 1 diabetes mellitus; Hemoglobin A1c; Glycemic control; Children; Adolescents
In type 2 diabetes, early effects of strict near-normalization of glucose control on macrovascular and microvascular disease are still uncertain. We evaluated the effects of early dramatic improvement in glycemia on retinal disease in poorly controlled diabetes.
A retrospective, case-control study in public hospital patients with type 2 diabetes, who had annual retinal imaging as part of a case management program or standard diabetes care. Patients included had ≥2 two retinal images ≥1 one year apart, and at least 3 HbA1C measurements. Retinal images were graded using a modified Scottish Diabetic Retinopathy grading scheme. An ‘intensive’ group (n=34) with HbA1C decrease >1.5% was compared with randomly chosen patients (n=34) with minimal HbA1C changes.
Mean HbA1C (±SEM) over two years was similar in intensive (8.5±0.21%) and control groups (8.1±0.28%, p=NS). However, the intensive group had higher baseline HbA1C and a mean maximal decrease of 4.0±0.41% in contrast to the control group (0.2±0.11%). Retinopathy grade progressed +0.7±0.25 units from baseline in the intensive group (p = 0.015), a 22.6% worsening. The control group changed minimally from baseline (0.03±0.14 units, p=NS). Change in retinopathy grade was significantly different between groups (p=0.02). More eyes worsened by ≥1 retinal grade (p=0.0025) and developed sight-threatening retinopathy (p=0.003) in the intensive group. Visual acuity was unchanged.
Diabetic retinopathy significantly worsened in poorly controlled type 2 diabetes after early intensification of glycemic control and dramatic HbA1C change. Retinal status should be part of risk-factor evaluation in patients likely to experience marked reductions in HbA1C in poorly controlled diabetes.
PMCID: PMC3713071  PMID: 23566652
Diabetic Retinopathy; intensified glycemic control; case management; euglycemia; minority populations
12.  Problem Solving Interventions for Diabetes Self-management and Control: A Systematic Review of the Literature 
Problem solving is deemed a core skill for patient diabetes self-management education. The purpose of this systematic review is to examine the published literature on the effect of problem-solving interventions on diabetes self-management and disease control.
Data Sources
We searched PubMed and PsychINFO electronic databases for English language articles published between November 2006 and September 2012. Reference lists from included studies were reviewed to capture additional studies.
Study Selection
Studies reporting problem-solving intervention or problem solving as an intervention component for diabetes self-management training and disease control were included. Twenty-four studies met inclusion criteria.
Data Extraction
Study design, sample characteristics, measures, and results were reviewed.
Data Synthesis
Sixteen intervention studies (11 adult, 5 children/adolescents) were randomized controlled trials, and 8 intervention studies (6 adult, 2 children/adolescents) were quasi-experimental designs.
Studies varied greatly in their approaches to problem-solving use in patient education. To date, 36% of adult problem-solving interventions and 42% of children/adolescent problem-solving interventions have demonstrated significant improvement in HbA1c, while psychosocial outcomes have been more promising. The next phase of problem-solving intervention research should employ intervention characteristics found to have sufficient potency and intensity to reach therapeutic levels needed to demonstrate change.
PMCID: PMC3633671  PMID: 23312614
13.  Fructose Intake and Cardiovascular Risk Factors in Youth with Type 1 Diabetes: SEARCH for Diabetes in Youth Study 
High consumption of dietary fructose has been shown to contribute to dyslipidemia and elevated blood pressure in adults, but there are few data in youth, particularly those at greater risk of cardiovascular disease (CVD). The aim of this study was to examine the association between fructose intake and CVD risk factors in a diverse population of youth with type 1diabetes (T1D).
This was a cross-sectional analysis of data from the SEARCH for Diabetes in Youth study, including 2085 youth ages 10–22 years with T1D, of which 22% were racial/ethnic minority and 50% were female. A semi-quantitative food frequency questionnaire was used to assess intake.
Median daily fructose consumption was 7.9% of total calories. Fructose intake was positively associated with triglycerides (p<.01), but not with total cholesterol, LDL-cholesterol, HDL-cholesterol, or blood pressure after adjustment for physical activity and socio-demographic, clinical, and dietary covariates. An increase in fructose intake of 22 grams (equivalent to a 12 oz. can of soda) was associated with a 23% higher odds of borderline/ high versus low triglycerides (p<.005).
These data suggest that children with T1D should moderate their intake of fructose, particularly those with borderline or high triglycerides.
PMCID: PMC3764988  PMID: 23540682
Fructose; cardiovascular risk factors; triglycerides; adolescents; type 1 diabetes
14.  Cross-sectional and longitudinal relationships of body mass index with glycemic control in children and adolescents with type 1 diabetes mellitus 
Weight gain is an oft-cited outcome of improved glycemic control in adults with type 1 diabetes, though few studies have investigated this in youth. The purpose of this paper was to examine cross-sectional and longitudinal associations of body mass index (BMI, kg/m2) with glycemic control in youth with type 1 diabetes (n=340, 12.5±1.7y, 49% female, duration ≥1year) participating in a 2-year multicenter intervention study targeting family diabetes management.
BMI was calculated from height and weight measured at clinic visits. Glycohemoglobin (HbA1c) at each visit was assayed centrally. Cross-sectional associations of baseline BMI with glycemic control, and of change in BMI and HbA1c with baseline values, were examined. Longitudinal associations of time-varying BMI and HbA1c were examined using a multilevel linear mixed effects model controlling for time-varying time (months), insulin dose (units/kg/day), regimen, Tanner stage, and time invariant baseline diabetes duration, BMI, treatment group and sociodemographic characteristics.
Baseline HbA1c was unrelated to baseline BMI, but was related positively to subsequent BMI change (p=0.04) and inversely to HbA1c change (p=0.002). Baseline BMI was inversely related to BMI change (p=0.01) and unrelated to HbA1c change. In multilevel regression, BMI was related inversely to HbA1c (%) (β±SE=−0.11±0.02,p<0.001) and positively to insulin dose (0.23±0.07,p=0.001). In the treatment group only, BMI was positively related to pump regimen (0.18±0.08,p=0.02).
Increased insulin administered to improve glycemic control may contribute to increased BMI in youth with type 1 diabetes, indicating the importance of determining ways to minimize weight gain while optimizing glycemic control.
PMCID: PMC3634913  PMID: 23339757
BMI; children; adolescents; longitudinal
15.  Association of foot ulcer with tibial artery calcification is independent of peripheral occlusive disease in type 2 diabetes 
To determine the relationship between foot ulcers, arterial calcification, and peripheral occlusive disease in patients with type 2 diabetes.
We performed a cross-sectional study on 162 patients with type 2 diabetes who underwent assessment of tibial artery calcification (TAC) by non-contrasted CT scan. Peripheral artery occlusive disease was assessed by angiography. Foot status including the presence or absence of ulcers was documented at presentation. A multivariable logistic regression model was used to evaluate the association between foot ulcers, arterial calcification, and the extent of peripheral atherosclerotic occlusive disease.
Patients with foot ulcers (n= 31) were more likely to be older and have a history of tobacco use. They were also more likely to have higher TAC scores (median [IQR]: 4324.6 [609.9, 11163.6] vs. 9.4 [0.0, 343.9], P < 0.001) and more advanced peripheral artery occlusive disease (occlusion index 5.5 [4.8, 6.4] vs. 2.2 [1.0, 3.6], P < 0.001. Foot ulcer was strongly associated with elevated TAC scores in a multivariable regression model (Odds ratio [95% CI] =2.76 [1.61, 4.75], P=0.0002).
There is a strong association between arterial calcification and diabetic foot ulcers that persists after adjusting for the extent of atherosclerosis in patients with type 2 diabetes.
PMCID: PMC3628094  PMID: 23305901
diabetes; foot ulcer; artery calcification; atherosclerosis
16.  Comparison of type 2 diabetes prevalence estimates in Saudi Arabia from a validated Markov model against the International Diabetes Federation and other modelling studies 
To compare the estimates and projections of type 2 diabetes mellitus (T2DM) prevalence in Saudi Arabia from a validated Markov model against other modelling estimates, such as those produced by the International Diabetes Federation (IDF) Diabetes Atlas and the Global Burden of Disease (GBD) project.
A discrete-state Markov model was developed and validated that integrates data on population, obesity and smoking prevalence trends in adult Saudis aged ≥25 years to estimate the trends in T2DM prevalence (annually from 1992 to 2022). The model was validated by comparing the age- and sex-specific prevalence estimates against a national survey conducted in 2005.
Prevalence estimates from this new Markov model were consistent with the 2005 national survey and very similar to the GBD study estimates. Prevalence in men and women in 2000 was estimated by the GBD model respectively at 17.5% and 17.7%, compared to 17.7% and 16.4% in this study. The IDF estimates of the total diabetes prevalence were considerably lower at 16.7% in 2011 and 20.8% in 2030, compared with 29.2% in 2011 and 44.1% in 2022 in this study.
In contrast to other modelling studies, both the Saudi IMPACT Diabetes Forecast Model and the GBD model directly incorporated the trends in obesity prevalence and/or body mass index (BMI) to inform T2DM prevalence estimates. It appears that such a direct incorporation of obesity trends in modelling studies results in higher estimates of the future prevalence of T2DM, at least in countries where obesity has been rapidly increasing.
PMCID: PMC4013554  PMID: 24447810
Modelling; Diabetes; Prevalence; Saudi Arabia
17.  Greater hand-grip strength predicts a lower risk of developing type 2 diabetes over 10 years in leaner Japanese Americans 
Much is known about body composition and type 2 diabetes risk but less about body function such as strength. We assessed whether hand-grip strength predicted incident diabetes.
We followed 394 nondiabetic Japanese-American subjects (mean age 51.9) for the development of diabetes. We fit a logistic regression model to examine the association between hand-grip strength at baseline and type 2 diabetes risk over 10 years, adjusted for age, sex, and family history.
A statistically significant (p = 0.008) and negative (coefficient -0.208) association was observed between hand-grip strength and diabetes risk that diminished at higher BMI levels. Adjusted ORs for a 10-pound hand-grip strength increase with BMI set at the 25th, 50th or 75th percentiles were 0.68, 0.79, and 0.98, respectively.
Among leaner individuals, greater hand-grip strength was associated with lower risk of type 2 diabetes, suggesting it may be a useful marker of risk in this population.
PMCID: PMC3910507  PMID: 21281974
Epidemiology; muscle; hand strength; Japanese-American
18.  Asthma and the risk of type 2 diabetes in the Singapore Chinese Health Study 
Asthma is believed to increase the risk for several proinflammatory diseases, yet epidemiologic studies on asthma in relation to risk of developing type 2 diabetes are sparse and have reported inconsistent results. In the present study, we investigated the hypothesis that asthma is associated with an increased risk of incident type 2 diabetes in Chinese adults.
We used data from the Singapore Chinese Health Study, including Chinese men and women aged 45–74 years, free of cancer, heart disease, stroke, and diabetes at baseline (1993–1998) and followed through 2004 for incident physician-diagnosed diabetes. Cox regression models were used to examine the associations between self-reported history of physician-diagnosed asthma and risk of diabetes.
During an average follow-up of 5.7 years per person, 2,234 of the 42,842 participants included in the current analyses reported diagnoses of type 2 diabetes. After adjustment for potential confounders, not including body mass index (BMI), asthma was associated with a 31% increased risk of incident diabetes (HR = 1.31; 95% CI: 1.00–1.72). The association was attenuated after adjustment for adult BMI (HR = 1.25 95% CI: 0.95–1.64). The asthma-diabetes association appeared stronger for adult- versus child-diagnosed asthma cases, and for participants who were obese compared to non-obese.
In Singaporean Chinese adults we observed a positive association between self-reported, physician-diagnosed asthma and risk of developing type 2 diabetes that was modestly attenuated upon adjustment for BMI.
PMCID: PMC3615124  PMID: 23260853
Asthma; Type 2 diabetes; Obesity
19.  Health beliefs among individuals at increased familial risk for type 2 diabetes: Implications for prevention☆,☆☆ 
To evaluate perceived risk, control, worry, and severity about diabetes, coronary heart disease (CHD) and stroke among individuals at increased familial risk of diabetes.
Data analyses were based on the Family Healthware™ Impact Trial. Baseline health beliefs were compared across three groups: (1) no family history of diabetes, CHD or stroke (n = 836), (2) family history of diabetes alone (n = 267), and (3) family history of diabetes and CHD and/or stroke (n = 978).
After adjusting for age, gender, race, education and BMI, scores for perceived risk for diabetes (p < 0.0001), CHD (p < 0.0001) and stroke (p < 0.0001) were lowest in Group 1 and highest in Group 3. Similar results were observed about worry for diabetes (p < 0.0001), CHD (p < 0.0001) and stroke (p < 0.0001). Perceptions of control or severity for diabetes, CHD or stroke did not vary across the three groups.
Among individuals at increased familial risk for diabetes, having family members affected with CHD and/or stroke significantly influenced perceived risk and worry. Tailored lifestyle interventions for this group that assess health beliefs and emphasize approaches for preventing diabetes, as well as its vascular complications, may be an effective strategy for reducing the global burden of these serious but related chronic disorders.
PMCID: PMC3905745  PMID: 22257420
Family history; Health beliefs; Diabetes; Coronary heart disease; Stroke
20.  Association of Retinol Binding Protein 4 with Risk of Gestational Diabetes 
We investigated association of maternal retinol binding protein 4 (RBP4) with risk of gestational diabetes (GDM).
GDM cases (N=173) and controls (N=187) were selected from among participants of a cohort study of risk factors of pregnancy complications. Early pregnancy (16 weeks on average) serum RBP4 concentration was measured using an ELISA-based immunoassay. Logistic regression was used to estimate unadjusted and adjusted odds ratios (ORs/aORs) and 95% confidence intervals (95%CI).
Mean serum RBP4 was significantly higher among GDM cases compared with controls (47.1 vs. 41.1 μg/ml, respectively; p-value<0.05). Participants in the highest quartile for serum RBP4 had a 1.89-fold higher risk of GDM compared with participants in the lowest quartile (95%CI: 1.05-3.43). However, this relationship did not reach statistical significance after adjustment for confounders (aOR: 1.54; 95%CI: 0.82-2.90). Women who were ≥35 years old and who had high RBP4 (≥38.3 μg/ml, the median) had a 2.31-fold higher risk of GDM compared with women who were < 35 years old and had low RBP4 (<38.3 μg/ml) (aOR: 2.31; 95%CI: 1.26-4.23; p-value for interaction=0.021).
Overall, there is modest evidence of a positive association of early pregnancy elevated RBP4 concentration with increased GDM risk, particularly among women with advanced age.
PMCID: PMC3544538  PMID: 23153527
Retinol binding protein 4; gestational diabetes; pregnancy; maternal age
21.  Type 2 diabetes mellitus and 20 year incidence of periodontitis and tooth loss 
The objective of this study was to evaluate the prospective associations between type 2 diabetes mellitus (T2DM) and the risk of periodontitis and tooth loss.
35,247 male participants of the Health Professionals Follow-Up Study who were dentate, free of periodontitis and cancer at baseline, were followed from 1986-2006. Data on self-reported diabetes, periodontitis, tooth loss and potential confounders were collected at baseline and biennially through mailed questionnaires. The multivariable adjusted relationships between diabetes and first report of periodontitis and tooth loss were estimated using time-varying Cox models.
There were 3,009 incident self-reported periodontitis and 10,017 tooth loss events over 591,941 person-years. Men with T2DM showed a 29% (HR=1.29; 95% CI:1.13-1.47) increased risk of periodontitis compared to those without, when adjusted for age, race, smoking, BMI, fruit and vegetable intake, physical activity, alcohol consumption and dental profession. Men with T2DM with total fruit and vegetable intake
Type 2 diabetes mellitus was associated with a significantly greater risk of self-reported periodontitis.
PMCID: PMC3551264  PMID: 23040240
epidemiology; oral disease; type 2 diabetes mellitus; periodontitis
To determine whether inpatient diabetes management and education with improved transition to outpatient care (IDMET) improves glycemic control after hospital discharge in patients with uncontrolled type 2 diabetes (T2DM).
Adult inpatients with T2DM and HbA1c≥7.5% (11 mmol/mol) admitted for reasons other than diabetes to an academic medical center were randomly assigned to IDMET vs. usual care (UC). Linear mixed models estimated treatment-dependent differences in the change in HbA1c (measured at 3, 6, and 12 months) from baseline to 1 year follow-up.
Thirty-one subjects had mean age 55 ± 12.6 years, with mean HbA1c of 9.7 ± 1.6% (82 ± 18 mmol/mol). Mean inpatient glucose was lower in the IDMET than in the UC group (176 ± 66 vs. 195 ± 74 mg/dl [9.7 vs. 10.8 mmol/l]), p=0.001. In the year after discharge, the average HbA1c reduction was greater in the IDMET compared to the UC group by 0.6% (SE 0.5%, [7 (SE 5) mmol/mol], p=0.3). Among patients newly discharged on insulin, the average HbA1c reduction was greater in the in the IDMET than in the UC group by 2.4% (SE 1.0%, [25 (SE 11) mmol/mol] p=0.04).
Inpatient diabetes management (IDMET) substantially improved glycemic control one year after discharge in patients newly discharged on insulin; patients previously treated with insulin did not benefit.
PMCID: PMC3514591  PMID: 23036785
inpatient diabetes management; diabetes care management strategy; inpatient to outpatient transitions in care
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in people with diabetes in South Asia. The CARRS translation trial tests the effectiveness, cost-effectiveness, and sustainability of a clinic-based multi-component CVD risk reduction intervention among people with diabetes in India and Pakistan.
We randomly assigned 1,146 adults with diabetes recruited from 10 urban clinic sites, to receive usual care by physicians or to receive an integrated multi-component CVD risk reduction intervention. The intervention involves electronic health record management, decision-support prompts to the healthcare team, and the support of a care coordinator to actively facilitate patient and provider adherence to evidence-based guidelines. The primary outcome is a composite of multiple CVD risk factor control (blood glucose and either blood pressure or cholesterol, or all three). Other outcomes include control of the individual CVD risk factors, process and patient-centered measures, cost-effectiveness, and acceptability/feasibility.
The CARRS translation trial tests a low-cost diabetes care delivery model in urban South Asia to achieve comprehensive cardio-metabolic disease case-management of high-risk patients ( number: NCT01212328).
PMCID: PMC3544938  PMID: 23084280
diabetes; cardiovascular risk; South Asia; translation research; healthcare delivery
This study examined the long-term impact of a 24-month, empowerment-based diabetes self-management support (DSMS) intervention on sustaining health-gains achieved from previous diabetes self-management education (DSME).
This report is based on 60 African-American adults with type 2 diabetes (n=89 recruited at baseline) who completed the study. Prior to the intervention, all participants received 6 months of mailed DSME consisting of weekly educational newsletters coupled with clinical feedback. The intervention consisted of 88 weekly group-based sessions that participants were encouraged to attend as frequently as they needed. Sessions were guided by participants’ self-management questions and also emphasized experiential learning, coping, goal-setting, and problem-solving. Baseline, 6-month, and 30-month assessments measured A1C, weight, body mass index (BMI), blood pressure, lipids, self-care behaviors, and QOL.
Post 6-month DSME, participants demonstrated significant improvements for diastolic BP (p<0.05), serum cholesterol (p<0.001), healthy diet (p<0.01), blood glucose monitoring (p<0.05) and foot exams (p<0.01). Post 24-month intervention, participants sustained the improvements achieved from the 6-month DSME and reported additional improvements for healthy diet (p<0.05), carbohydrate spacing (p<0.01), insulin use, (p<0.05), and quality of life (p<0.05).
Findings suggest that an empowerment-based DSMS model can sustain or improve diabetes-related health gains achieved from previous short-term DSME.
PMCID: PMC3783218  PMID: 21872962
In recognition of the impact of chronic diseases on mental health and the lack of research on Asian American subgroups, the present study examined subjective perceptions of health as a potential mediator in the association between diabetes and depressive symptoms in Korean American older adults.
Multivariate analysis with data from 672 Korean American older adults in Florida explored the mediation model of health perceptions.
The presence of diabetes was associated with negative perceptions of health and elevated symptoms of depression. The proposed mediation model was also supported: negative perceptions of health served as an intervening step between diabetes and depressive symptoms.
The intervening role of health perceptions yields implications for developing health promotion interventions targeting older individuals with diabetes. Results suggest that even in the presence of chronic health conditions, mental well-being of older adults can be maintained by having optimistic beliefs and positive attitudes towards their own health.
PMCID: PMC3404238  PMID: 22520623
Diabetes; Depressive symptoms; Korean American older adults

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