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1.  Do Static and Dynamic Insulin Resistance Indices Perform Similarly in Predicting Pre-diabetes and Type 2 Diabetes? 
We designed a study to compare the predictive power of static and dynamic insulin resistance indices for categorized pre-diabetes (PDM) / type 2 diabetes (DM).
Participants included 1,134 adults aged 18-60 years old with normal glucose at baseline who completed both baseline and 6-years later follow-up surveys. Insulin resistance indices from baseline data were used to predict risk of PDM or DM at follow-up. Two static indices and two dynamic indices were calculated from oral glucose tolerance test results (OGTT) at baseline. Area under the receiver operating characteristic curve (AROC) analysis was used to estimate the predictive ability of candidate indices to predict PDM/DM. A general estimation equation (GEE) model was applied to assess the magnitude of association of each index at baseline with the risk of PDM/DM at follow-up.
The dynamic indices displayed the largest and statistically predictive AROC for PDM/DM diagnosed either by fasting glucose or by postprandial glucose. The bottom quartiles of the dynamic indices were associated with an elevated risk of PDM/DM vs. the top three quartiles. However, the static indices only performed significantly to PDM/DM diagnosed by fasting glucose.
Dynamic insulin resistance indices are stronger predictors of future PDM/DM than static indices. This may be because dynamic indices better reflect the full range of physiologic disturbances in PDM/DM.
PMCID: PMC4138243  PMID: 24882014
insulin resistance indices; predict; pre-diabetes; type 2 diabetes; Chinese; twin; adult
2.  Caregiver Reports of Provider Recommended Frequency of Blood Glucose Monitoring and Actual Testing Frequency for Youth with Type 1 Diabetes 
To identify demographic, family and clinical characteristics associated with provider recommended frequency of blood glucose monitoring (BGM), actual frequency of BGM, and concordance between these categories in youth with type 1 diabetes (T1D) as reported by child’s caregiver.
Caregivers of 390 children 10–17 years were interviewed about their children’s providers’ recommendations for frequency of BGM and their child’s frequency of performance of BGM.
The majority (92%) of caregivers reported being told that their child should BGM ≥4 times per day and 78% reported their child checked that frequently. Caregivers of children who were younger, non-Hispanic White, from two-parent households, higher income households, and on insulin pumps were more likely to report being told by their provider to perform BGM ≥6 times per day and more likely to report that their child performed BGM ≥6 times per day. Younger children and those with private health insurance were more likely to adhere to reported recommendations. Children whose caregivers reported that their child met/exceeded their provider recommendations had lower A1c values than those who did not.
These findings may help clinicians identify subgroups of youth at-risk for poor diabetes management and provide further education in order to improve outcomes.
PMCID: PMC4519093  PMID: 21940061
Blood glucose monitoring; Adherence; Type 1 Diabetes; Youth
3.  All-Cause Mortality in a Population-Based Type 1 diabetes Cohort in the U.S. Virgin Islands 
Type 1 diabetes remains a significant source of premature mortality; however, its burden has not been assessed in the U.S. Virgin Islands (USVI). As such, the objective of this study was to estimate type 1 diabetes mortality in a population-based registry sample in the USVI.
Research Design and Methods
We report overall and 20-year mortality in the USVI Childhood (<19 years old) Diabetes Registry Cohort diagnosed 1979-2005. Recent data for non-Hispanic blacks from the Allegheny County, PA population-based type 1 diabetes registry were used to compare mortality in the USVI to the contiguous US.
As of December 31, 2010, the vital status of 94 of 103 total cases was confirmed (91.3%) with mean diabetes duration 16.8 ± 7.0 years. No deaths were observed in the 2000-2005 cohort. The overall mortality rates for those diagnosed 1979-1989 and 1990-1999 were 1852 and 782 per 100,000 person-years, respectively. Overall cumulative survival for USVI was 98% (95% CI: 97-99) at 10 years, 92% (95% CI: 89-95) at 15 years and 73% (95% CI: 66-80) at 20 years. The overall SMR for non-Hispanic blacks in the USVI was 5.8 (95% CI 2.7-8.8). Overall mortality and cumulative survival for non-Hispanic blacks did not differ between the USVI and Allegheny County, PA.
This study, as the first type 1 diabetes mortality follow-up in the USVI, confirmed previous findings of poor disease outcomes in racial/ethnic minorities with type 1 diabetes.
PMCID: PMC4516118  PMID: 24439208
4.  Probable NAFLD, by ALT levels, and Diabetes among Filipino-American Women 
Studies have shown alanine aminotransferase (ALT), a marker for nonalcoholic fatty liver disease (NAFLD), to predict type 2 diabetes (T2DM).
To examine the association between probable NAFLD and T2DM in non-obese, non-alcoholic consuming Filipino-American women aged 48 − 73 years.
The UCSD Filipino Women's Health Study measured glucose, hepatic enzymes, adiponectin and visceral fat (VAT) during clinical visits (1995 −2002). We defined T2DM by 1999 WHO criteria and probable NAFLD as ALT > 31 U/L.
Prevalence of T2DM was 34.4% and probable NAFLD was 17.2%. Women with T2DM (n = 56) had higher VAT, total:HDL cholesterol, SBP, fasting glucose and insulin, postchallenge glucose, ALT (28.7 vs. 19.1 U/L, p<0.0001), GGT, AST, and probable NAFLD (32.1 vs. 9.35%, p = 0.0002) and lower adiponectin than those without T2DM (n = 107). GGT (p = 0.0008) and ALT (p = 0.002) were associated with increasing VAT levels. Probable NAFLD was independently associated with T2DM (AOR 6.32, 95% CI 2.2−18.0), after adjusting for risk factors.
Probable NAFLD was elevated and associated with T2DM, independent of VAT, adiponectin and other risk factors. ALT may serve as a useful marker for NAFLD or diabetes risk in Filipino women.
PMCID: PMC4512638  PMID: 17764776
NAFLD; non-alcoholic fatty liver disease; ALT; alanine aminotransferase; Filipino women; Adiponectin; Diabetes
5.  Cigarette Smoking and Gestational Diabetes Mellitus in Hispanic Woman 
Hispanic women are at increased risk of gestational diabetes mellitus (GDM) as compared to non-Hispanic white women. While smoking has been associated with increased risk of type 2 diabetes, studies of smoking and GDM are sparse and conflicting. Therefore, we evaluated the relationship between cigarette smoking and GDM in Hispanic women.
We conducted a pooled analysis of two Hispanic datasets based in Massachusetts: the UMass Medical Health Care dataset and the Proyecto Buena Salud dataset. A total of 3,029 Hispanic prenatal care patients with singleton gestations were included. Cigarette smoking prior to and during pregnancy was collected via self-report. Diagnosis of GDM was abstracted from medical records and confirmed by study obstetricians.
One-fifth of participants (20.4%) reported smoking prior to pregnancy, and 11.0% reported smoking in pregnancy. A total of 143 women (4.7%) were diagnosed with GDM. We did not observe an association between pre-pregnancy cigarette smoking and odds of GDM (multivariable OR=0.77, 95% CI 0.47–1.25). In contrast, smoking during pregnancy was associated with a 54% reduction in odds of GDM (OR=0.46, 95% CI 0.22, 0.95). However, this association was no longer statistically significant after adjustment for age, parity, and study site (OR=0.47, 95% CI 0.23, 1.00).
In this population of Hispanic pregnant women, we did not observe statistically significant associations between pre-pregnancy smoking and odds of GDM. A reduction in odds of GDM among those who smoked during pregnancy was no longer apparent after adjustment for important diabetes risk factors.
PMCID: PMC4096822  PMID: 24857814
cigarettes; smoking; gestational diabetes; pregnancy; Latina
6.  Family history and body mass index predict perceived risks of diabetes and heart attack among community-dwelling Caucasian, Filipino, Korean, and Latino Americans—DiLH Survey 
The purpose of the study was to explore the perceived risk for diabetes and heart attack and associated health status of Caucasian, Filipino, Korean, and Latino Americans without diabetes.
A cross-sectional survey was conducted with 904 urban adults (mean age 44.3 ± 16.1 years; 64.3% female) in English, Spanish or Korean between August and December 2013.
Perceived risk for developing diabetes was indicated by 46.5% (n = 421), and 14.3% (n = 129) perceived themselves to be at risk for having a heart attack in their lifetime. Significant predictors of pessimistic diabetes risk perceptions: Filipino (adjusted odds ratio [AOR] = 1.7; 95% CI: 1.04–2.86) and Korean (AOR = 2.4; 1.33–4.48) ethnicity, family history of diabetes (AOR = 1.4; 1.00–1.84), female gender (AOR = 1.4; 1.04–1.96), high cholesterol (AOR= 1.6; 1.09–2.37) and higher body mass index (BMI) (AOR = 1.1; 1.08–1.15). Predictors of pessimistic heart attack risk perceptions were family history of an early heart attack (AOR = 2.9; 1.69–5.02), high blood pressure (AOR = 2.4; 1.45–3.84), and higher BMI (AOR = 1.1; 1.04–1.12) after controlling for socio-demographic factors. Older age, physical inactivity, smoking, and low HDL levels were not associated with risk perceptions.
Multiple risk factors were predictive of greater perceived diabetes risk, whereas, only family history of heart attack, high blood pressure and increases in BMI significantly contributed to perceived risk of heart attack among ethnically diverse at risk middle-aged adults. It is important that healthcare providers address the discordance between an individual’s risk perceptions and the presence of actual risk factors.
PMCID: PMC4470846  PMID: 25931282
Risk perception; Diabetes mellitus; Heart attack; Family history; Body mass index; Latino; Filipino; Korean; Risk factors
7.  Change in cardio-protective medication and health-related quality of life after diagnosis of screen-detected diabetes: Results from the ADDITION-Cambridge cohort 
•We examined individuals with screen-detected diabetes over five years.•Two cardio-protective agents were prescribed at diagnosis, 3 at one year and 4 at five years.•Increases in cardio-protective medication did not impact negatively on HRQoL.
Establishing a balance between the benefits and harms of treatment is important among individuals with screen-detected diabetes, for whom the burden of treatment might be higher than the burden of the disease. We described the association between cardio-protective medication and health-related quality of life (HRQoL) among individuals with screen-detected diabetes.
867 participants with screen-detected diabetes underwent clinical measurements at diagnosis, one and five years. General HRQoL (EQ5D) was measured at baseline, one- and five-years, and diabetes-specific HRQoL (ADDQoL-AWI) and health status (SF-36) at one and five years. Multivariable linear regression was used to quantify the association between change in HRQoL and change in cardio-protective medication.
The median (IQR) number of prescribed cardio-protective agents was 2 (1 to 3) at diagnosis, 3 (2 to 4) at one year and 4 (3 to 5) at five years. Change in cardio-protective medication was not associated with change in HRQoL from diagnosis to one year. From one year to five years, change in cardio-protective agents was not associated with change in the SF-36 mental health score. One additional agent was associated with an increase in the SF-36 physical health score (2.1; 95%CI 0.4, 3.8) and an increase in the EQ-5D (0.05; 95%CI 0.02, 0.08). Conversely, one additional agent was associated with a decrease in the ADDQoL-AWI (−0.32; 95%CI −0.51, −0.13), compared to no change.
We found little evidence that increases in the number of cardio-protective medications impacted negatively on HRQoL among individuals with screen-detected diabetes over five years.
PMCID: PMC4504034  PMID: 25937542
Diabetes; HRQoL; Medication
8.  Adherence and renal biopsy feasibility in the Renin Angiotensin-System Study (RASS) primary prevention diabetes trial☆,☆☆ 
Enhancing adherence in research trials is fundamental to the proper testing of treatment hypotheses.
Regimen and follow-up adherence as well as factors associated with adherence in the Renin Angiotensin-System Study (RASS) diabetic nephropathy primary prevention trial were evaluated. Adherence to medication (i.e., pill count), follow-up visits, and follow-up renal biopsies was evaluated.
89.8% of subjects completed the second renal biopsy. 96% of follow-up visits were attended within prescribed time windows. Mean medication adherence was 85.6%. Subgroup analyses revealed greater declines in the least adherent participants over time. Factors associated with greater adherence levels included older age, type 1 diabetes (TIDM) duration, lower HbA1c and blood pressure, GFR, ethnicity, and participants’, principal investigators’ (PI), and trial coordinators’ (TC) baseline predictions of adherence.
T1DM patients without nephropathy were willing to take experimental medications and undergo repeat renal biopsies. Although overall adherence was excellent, patterns of adherence varied among participants, suggesting the need to better track adherence and to develop customized and targeted approaches for promoting adherence to clinical research regimens. Staff subjective predictions of adherence were imprecise, supporting need for further development of adherence predictors.
PMCID: PMC4452734  PMID: 24050942
Adherence; Research; Clinical trial; Kidney biopsy; Diabetes; Psychology
9.  Early pregnancy urinary biomarkers of fatty acid and carbohydrate metabolism in pregnancies complicated by gestational diabetes 
Alterations in organic acid biomarkers from fatty acid and carbohydrate metabolism have been documented in type 2 diabetes patients. However, their association with gestational diabetes mellitus (GDM) is largely unknown.
Participants were 25 GDM cases and 25 non-GDM controls. Biomarkers of fatty acid (adipate, suberate and ethylmalonate) and carbohydrate (pyruvate, l-lactate and β-hydroxybutyrate) metabolism were measured in maternal urine samples collected in early pregnancy (17 weeks) using liquid chromatography–mass spectrometry methods. Logistic regression were used to calculate odds ratios (OR) and 95% confidence intervals (CI).
GDM cases and controls differed in median urinary concentrations of ethylmalonate (3.0 vs. 2.3 µg/mg creatinine), pyruvate (7.4 vs. 2.1 µg/mg creatinine), and adipate (4.6 vs. 7.3 µg/mg creatinine) (all p-values <0.05). Women in the highest tertile for ethylmalonate or pyruvate concentrations had 11.4-fold (95%CI 1.10–117.48) and 3.27-fold (95%CI 0.72–14.79) increased risk of GDM compared with women in the lowest tertile for ethylmalonate and pyruvate concentrations, respectively. Women in the highest tertile for adipate concentrations, compared with women in the lowest tertile, had an 86% reduction in GDM risk (95%CI 0.02–0.97).
These preliminary findings underscore the importance of altered fatty acid and carbohydrate metabolism in the pathogenesis of GDM.
PMCID: PMC4077203  PMID: 24703806
Organic acid profile; Adipate; Ethylmalonate; Fatty acid metabolism; Carbohydrate metabolism; Gestational diabetes mellitus
10.  No Association between Psoriasis and Diabetes in the U.S. Population 
Previous studies have found a positive association between psoriasis and diabetes/diabetes-related complications, but the association has not been studied in a nationally representative U.S. sample. Our analysis of NHANES data indicated that psoriasis was not associated with diabetes but was positively associated with hypertension, overweight/obesity and waist circumference.
PMCID: PMC4067950  PMID: 24835483
11.  Alteration in Fasting Glucose after Prolonged Treatment with a Thiazide Diuretic 
Thiazide diuretics are recommended as first line antihypertensive treatment, but may contribute to new onset diabetes. We aimed to describe change in fasting glucose (FG) during prolonged thiazide treatment in an observational setting.
We conducted an observational, non-randomized, open label, follow-up study of the Pharmacogenomic Evaluation of Antihypertensive Responses (PEAR) and PEAR-2 studies. We enrolled previous participants from the PEAR or PEAR-2 studies with at least six months of continuous treatment with either hydrochlorothiazide (HCTZ) or chlorthalidone. Linear regression was used to identify associations with changes in FG after prolonged thiazide and thiazide-like diuretic treatment.
A total of 40 participants were included with a mean 29 (range 8–72) months of thiazide treatment. FG increased 6.5 (SD 13.0) mg/dL during short-term thiazide treatment and 3.6 (SD 15.3) mg/dL FG during prolonged thiazide treatment. Increased FG at follow-up was associated with longer thiazide treatment duration (beta=0.34, p=0.008) and lower baseline FG (beta=−0.46, p=0.02). β blocker treatment in combination with prolonged thiazide diuretic treatment was also associated with increased FG and increased two-hour glucose obtained from OGTT.
Our results indicate that prolonged thiazide treatment duration is associated with increased FG and that overall glycemic status worsens when thiazide/thiazide-like diuretics are combined with β blockers.
PMCID: PMC4074403  PMID: 24794890
hypertension; hydrochlorothiazide; chlorthalidone; glucose; diabetes; thiazide diuretics; β blockers
12.  Population analysis of ethnicity and first-phase insulin release 
A mechanistic, physiologically-based pharmacokinetic (PK/PD) model was developed to describe the biphasic insulin release and evaluate the racial effects on the glucose– insulin kinetics in response to intravenous glucose.
Fifteen African-American and 18 Caucasian children and adolescents between 8 and 18 years of age were enrolled in the study. Intravenous bolus of glucose (250 mg/kg) was administered and blood samples collected at frequent intervals for three hours following the glucose injection. A nonlinear mixed-effect population kinetic analysis with covariate structure was performed using Monolix.
A significantly higher initial insulin secretion from a readily releasable pool, which is responsible for the first-phase insulin secretion, was detected in African-Americans compared to Caucasians (p < 0.05).
The proposed kinetic model is able to describe the glucose-stimulated insulin response, account for the first-phase insulin release and identify a racially-based pharmacokinetic difference in insulin’s biphasic secretion behavior. It is hypothesized that the first-phase insulin component may play an important role in the development of type 2 diabetes. The proposed mechanistic model provides a quantitative analysis of the biphasic insulin release that may be useful in the early detection of diabetes.
PMCID: PMC4445972  PMID: 20570007
First-phase insulin; Beta-cell; Ethnicity; Intravenous glucose tolerance test; Insulin modeling; Pharmacokinetics; Pharmacodynamics
13.  Anthropometric measures of abdominal adiposity for the identification of cardiometabolic risk factors in adolescents 
Sagittal abdominal diameter (SAD) was obtained in 65 adolescents referred for assessment of cardiometabolic risk. We found that SAD was associated with cardiometabolic risk factors independent of BMI in males, but that SAD was not superior to BMI or other measures of abdominal adiposity for the detection of metabolic syndrome.
PMCID: PMC4384445  PMID: 24552682
14.  Development and Validation of PRISM: A Survey Tool to Identify Diabetes Self-Management Barriers 
Although most children with type 1 diabetes don’t achieve optimal glycemic control, no systematic method exists to identify and address self-management barriers. This study develops and validates PRISM (Problem Recognition in Illness Self-Management), a survey-based tool for efficiently identifying self-management barriers experienced by children/adolescents with diabetes and their parents.
Adolescents 13 years and older and parents of children 8 years and older visiting for routine diabetes management (n=425) were surveyed about self-management barriers. HbA1c was abstracted from the electronic health record. To develop PRISM, exploratory and confirmatory factor analyses were used. To assess validity, the association of PRISM scores with HbA1c was examined using linear regression.
Factor analyses of adolescent and parent data yielded well-fitting models of self-management barriers, reflecting the following domains: 1) Understanding and Organizing Care, 2) Regimen Pain and Bother, 3) Denial of Disease and Consequences, and 4) Healthcare Team, 5) Family, or 6) Peer Interactions. All models exhibited good fit, with X2 ratios<2.21, root mean square errors of approximation<0.09, Confirmatory Fit Indices and Tucker-Lewis Indices both >0.92, and weighted root mean square residuals<1.71. Greater PRISM barrier scores were significantly associated with higher HbA1cs.
Our findings suggest at least six different domains exist within self-management barriers, nearly all of which are significantly related to HbA1c. PRISM could be used in clinical practice to identify each child and family’s unique self-management barriers, allowing existing self-management resources to be tailored to the family’s barriers, ultimately improving effectiveness of such services.
PMCID: PMC3992923  PMID: 24552680
Type 1 Diabetes Mellitus; Factor Analysis; Self-Care; Adherence; Patient-Centered Care
15.  Cohort study of diabetes in HIV-infected adult patients: evaluating the effect of diabetes mellitus on immune reconstitution 
We conducted a retrospective cohort study assessing the association between diabetes mellitus (DM) and immune recovery in HIV-infected adults. Immune reconstitution after initiating antiretroviral therapy was more rapid in DM patients (120.4 cells/year) compared to non-DM patients (94.2 cells/year, p < 0.023). Metformin use was associated with improved CD4 recovery (p= 0.034).
PMCID: PMC3989401  PMID: 24485344
16.  Understanding perceived risk of type 2 diabetes in healthy middle-aged adults: A cross-sectional study of associations with modelled risk, clinical risk factors, and psychological factors 
To determine the perceived risk of type 2 diabetes in a sample of healthy middle-aged adults and examine the association between perceived risk and modelled risk, clinical risk factors, and psychological factors theorised to be antecedents of behaviour change.
An exploratory, cross-sectional analysis of perceived risk of type 2 diabetes (framed according to time and in comparison with peers) was conducted using baseline data collected from 569 participants of the Diabetes Risk Communication Trial (Cambridgeshire, UK). Type 2 diabetes risk factors were measured during a health assessment and the Framingham Offspring Diabetes Risk Score was used to model risk. Questionnaires assessed psychological factors including anxiety, diabetes-related worry, behavioural intentions, and other theory-based antecedents of behaviour change. Multivariable regression analyses were used to examine associations between perceived risk and potential correlates.
Participants with a high perceived risk were at higher risk according to the Framingham Offspring Diabetes Risk Score (p < 0.001). Higher perceived risk was observed in those with a higher body fat percentage, lower self-rated health, higher diabetes-related worry, and lower self-efficacy for adhering to governmental recommendations for physical activity (all p < 0.001). The framing of perceived risk according to time and in comparison with peers did not influence these results.
High perceived risk of type 2 diabetes is associated with higher risk of developing the disease, and a decreased likelihood of engagement in risk-reducing health behaviours. Risk communication interventions should target high-risk individuals with messages about the effectiveness of prevention strategies.
PMCID: PMC4337811  PMID: 25467619
Type 2 diabetes; Perceived risk; Modelled risk; Psychology; Risk communication; Prevention
17.  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
18.  [No title available] 
PMCID: PMC3982306  PMID: 24485858
19.  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
20.  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
21.  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
22.  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
23.  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
24.  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
25.  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

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