How I Learned to Conduct Research That Makes a Difference in the Lives of Arizona’s Kids

The Canadian Diabetes Association 2013 Clinical Practice Guidelines—Raising the Bar and Setting Higher Standards!

Alas, a Patient-Centred Guidelines on the Glycemic Management in People with Type 2 Diabetes Mellitus

It is predicted that there will be 552 million people, or one adult in 10, diagnosed with diabetes in the world by 2030, a 93% increase almost doubling the number of those diagnosed with the condition in 2010 (285 million people, prevalence 6.6%).1 In England, the prevalence of people with diabetes in 2011 was 3 million. It is alarming that the prevalence in England is set to increase beyond the average world prevalence to 9.5%, i.e. 4.6 million people by 2030.2 Some 280 million people worldwide, or 6.5% of adults, were estimated to have impaired glucose tolerance (IGT) in 2011. By 2030, the number of people with IGT is projected to increase to 398 million, or 7.1% of the adult population.1 The development of type 2 diabetes is often preceded by a variety of altered metabolic states, including impaired glucose regulation, dyslipidaemia and insulin resistance.3 Although not all people with such metabolic abnormalities progress to diabetes, their risk of developing the disease is significantly enhanced. However, randomised clinical trials have demonstrated that type 2 diabetes can largely be prevented through diet and lifestyle modifications.4 In the Swedish Malmo study, increased physical exercise and weight loss prevented or delayed type 2 diabetes in patients with IGT to less than half the risk in the control group, during five years of follow up.5 In a Chinese study, 577 individuals with IGT were randomised into one of four groups: exercise only, diet only, diet plus exercise, and a control group. The cumulative incidence of type 2 diabetes during six years was significantly lower in the three intervention groups than in the control group.6 In the Finnish Diabetes Prevention Study, a 5% reduction in body weight, achieved through an intensive diet and exercise programme, was associated with a 58% reduction in the risk of developing type 2 diabetes in overweight middle-aged men and women with IGT.7 The reduction in the risk of progression to diabetes was directly related to the magnitude of the changes in lifestyle; none of the patients who had achieved at least four of the intervention goals by one year developed type 2 diabetes during follow up.8 The US Diabetes Prevention Program (DPP), comparing active lifestyle modification or metformin to standard lifestyle advice combined with placebo, found that lifestyle modification reduced the incidence of type 2 diabetes by 58% in overweight American adults with IGT.9 The goal of the programme was to achieve a 7% reduction in body weight and physical activity of moderate intensity for at least 150 minutes per week. The cumulative incidence of diabetes was 4.8, 7.8 and 11.0 cases per 100 person-years in the lifestyle, metformin and control groups, respectively. This reduction in incidence equated to one case of diabetes prevented for every seven people with IGT treated for three years in the lifestyle intervention group, compared with 14 for the metformin group. In addition, a review has also indicated that the numbers needed to treat (NNT) to prevent one case of type 2 diabetes with lifestyle intervention in people at risk of diabetes is dramatically low at 6.4 (over 1.8 to 4.6 years).10 Further-more, since patients with the metabolic syndrome have an increased risk of cardiovascular disease (CVD) and mortality,11–13 lifestyle interventions in obese patients and those with evidence of hyperglycaemia are likely to be beneficial in terms of overall health and life expectancy. It has been proposed that control of LDL cholesterol and blood pressure to normal levels in patients with the metabolic syndrome, could result in preventing 81% of CVD events.14 In the light of these impressive results, the NICE Guidance ‘Preventing type 2 diabetes: risk identification and interventions for individuals at high risk’15 was published in July 2012. This guidance focuses on identifying people at high risk of type 2 diabetes and on the provision of effective, cost-effective and appropriate interventions for them. The guidance does not advocate a national screening programme for type 2 diabetes but includes recommendations to remind practitioners that age is no barrier to being at high risk of, or developing, type 2 diabetes. The 20 NICE recommendations can be used alongside the NHS Health Check programme. They are extensive and consider: risk assessment and encouraging people to have an assessment; two-stage risk identification; matching interventions to risk and reassessing risk; commissioning prevention services; intensive lifestyle-change programmes, weight management, dietary advice and physical activity; vulnerable groups; audit and quality assurance; training and professional development; metformin and orlistat. The recommendations can be found online at: http://guidance.nice.org.uk/PH38. A structured and comprehensive literature review of the international evidence base was undertaken by the Programme Development Group (PDG), the NICE project team and external contractors in order to develop the guidance. Where there are gaps in current knowledge, recommendations have been made for further research. Much less is known about the progression to type 2 diabetes using glycated haemoglobin versus the oral glucose tolerance test (OGTT) as a marker, especially as the HbA1c assessment is much less sensitive to weight change. Thus, identifying which combination of risk-assessment tools and blood tests are the most cost effective and effective at assessing the risk of type 2 diabetes is recommended. Other recommendations for further research include determining: the demographic characteristics and rates of progression to type 2 diabetes among people with a high risk score but with normal blood glucose levels; the most cost-effective and effective methods of increasing uptake of risk assessments; the components of an intensive lifestyle-change programme that contribute most to the effectiveness and cost effectiveness of diabetes prevention interventions; the effectiveness of different types of dietary and physical activity regimens; and the most effective and cost-effective methods for identifying, assessing and managing the risk among high-risk vulnerable groups. The PDG considered and made provision for the fact that type 2 diabetes affects people of South Asian, African-Caribbean, Chinese or black African descent up to a decade or more earlier than white Europeans. Although it is unclear what the prevalence of impaired glucose regulation and undiagnosed type 2 diabetes is among black, Asian and minority ethnic people aged 25–39 years in the UK, they have recommended that risk assessments should be carried out in this age-specific sub-group and that health professionals provide advice and monitor according to each person's particular risk profile. People identified as being at high risk of developing type 2 diabetes in the international diabetes prevention trials were identified by blood glucose tests, not by risk score. The guidance acknowledges that it may not be effective to intervene with all people identified as being at high risk using a risk assessment tool as only a small proportion of people may have impaired glucose regulation. It has therefore issued two stages of risk identification. Stage 1 acknowledges that while the risk scores can identify those at high risk and those who may have undiagnosed type 2 diabetes, they cannot be used to give a diagnosis of type 2 diabetes. If people refuse a blood test, they should be offered brief advice and/or a place on an intensive lifestyle-change programme instead. The PDG considered that people over age 74 from all ethnic groups might benefit from type 2 diabetes risk assessment and prevention as the risk increases with age. However, it recognised that many of the risk-assessment tools are not validated for this age group and that comorbidities may prevent participation in lifestyle programmes. Nevertheless, there is evidence that older people can benefit from being more physically active and improving their diet, and the recommendations advise that people should not be excluded on the basis of age. The recommendations acknowledge that not all people identified as being at high risk will develop diabetes. However, informing them of the risk will not harm them and may even have a beneficial effect on their lifestyle. Frequency of follow up is identified and included in the recommendations for low, moderate and high risk individuals. This will assist practitioners in providing good quality, structured care. There has also been consideration of people from lower socioeconomic groups who may be less likely to attend for a risk assessment or a blood test. This has led to a recommendation that prevention services do not have to be carried out by GPs or in GP surgeries but can be offered in a range of settings, such as community pharmacies, occupational health departments, community and faith-based centres where these people are more likely to visit regularly. However, this raises a communication challenge to ensure that the data are passed securely to the person's GP and that the person is monitored and followed up regularly. A possible further limitation is the recommendation that a variety of practitioners and organisations be involved in the diabetes prevention services. While this may assist in raising awareness and improving the standard and continuity of care for all risk groups, it may also cause problems as no single organisation or service may take the lead. This could result in unnecessary duplication, unstructured care or the service being omitted altogether. Another communication challenge for practitioners considering an individual's level of risk could be in the limitations of the health care computer systems. These have Read codes for recording impaired fasting plasma glucose and OGTT but there is none for impaired HbA1c nor for recording that someone has had a risk assessment, what their level of risk is, and whether they have been referred to an intensive lifestyle-change programme. Also, although the waist circumference clinical indicator is a very important type 2 diabetes risk factor, it is not taken into account in the NHS Health Check programme. Therefore there is a need to raise awareness and train staff to measure waist circumference as an initial step in identifying risk. Unfortunately, there are no recommendations for reducing type 2 diabetes in children and young adults although the prevalence of type 2 diabetes in this age group in increasing. The guidance states that further research is required to identify effective dietary regimens in the prevention of type 2 diabetes. However, the literature did not include nutritional epidemiology research already undertaken which has been summarised in a diabetes prevention educator's manual.16 The X-PERT Prevention of Diabetes (X-POD) Programme is an evidence-based, quality-assured intensive lifestyle-change programme that fully meets NICE guidance. It involves the delivery of person-centred, empowering lifestyle education initially over six consecutive weekly sessions with follow up at three to six months, 12 months and thereafter every year by trained educators. An overview of the content of the programme is summarised in Table 1. The NICE guidance for preventing type 2 diabetes is a much-needed and ambitious strategy to combat the rising prevalence of type 2 diabetes. Will it achieve what it recommends or will it be largely ignored and gather dust in the fight for competing resources? Only time will tell. If organisations were monitored and held accountable for implementing the guidance, it is likely to have much more impact. In the meantime, it is hoped that commissioners, managers and practitioners will see the huge opportunity to prevent the diabetes pandemic by implementing simple and cost-effective interventions. The author is Chief Executive of the charitable not-for-profit organisation, X-PERT Health.

Type 2 diabetes is increasing in Kenya, especially in urban settings, and prevention interventions based on local evidence and context are urgently needed. Therefore, this study aimed to explore diabetes risk and co-create a diabetes prevention theory of change in two socioeconomically distinct communities to inform future diabetes prevention interventions. In-depth interviews were conducted with middle-aged residents in two communities in Nairobi (one low-income (n = 15), one middle-income (n = 14)), and thematically analysed. The theory of change for diabetes prevention was informed by analysis of the in-depth interviews and the Behaviour Change Wheel framework, and reviewed by a sub-set (n = 13) of interviewees. The key factors that influenced diabetes preventive practices in both communities included knowledge and skills for diabetes prevention, understanding of the benefits/consequences of (un)healthy lifestyle, social influences (e.g., upbringing, societal perceptions), and environmental contexts (e.g., access to (un)healthy foods and physical activity facilities). The proposed strategies for diabetes prevention included: increasing knowledge and understanding about diabetes risk and preventive measures particularly in the low-income community; supporting lifestyle modification (e.g., upskilling, goal setting, action planning) in both communities; identifying people at high risk of diabetes through screening in both communities; and creating social and physical environments for lifestyle modification (e.g., positive social influences on healthy living, access to healthy foods and physical activity infrastructure) particularly in the low-income community. Residents from both communities agreed that the strategies were broadly feasible for diabetes prevention but proposed the addition of door-to-door campaigns and community theatre for health education. However, residents from the low-income community were concerned about the lack of government prioritisation for implementing population-level interventions, e.g., improving access to healthy foods and physical activity facilities/infrastructure. Diabetes prevention initiatives in Kenya should involve multicomponent interventions for lifestyle modification including increasing education and upskilling at individual level; promoting social and physical environments that support healthy living at population level; and are particularly needed in low-income communities.

Reducing the Risk of Developing Diabetes.

Reducing the Risk of Developing Diabetes

Reducing the rates of diabetes across the United States

Purpose: Hypertension and diabetes used to occur in adults but are now prevalent in children however, there is no enough information on student’s knowledge on prevention and management of these conditions. Therefore, this study aimed at assessing knowledge on prevention and management of hypertension and diabetes among students in Morogoro Municipality. Methods: A cross-sectional study was conducted at Kihonda and SUA secondary schools among 253 randomly selected students. Data were collected using KAP questionnaire adapted from the FAO and analyzed using the Statistical Package for Social Science™ Version 20. Results: Over 95% of the students have never tested their blood pressure and glucose. Also, 34.4% have never measured body weight before the study. Majority (75.5%) understood that hypertension and diabetes can be prevented through managing diet and physical activity (19.2%) while 18.7% mentioned engaging in physical activities only. Furthermore, 64.4% and 69.2% did not know the management of diabetes and hypertension respectively. About 42% and 32% did not know any good and risk foods for hypertension respectively. Also, 38.3% and 35.2% did not know the appropriate and risk foods for diabetes patients respectively. Knowledge on prevention of diabetes and hypertension was associated with age AOR 1.421(95%CI: 1.015-1.989) p=0.040, education level AOR (1.118, 95%CI: 1.039-3.355) p< 0.01 and studying science subjects AOR 1.65 (95%CI: 1.306-1.692) p=0.028. Conclusion: Majority of students do not actively monitor their health and have limited knowledge on prevention and management of diabetes and hypertension creating a need for improving knowledge as a window of opportunity for prevention of non-communicable diseases.

UN Resolution 61/225: a gift to the diabetes world

A Changing World and a New Beginning

Diabetes mellitus is a fast-growing disease with a major influence on people’s quality of life. Oral hypoglycemic drugs and insulin are currently the main effective drugs in the treatment of diabetes, but chronic consumption of these drugs has certain side effects. Polysaccharides, saponins, flavonoids, and phenolics are the primary secondary metabolites isolated from the rhizomes of Polygonatum sibiricum Redouté [Asparagaceae], Polygonatum kingianum Collett & Hemsl [Asparagaceae], or Polygonatum cyrtonema Hua [Asparagaceae], which have attracted much more attention owing to their unique therapeutic role in the treatment and prevention of diabetes. However, the research on the mechanism of these three Polygonatum spp. in diabetes has not been reviewed. This review provides a summary of the research progress of three Polygonatum spp. on diabetes and its complications, reveals the potential antidiabetic mechanism of three Polygonatum spp., and discusses the effect of different processed products of three Polygonatum spp. in treating diabetes, for the sake of a thorough understanding of its effects on the prevention and treatment of diabetes and diabetes complications.

The increasing prevalence of diabetes is reaching epidemic proportion worldwide. Because of the associated morbidity and mortality, it is exerting major pressure on the healthcare system. With a better understanding of the pathophysiology of type-2 diabetes, the concept of primary prevention has emerged. A number of studies have confirmed that intensive lifestyle modification was very effective in the prevention of diabetes in the impaired glucose tolerance (IGT) population. However, maintaining long-term lifestyle modification is a major challenge. It is, therefore, important to have other strategies, either pharmacological or surgical, that can be used as an adjunct or alternative to lifestyle modification. The Chinese study showed that metformin and acarbose could reduce the risk of diabetes by 65 and 83%, respectively, in IGT subjects. The efficacy of metformin was confirmed by the Diabetes Prevention Program (31% risk reduction) and that of acarbose by the STOP-NIDDM trial (36% risk reduction) in a similar high-risk population. The TRIPOD study showed that troglitazone could reduce the risk of diabetes by 55% in Hispanic women with a history of gestational diabetes. And more recently, the XENDOS study showed that orlistat could reduced the risk of diabetes by 37% in obese subjects when used as an adjunct to an intensive lifestyle program. Three studies have suggested that bariatric surgery in morbidly obese subjects could reduce the risk of diabetes to near zero. Furthermore, a number of studies have examined the effect of a renin angiotensin aldosterone system inhibitor, as well as statin and hormone replacement therapy on the prevention of type-2 diabetes in high-risk subjects as secondary outcomes and have suggested that they could be of potential benefit. The accumulating evidence is now overwhelming. Yes, diabetes can be prevented or delayed in high-risk populations. With this new information, we need to design new strategies to screen high-risk populations and to implement the new treatments that have proven effective in the prevention of type-2 diabetes.

The 2006 American Diabetes Association (ADA) nutrition recommendations reaffirm the importance of medical nutrition therapy (MNT) in the prevention of diabetes, treatment of existing diabetes, and prevention and treatment of the complications of diabetes in which MNT plays a role. The differences between the 2002 technical review1 and the 2006 position statement2 reflect research published after 2000. The recommendations continue to be graded according to the ADA evidence grading system. MNT, as illustrated in Table 1, plays a vital role across the continuum of diabetes, and interventions change as the disease progresses. Primary prevention first seeks to reduce the prevalence of obesity and thus reduce the risk of developing pre-diabetes and diabetes. For individuals with pre-diabetes, MNT focuses on the prevention or delay of diabetes by moderate weight loss and increased physical activity. However, when overt diabetes develops, MNT interventions focus on normalization of metabolic parameters to prevent or control the complications of diabetes. View this table: Table 1. Nutrition and MNT MNT for people at risk for and with diabetes should be individualized, and clinical trials and outcome studies suggest that such therapy is best provided by a registered dietitian familiar with diabetes. Monitoring of metabolic parameters, including glucose, hemoglobin A1c (A1C), lipids, blood pressure, body weight, and renal function, is essential to assess the need for changes in therapy to ensure successful outcomes. Taking into account an individual's personal needs, willingness, and ability to change remains crucial. Clinical trials and outcome studies of MNT have reported decreases in A1C of ∼ 1% in type 1 diabetes and 1–2% in type 2 diabetes, depending on the duration of diabetes.3 After initiation of MNT, improvements were apparent in 6 weeks to 3 months. Meta-analysis of studies in nondiabetic, free-living subjects and expert committees report that MNT reduces LDL cholesterol by …

An increase in the oxidative stress and a decrease in the antioxidant levels have been described in diabetic patients, that have been related with the etiopathogenesis of diabetes and its chronic complications. We performed a non-systematic review to evaluate the relationship between oxidative stress and diabetes, and the possible effects of antioxidants in the prevention and treatment of diabetes and its complications. The intervention studies including different antioxidants have not demonstrated any beneficial effect on cardiovascular and global morbimortality in different populations, including diabetic patients. Neither of these studies has demonstrated a beneficial effect of antioxidant supplementation on the prevention of diabetes. According to these studies, these substances can decrease lipid peroxidation, LDL-cholesterol particles oxidation and improve endothelial function and endothelial-dependent vasodilatation, without significant improvement in the metabolic control of these patients. The current evidence does not support the use of high doses of antioxidants on the prevention and treatment of diabetes and its complications.

Nowadays, diabetes is the fastest growing disease among the high incidence chronic diseases in the world. It is one of the main causes of cardiovascular disease, renal failure, and other major diseases. The current situation and prevention of diabetes is one of the key research topics. Some researchers have found the current situation and progress of diabetes in the world, but there is still a lack of unified explanation and systematic research on specific prevention strategies for diabetes in China. Therefore, this paper collects the data from 2008, 2013, and 2018, analyzes the data of China by using the methods of correlation analysis and prediction analysis, and proposes the prevention and treatment measures for diabetes based on the research on the etiology and status of diabetes, and provides a theoretical reference for solving related problems. This study found that the prevalence of diabetes in China showed an increasing trend year by year, and will continue to grow in the future. Men have a higher risk of diabetes than women, and people over 50 years old have a higher risk of diabetes than other age groups. So the prevention and treatment of diabetes, especially diabetes among Chinese people, is very important.