Cardiometabolic Risk Factor Control Research Articles

1207-P: Early vs. Late Initiation of SGLT2 and GLP-1RA for Cardiometabolic Risk Factor Control: A Real-World Study

Aim: Benefits of early initiation of SGLT2 and GLP-1RA for glucose and cardiovascular (CV) risk factor control at population level real-world setting is not known. Association of early (≤ 6 months) vs. late (>6 months) initiation of these drugs in the antidiabetic therapy management pathway on sustainable HbA1c, body weight, blood pressure and lipid control was evaluated. Method: U.S. Centricity Electronic Medical Records of 21,897/28,266 pts with T2DM receiving SGLT2/GLP-1RA post 2013 without therapy overlap with min of 1 year follow-up was used. Odds of reducing CV risk factors within 6 month and maintaining the control over 1 year was estimated by timeline of these antidiabetes drug (ADD) initiation (first prescription date of SGLT2 or GLP-1RA - first prescription date of any first line ADD): HbA1c < 7.5%, body weight reduction > 5%, SBP < 130/140 mmHg and LDL-C 70/100 mg/dL for patients with/without CVD history. Propensity score based balanced analyses were conducted. Results: At SGLT2/GLP-1RA initiation, patients were 57/58 years old, mean HbA1c 8.7/8.8%, 79/76% had HbA1c ≥ 7.5%, body weight 102/107 Kg, 26/28% and 45/45% had uncontrolled SBP and LDL-C respectively, 22/22% had existing CVD, 80/78% and 84/86% were on lipid lowering and anti-hypertensive drugs respectively. Compared to late initiators, the early initiation of SGLT2/GLP-1RA was significantly associated with 47% (CI of OR: 1.27, 1.71)/23% (CI of OR: 1.07, 1.42) higher odds for longer term HbA1c control, and 58% (CI of OR: 1.31, 1.91)/52% (CI of OR: 1.28, 1.83) higher odds for at least two of the CV risk factors control simultaneously. The odds for risk factor control was similar for the two drugs, and similar for those with and without history of CVD. Conclusion: This study based on large representative U.S. data suggests significant benefits of initiating SGLT2 or GLP-1RA early on the antidiabetes therapy management pathway for holistic glycaemic and cardiovascular risk factor control in patients with and without existing CVD. Disclosure S.K. Paul: Consultant; Self; AstraZeneca, Roche Pharma. Research Support; Self; Roche Pharma. D. Koye: None. K. Khunti: Advisory Panel; Self; Amgen Inc., AstraZeneca, Eli Lilly and Company, Merck Sharp & Dohme Corp., Novo Nordisk A/S, Sanofi. Consultant; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck Sharp & Dohme Corp., Novartis AG, Novo Nordisk A/S, Pfizer Inc., Sanofi-Aventis, Servier, Takeda Pharmaceutical Company Limited. Research Support; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Merck Sharp & Dohme Corp., Novartis AG, Novo Nordisk A/S, Pfizer Inc., Sanofi-Aventis. Speaker's Bureau; Self; AstraZeneca, Berlin-Chemie AG, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Menarini Group, Merck Sharp & Dohme Corp., Novartis AG, Novo Nordisk A/S, Roche Pharma, Sanofi, Servier, Takeda Pharmaceutical Company Limited. O. Montvida: None.

Excess Burden of Mental Illness and Hospitalization in Young-Onset Type 2 Diabetes: A Population-Based Cohort Study.

Type 2 diabetes (T2D) increases hospitalization risk. Young-onset T2D (YOD) (defined as onset before age 40 years) is associated with excess morbidity and mortality, but its effect on hospitalizations is unknown. To determine hospitalization rates among persons with YOD and to examine the effect of age at onset on hospitalization risk. Prospective cohort study. Hong Kong. Adults aged 20 to 75 years in population-based (2002 to 2014; n= 422908) and registry-based (2000 to 2014; n= 20886) T2D cohorts. All-cause and cause-specific hospitalization rates. Negative binomial regression models estimated effect of age at onset on hospitalization rate and cumulative bed-days from onset to age 75 years for YOD. Patients with YOD had the highest hospitalization rates by attained age. In the registry cohort, 36.8% of YOD bed-days before age 40 years were due to mental illness. The adjusted rate ratios showed increased hospitalization in YOD versus usual-onset T2D (onset at age ≥40 years) (all-cause, 1.8 [95% CI, 1.7 to 2.0]; renal, 6.7 [CI, 4.2 to 10.6]; diabetes, 3.7 [CI, 3.0 to 4.6]; cardiovascular, 2.1 [CI, 1.8 to 2.5]; infection, 1.7 [CI, 1.4 to 2.1]; P< 0.001 for all). Models estimated that intensified risk factor control in YOD (hemoglobin A1c level <6.2%, systolic blood pressure <120 mm Hg, low-density lipoprotein cholesterol level <2.0 mmol/L [<77.3 mg/dL], triglyceride level <1.3 mmol/L [<115.1 mg/dL], waist circumference of 85 cm [men] or 80 cm [women], and smoking cessation) was associated with a one-third reduction in cumulative bed-days from onset to age 75 years (97 to 65 bed-days). Possible residual confounding. Adults with YOD have excess hospitalizations across their lifespan compared with persons with usual-onset T2D, including an unexpectedly large burden of mental illness in young adulthood. Efforts to prevent YOD and intensify cardiometabolic risk factor control while focusing on mental health are urgently needed. Asia Diabetes Foundation.

Direct and indirect effects of central and general adiposity on cardiovascular diseases: The Tehran Lipid and Glucose Study.

Aim The mechanisms linking body mass index to cardiovascular disease are still not clearly defined. The purpose of this study was to find out how much of the effect of central and general adiposity on cardiovascular disease is mediated through blood pressure, cholesterol, and glucose, and how much is independent of these factors. Methods and results The study population included participants, aged ≥30 years, free of cardiovascular disease at baseline with median follow-up of 13.9 years. The total effects were broken down into natural direct and indirect effects using the inverse odds weighting method in the context of survival models. Systolic blood pressure, total serum cholesterol, and fasting plasma glucose as the primary measure of blood glucose were used as mediators. Blood pressure and cholesterol with indirect hazard ratios of 1.09 (95% confidence interval: 1.006-1.18) and 1.35 (95% confidence interval: 1.12-1.62) were the most important mediators for overweight-cardiovascular disease and obesity-cardiovascular disease relationships, respectively. The proportion mediated of overweight was 22% (6-47%) for blood pressure, 18% (5-37%) for blood glucose, and 20% (7-43%) for cholesterol. The same measure for obesity was 65% (35-91%) for cholesterol. For central adiposity, blood pressure, glucose, and cholesterol were the most important mediators with proportion mediated of 36% (17-72%), 23% (9-48%), and 21% (8-45%), respectively. Conclusions The findings of this study show that proper control of cardiometabolic risk factors of blood pressure, blood glucose, and dyslipidemia in an adult population can be effective to significantly reduce the effects of general and abdominal adiposity on cardiovascular diseases.

Depressive Symptoms, Co-Morbidities, and Glycemic Control in Hong Kong Chinese Elderly Patients With Type 2 Diabetes Mellitus.

Undiagnosed depression is an important comorbidity in type 2 diabetes (T2D) which can be detected using the Geriatric Depression Scale (GDS-15) questionnaire. In this cross-sectional study, we examined the associations of depression using GDS score with control of cardiometabolic risk factors and health status in elderly patients with T2D. Between February and December 2013, patients aged ≥65 years who underwent structured comprehensive assessment as a quality improvement program at the Diabetes Center of a teaching hospital were invited to complete the GDS-15 questionnaire. Depression was defined as a GDS score ≥7. Demographic data, prior history of co-morbidities, frequency of self-reported hypoglycemia, and attainment of treatment targets defined as HbA1c, <7%, blood pressure <130/80 mmHg, and LDL-C <2.6 mmol/L were documented. Among 325 participants (65% male, median [interquartile range] age: 69 [8] years), 42 (13%) had depression. Patients with depression had longer disease durations (mean ± SD: 15.1 ± 9.1 vs. 11.6 ± 8.1 years, P = 0.02), more frequent self-reported hypoglycemic events (17 vs. 6%, P = 0.03) and were less likely to attain all three treatment targets (0 vs. 16%, P = 0.004) than those without depression. On multivariable analysis, patients with depression had an odds ratio of 2.84 (95% confidence intervals: 1.35-6.00, P = 0.006) of reporting prior history of co-morbidities. In elderly patients with T2D, depression was not uncommon especially in those with poor control of risk factors, hypoglycemia, and co-morbidities. Inclusion of GDS-15 questionnaire during structured assessment for complications and risk factors can identify these high-risk patients for more holistic management of their physical and mental health.

A randomised controlled multimodal intervention trial in patients with ischaemic stroke in Shandong, China: design and rationale

BackgroundStroke is the leading cause of death and disability in China and has conferred a huge economic and societal burden. The effectiveness of primary prevention of stroke by targeting major vascular or cardiometabolic risk factors (eg, smoking, hypertension, diabetes) has been well established. This study aims to investigate whether a personalised, multimodal, multilevel intervention programme is effective in modifying unhealthy lifestyle and improving control of major cardiometabolic risk factors in patients with ischaemic stroke, and thus in reducing the risk of recurrent stroke and associated complications (functional disability, cognitive impairment). MethodsThis is a single-blind randomised controlled intervention study. Participants are recruited from two tertiary hospitals in Shandong, China. The inclusion criteria are first-ever ischaemic stroke or transient ischaemic attacks, age 40 years or older, and no loss of consciousness. Using local randomisation at participating hospitals, all eligible patients are randomly assigned (1:1), according to random number tables, to either the control group or the intervention group. Study participants but not investigators are blind to the intervention assignment. Patients in the control group receive standard care and treatment according to current guidelines, and those in the intervention group receive an additional personalised multilevel intervention procedure that consists of motivational interviewing for behavioural change (smoking, alcohol use, and medical adherence), dietary advice, and regular monitor of major cardiometabolic risk factors (high blood pressure, high serum cholesterol, and high blood glucose). Participants are being followed up every 6 months for up to 2 years. The primary outcomes are recurrent stroke, functional ability (at year 1), and cognitive performance (at year 2). The secondary outcomes are survival, quality of life, and depression. The protocols of this study were reviewed and approved by the Ethics Committee at Jining Medical University, Shandong, China. Written informed consent was obtained from participants or from health care proxies (next of kin). This trial is registered with the Chinese Clinical Trial Registry, number ChiCTR-IOR-16007741. FindingsThe baseline recruitment procedure was tested to be feasible in the pilot study, with minor modifications. From Oct 15, 2015, to Dec 31, 2016, a total of 2000 patients (aged 40–92 years; 37% women) were recruited; of these, 999 patients were randomly assigned to the control group and 1001 to the intervention group. The intervention and follow-up assessments of participants are ongoing. InterpretationThis study will hopefully demonstrate the feasibility to implement a personalised, multimodal, multilevel intervention programme in patients with ischaemic stroke and TIAs. Findings from this study are expected to help improve secondary prevention of stroke and complications. FundingJining No. 1 People's Hospital, the Affiliated Hospital of Shandong Jining Medical University, and the Foreign Expert Program of the State Administration of Foreign Experts Affairs of China (20153500002).

Race-Ethnic Disparities in Cardiometabolic Risk Profiles among Stroke Survivors with Undiagnosed Diabetes and Prediabetes in the United States

Up to 25% of the U.S. population has undiagnosed diabetes. Diabetes and stroke both disproportionately afflict race/ethnic minorities. We assessed race/ethnic differences in the prevalence of undiagnosed diabetes, prediabetes, and cardiometabolic risk profiles among stroke survivors in the United States. The prevalence of diabetes and prediabetes among adults (≥20 years) with a self-reported history of stroke was assessed using the National Health and Nutrition Examination Surveys (NHANES) from 1999 to 2010. Cardiometabolic risk factors across race/ethnic groups were compared using linear and logistic regression before and after adjusting for covariates. From 1999 to 2010, 1070 individuals who participated in NHANES had a self-reported history of stroke. Among stroke survivors without a formal diagnosis of diabetes and prediabetes, 233 (32%) had undiagnosed prediabetes and 27 (3.7%) had undiagnosed diabetes. The prevalence of undiagnosed diabetes and prediabetes was the highest among non-Hispanic (NH) blacks (8% and 38%) compared with Mexican Americans (4% and 26%) and NH whites (3% and 32%). Compared with NH whites, NH blacks were significantly younger, more likely to take antihypertensive medications, more likely to smoke, and have poorly controlled diabetes. NH blacks were twice as likely as NH whites to have poorly controlled blood pressure, after adjustment for sociodemographic and vascular risk factors. In the United States, NH black stroke survivors have the highest rates of undiagnosed diabetes and prediabetes, and have poorer cardiometabolic risk factor control than their NH white counterparts.

A systematic review of interventions targeting primary care or community based professionals on cardio-metabolic risk factor control in people with diabetes

ObjectiveTo review the interventions targeting primary care or community based professionals on glycaemic and cardiovascular risk factor control in people with diabetes. Research design and methodsA systematic review of randomised controlled trials evaluating the effectiveness of interventions targeting primary care or community based professionals on diabetes and cardiovascular risk factor control. We conducted searches in MEDLINE database from inception up to 27th September 2015. We also retrieved articles related to diabetes from the Cochrane EPOC database and EMBASE and scanned bibliographies for key articles. ResultsThere was heterogeneity in terms of interventions and participants amongst the 30 studies (39,439 patients) that met the inclusion criteria. Nine of the studies focused on general or family practitioners, five on pharmacists, three on nurses and one each on dieticians and community workers. Twelve studies targeted multi-disciplinary teams.Educational interventions did not seem to have a positive impact on HbA1c, systolic blood pressure or lipid profiles. The use of telemedicine, clinician reminders and feedback showed mixed results but there was a level of consistency in improvement in HbA1c when multifaceted interventions on multidisciplinary teams were implemented. Targeting general or family physicians was largely ineffective in improving the cardiovascular risk factors considered, except when using a computer application on insulin handling of type 2 diabetes or customised simulated cases with feedbacks. Similarly, interventions targeting nurses did not improve outcomes compared to standard care. ConclusionsMultifaceted professional interventions were more effective than single interventions targeting single primary or community care professionals in improving glycaemic control.

Capsule Commentary on Lafata et al., Medication Adherence Does Not Explain Black-White Differences in Cardiometabolic Risk Factor Control among Insured Patients with Diabetes.

T he study by Lafata et al. evaluated whether medication adherence mediated racial disparities in achieving HBA1c, LDL or SBP targets among diabetics. The authors found that blacks had poorer medication adherence compared to whites in all three classes of medications, and were less likely to achieve clinical targets. Racial disparities persisted in multivariable models that included medication adherence and treatment intensification. The strengths of the study are the inclusion of patients from multiple sites and the use of objective adherence and outcome data. A limitation was the use of an adherence definition that required having at least two prescriptions filled, since the exclusion of subjects with no or one refill could have introduced bias. Other investigators have reported persistent disparities in cardiovascular outcomes between black and white subjects after adjusting for variables such as adherence, income, education, or burden of disease. This study highlights the complexity of the factors influencing disparities in health outcomes, which are diverse and dynamic and include a range of environmental exposures that shape beliefs, behaviors and interactions with the health system. The authors appropriately advocate the systematic evaluation of multiple types of barriers among subjects not reaching quality targets. This is important, since improvements in quality of care have not eliminated disparities. Chin et al. concluded that reducing disparities requires six key steps which include making equity a priority of quality improvement efforts and designing interventions based on the local root causes. The patient-centered model of care may facilitate this individualized approach and should be a focus of future research. In the meantime, we must be careful in how we interpret the evidence. Factors such as medication adherence, depression, health literacy, or income play a role, though don’t completely explain differences in clinical outcomes among minorities. This should not diminish efforts to recognize or target them. In this study, the percentage of black subjects achieving targets was higher among adherent subjects. We should continue to search for factors that more fully explain disparities, but also develop strategies to improve known mediators of outcomes, among those medication adherence. Equity must be a priority.

Medication Adherence Does Not Explain Black-White Differences in Cardiometabolic Risk Factor Control among Insured Patients with Diabetes

Among patients with diabetes, racial differences in cardiometabolic risk factor control are common. The extent to which differences in medication adherence contribute to such disparities is not known. We examined whether medication adherence, controlling for treatment intensification, could explain differences in risk factor control between black and white patients with diabetes. We identified three cohorts of black and white patients treated with oral medications and who had poor risk factor control at baseline (2009): those with glycated hemoglobin (HbA1c) >8% (n = 37,873), low-density lipoprotein cholesterol (LDL-C) >100mg/dl (n = 27,954), and systolic blood pressure (SBP) >130mm Hg (n = 63,641). Subjects included insured adults with diabetes who were receiving care in one of nine U.S. integrated health systems comprising the SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) consortium. Baseline and follow-up risk factor control, sociodemographic, and clinical characteristics were obtained from electronic health records. Pharmacy-dispensing data were used to estimate medication adherence (i.e., medication refill adherence [MRA]) and treatment intensification (i.e., dose increase or addition of new medication class) between baseline and follow-up. County-level income and educational attainment were estimated via geocoding. Logistic regression models were used to test the association between race and follow-up risk factor control. Models were specified with and without medication adherence to evaluate its role as a mediator. We observed poorer medication adherence among black patients than white patients (p < 0.01): 50.6% of blacks versus 39.7% of whites were not highly adherent (i.e., MRA <80%) to HbA1c oral medication(s); 58.4% of blacks and 46.7% of whites were not highly adherent to lipid medication(s); and 33.4% of blacks and 23.7% of whites were not highly adherent to BP medication(s). Across all cardiometabolic risk factors, blacks were significantly less likely to achieve control (p < 0.01): 41.5% of blacks and 45.8% of whites achieved HbA1c <8%; 52.6% of blacks and 60.8% of whites achieved LDL-C <100; and 45.7% of blacks and 53.6% of whites achieved SBP <130. Adjusting for medication adherence/treatment intensification did not alter these patterns or model fit statistics. Medication adherence failed to explain observed racial differences in the achievement of HbA1c, LDL-C, and SBP control among insured patients with diabetes.

Prevalence, pharmacological treatment, and control of cardiometabolic risk factors among older people in central Stockholm: a population-based study.

BackgroundCardiometabolic risk factors and related cardiovascular diseases represent major threats to healthy aging.ObjectiveWe aimed to estimate distribution, pharmacological treatment, and control of main cardiometabolic risk factors among older people.MethodsThis population-based study included 3363 participants (age≥60 years, 64.9% women) in the Swedish National study on Aging and Care in Kungsholmen, in central Stockholm, Sweden (2001-2004). Data on demographics, cardiometabolic risk factors (hypertension, obesity, diabetes, and high cholesterol), and medication use were collected through face-to-face interviews, clinical examinations, laboratory tests, and the inpatient register. Cardiometabolic risk factors were defined following the most commonly used criteria. Prevalence was standardized using local census data.ResultsThe age- and sex-standardized prevalence of diabetes, obesity, high cholesterol, and hypertension was 9.5%, 12.8%, 49.7%, and 74.9%, respectively. The prevalence of hypertension and diabetes increased with age, whereas the prevalence of obesity and high cholesterol decreased with age. Forty-nine percent of older adults had two or more cardiometabolic risk factors; 9.8% had three or more. Overall, 55.5% of people with hypertension, 50.3% with diabetes, and 25.0% with high cholesterol received pharmacological treatment. Of those treated pharmacologically, 49.4%, 38.1%, and 85.5% reached therapeutic goals for hypertension (blood pressure<150/90 mmHg), diabetes (glycated haemoglobin<7%), and high cholesterol (total cholesterol<6.22 mmol/l), respectively.ConclusionsHypertension, high cholesterol, and clustering of cardiometabolic risk factors were common among older people in Stockholm, but pharmacological treatment and control of these major factors can be improved. Appropriate management of cardiometabolic profiles among older people may help improve cardiovascular health and achieve healthy aging.

Cardiometabolic risk factor control in diabetic patients

Cardiometabolic risk factor control in diabetic patients <65 and ≥65 years: illuminating disparities in ‘younger’ minorities

Impact of Performance Improvement Continuing Medical Education on Cardiometabolic Risk Factor Control: The COSEHC Initiative

The Consortium for Southeastern Hypertension Control (COSEHC) implemented a study to assess benefits of a performance improvement continuing medical education (PI CME) activity focused on cardiometabolic risk factor management in primary care patients. Using the plan-do-study-act (PDSA) model as the foundation, this PI CME activity aimed at improving practice gaps by integrating evidence-based clinical interventions, physician-patient education, processes of care, performance metrics, and patient outcomes. The PI CME intervention was implemented in a group of South Carolina physician practices, while a comparable physician practice group served as a control. Performance outcomes at 6 months included changes in patients' cardiometabolic risk factor values and control rates from baseline. We also compared changes in diabetic, African American, the elderly (> 65 years), and female patient subpopulations and in patients with uncontrolled risk factors at baseline. Only women receiving health care by intervention physicians showed a statistical improvement in their cardiometabolic risk factors as evidenced by a -3.0 mg/dL and a -3.5 mg/dL decrease in mean LDL cholesterol and non-HDL cholesterol, respectively, and a -7.0 mg/dL decrease in LDL cholesterol among females with uncontrolled baseline LDL cholesterol values. No other statistical differences were found. These data demonstrate that our PI CME activity is a useful strategy in assisting physicians to improve their management of cardiometabolic control rates in female patients with abnormal cholesterol control. Other studies that extend across longer PI CME PDSA periods may be needed to demonstrate statistical improvements in overall cardiometabolic treatment goals in men, women, and various subpopulations.

Patient–provider communication and diabetes medication adherence: where do we go from here?

185 ISSN 1758-1907 10.2217/DMT.13.9 © 2013 Future Medicine Ltd Diabetes Manage. (2013) 3(3), 185–188 For several decades, researchers have explored how patient–provider relationships can influence chronic illness care and outcomes. The domains of patient–provider communication – such as shared decision-making, trust and/or respect, and mutual understanding regarding treatment plans – are increasingly central to patient-centered models of care delivery. For example, new diabetes treatment guidelines call for individualizing clinical control targets, taking into consideration patient health status and risk factors, as well as psychological, social and economic conditions [1]. Actively engaging patients in setting treatment goals by assessing and incorporating their capacities, desires and values inherently requires effective patient–provider communication strategies. While much of the research on patient–provider communication among diabetes patients has focused on its influence on intermediate outcomes, such as control of cardiometabolic risk factors for complications (i.e., HbA1c, blood pressure and cholesterol), fewer studies have focused on the pathways between communication and diabetes self-management, such as medication adherence. Medication adherence among diabetes patients is theorized to be a proximal outcome of effective patient–provider communication, linked by such potential mechanisms as advancing patient understanding/knowledge, increasing the quality of medical decision-making and/or increasing patient self-efficacy or empowerment [2]. Improving medication adherence among diabetic patients is an important healthcare priority, given that nonadherence rates for medication regimens range from 10 to 40% depending on the study and pharmacological agent of interest [3]. In the longer term, poor adherence can lead to poorer clinical control and, in turn, higher rates of macroand micro-vascular complications. Moreover, poor adherence can jeopardize patient safety, when unsuspecting clinicians escalate dosages or intensify regimens, instead of addressing barriers to adherence. This editorial summarizes some of the most relevant literature on patient–provider communication and medication adherence among diabetes patients, raises important

Oral hygiene and cardiometabolic disease risk in the survey of the health of Wisconsin

Poor oral health is an increasingly recognized risk factor for cardiovascular disease (CVD) and type 2 diabetes (T2D), but little is known about the association between toothbrushing or flossing and cardiometabolic disease risk. The purpose of this study was to examine the degree to which an oral hygiene index was associated with CVD and T2D risk scores among disease-free adults in the Survey of the Health of Wisconsin. All variables were measured in 2008-2010 in this cross-sectional design. Based on toothbrushing and flossing frequency, an oral hygiene index (poor, fair, good, excellent) was created as the primary predictor variable. The outcomes, CVD and T2D risk score, were based on previous estimates from large cohort studies. There were 712 and 296 individuals with complete data available for linear regression analyses in the CVD and T2D samples, respectively. After covariate adjustment, the final model indicated that participants in the excellent (β ± SE = -0.019 ± 0.008, P = 0.020) oral hygiene category had a significantly lower CVD risk score as compared to participants in the poor oral hygiene category. Sensitivity analyses indicated that both toothbrushing and flossing were independently associated with CVD risk score, and various modifiable risk factors. Oral hygiene was not significantly associated with T2D risk score. Regular toothbrushing and flossing are associated with a more favorable CVD risk profile, but more experimental research is needed in this area to precisely determine the effects of various oral self-care maintenance behaviors on the control of individual cardiometabolic risk factors. These findings may inform future joint medical-dental initiatives designed to close gaps in the primary prevention of oral and systemic diseases.

Racial and Ethnic Differences in Cardio-Metabolic Risk in Individuals with Undiagnosed Diabetes: National Health and Nutrition Examination Survey 1999–2008

Although early recognition and treatment of diabetes may be essential to prevent complications, roughly one-fifth of diabetes remains undiagnosed. Examine cardio-metabolic risk factors and their control in non-Hispanic white (NHW), non-Hispanic black (NHB) and Mexican American (MA) individuals with undiagnosed diabetes. Nationally representative cross-sectional study of participants in the National Health and Nutrition Examination Survey (NHANES) continuous cycles conducted 1999 through 2008. Of 22,621 non-pregnant individuals aged ≥20years, 2521 had diagnosed diabetes. Of the remaining 20,100 individuals, 17,963 had HbA1c measured, 551 of whom were classified as having undiagnosed diabetes and comprise the study population. Undiagnosed diabetes was defined as HbA1c ≥ 6.5% without a self-report of physician diagnosed diabetes. Cardio-metabolic risk factor control was examined using regression methods for complex survey data. Among individuals with undiagnosed diabetes, mean HbA1c level was 7.7% (95% CI: 7.5, 7.9), 19.3% (95% CI: 14.2, 24.3) smoked, 59.7% (95% CI: 54.5, 64.8%) had hypertension and 96.5% (95% CI: 94.6, 98.4%) had dyslipidemia. Lipid profiles were remarkably different across racial-ethnic groups: NHB had the highest LDL- and HDL-cholesterol, but the lowest triglycerides, while MA had the highest triglycerides and the lowest LDL-cholesterol. After adjusting for age, sex, NHANES examination cycle and use of either blood pressure or lipid medication, the odds of having blood pressure ≥130/80mmHg was higher in NHB [1.92 (95% CI: 1.09, 3.55)] than NHW, while the odds of having LDL-cholesterol >100mg/dl was higher in NHW[2.93 (95% CI: 1.37, 6.24)] and NHB[3.34 (95% CI: 1.08, 10.3)] than MA. In a nationally representative sample of individuals with undiagnosed diabetes, cardio-metabolic risk factor levels were high across all racial/ethnic groups, but NHB and MA had poorer control compared to NHW. Interventions that target identification of diabetes and treatment of cardio-metabolic risk factors are needed.

Improved Glycemic Control and Reduction of Cardiometabolic Risk Factors in Subjects with Type 2 Diabetes and Metabolic Syndrome Treated with Exenatide in a Clinical Practice Setting

Type 2 diabetes mellitus (T2DM) with the presence of metabolic syndrome (MetS) carries increased risk for cardiovascular disease. Adjunctive exenatide treatment in patients with T2DM is associated with improvements in glycemic control coupled with progressive weight reduction. We evaluated exenatide use on glycosylated hemoglobin A1c (HbA(1c)) and cardiometabolic risk factors in patients with T2DM and MetS in a single clinical practice setting. A retrospective analysis of clinical data extracted from the records of 176 adult patients with T2DM and MetS (106 women, 70 men) who received exenatide along with existing therapeutic regimes from 2005 to 2007 was performed. HbA(1c), lipid profiles, blood pressure, and anthropometric measures were evaluated at baseline and after 16 (+/-4) weeks of exenatide therapy. Mean HbA(1c) was significantly reduced from baseline in 16 weeks (P < 0.001), with 68% of patients achieving HbA(1c) <7%. Total, high-density lipoprotein-, and low-density lipoprotein-cholesterol levels decreased significantly. This decline was not attributable to changes in lipid-lowering agents. Significant reductions were also noted in body mass index, mean body weight, and abdominal girth (AG) with the addition of exenatide. Additional analyses showed 76% of subjects lost weight. Lessening of AG was much more pronounced in female compared with male subjects with diabetes (P < 0.032). No consistent changes in blood pressure were observed. We found that addition of exenatide to an existing treatment regimen in patients with T2DM and MetS resulted in significant reductions in HbA(1c) along with decline in lipids, AG, and body weight. This indicates improvement in these patients' metabolic profiles.

Is the Number of Documented Diabetes Process-of-Care Indicators Associated With Cardiometabolic Risk Factor Levels, Patient Satisfaction, or Self-Rated Quality of Diabetes Care?

Simple process-of-care indicators are commonly recommended to assess and compare quality of diabetes care across health plans. We sought to determine whether variation in the number of simple diabetes processes of care across provider groups is associated with variation in other quality indicators, including cardiometabolic risk factor levels, patient satisfaction with care, or patient-rated quality of care. We used cross-sectional survey and chart audit data for 8,733 patients with diabetes who received care from 68 provider groups nested in 10 health plans that participated in the Translating Research Into Action for Diabetes study. Analyses using hierarchical regression models assessed associations of the mean number of seven simple process measures with each of the following: HbA(1c) (A1C), systolic blood pressure (SBP), HDL and LDL cholesterol levels, patient satisfaction with care, and patient-rated quality of care. After adjusting for case-mix differences across groups and plans, an average of one additional documented process of care for each patient in a group or plan was associated with significantly lower mean LDL cholesterol levels (-4.51 mg/dl [95% CI 1.46-7.58]) but not with A1C, SBP, or HDL cholesterol levels. The number of care processes documented was associated with patient satisfaction measures and self-rated quality of diabetes care. Variation in the number of simple process-of-care indicators across provider groups or health plans is associated with differences in patient-centered measures of quality, but assessment of the quality of cardiometabolic risk factor control will require more advanced clinical performance indicators.