Recent Diagnosis Of Diabetes Research Articles

Oral Semaglutide in Routine Clinical Practice: Characteristics of People with Type 2 Diabetes Started on the Drug and Changes in Their Clinical Parameters after 24 Weeks of Treatment.

Background/Objectives: Semaglutide is the unique once-daily oral glucagon-like receptor agonist presently available. Aims of this study were to describe clinical characteristics of patients with type 2 diabetes (T2D) initiating oral semaglutide, to assess its effects on glycemic control, body weight (BW) and its tolerability in routine clinical practice. Methods: Electronic medical records from two Italian diabetes clinics were evaluated. Mean glycated hemoglobin (HbA1c) and BW were assessed in adults with T2D before and 6 months after oral semaglutide prescription. Treatment discontinuation and safety data were reported. Results: A total of 192 patients initiating oral semaglutide (44% female) presented a mean age of 66 years, a diabetes duration of 10 years, HbA1c of 7.9% and a BW of 82.6 kg. Almost 50% of patients were obese. Mean HbA1c and BW changes from baseline to follow up were -0.7% and -2.6 kg, respectively. Greater HbA1c reduction was observed in patients with baseline HbA1c ≥ 8% and with diabetes duration <5 years. The composite endpoint of HbA1c ≤7% and a weight loss ≥5% was achieved in 22.5% of the participants. A total of 40 patients (20.8%) discontinued treatment: 26 because of gastrointestinal adverse events, and 10 due to limited effectiveness in lowering HbA1c and/or BW. Conclusions: In a real clinical setting, patients initiating oral semaglutide showed suboptimal metabolic control, short diabetes duration and obesity; a significant improvement in HbA1c and BW was achieved mainly in patients with a more recent diabetes diagnosis, supporting the use of oral semaglutide in the early phase of the disease.

Impact of Fatigue and Its Influencing Factors on Diabetes Self-Management in Adults With Type 2 Diabetes: A Structural Equation Modeling Analysis.

The purposes of this study were to (1) examine the relationships between fatigue, its influencing factors, and diabetes self-management and (2) test the mediation effects of fatigue on the link between the influencing factors and diabetes self-management in adults with type 2 diabetes. This cross-sectional, correlational study was guided by the theory of unpleasant symptoms. Data were collected using structured questionnaires. Fatigue was measured by the Fatigue Symptom Inventory and the Multidimensional Fatigue Inventory. Diabetes self-management was measured by the Summary of Diabetes Self-Care Activities. From March to July 2021, a convenience sample of 150 participants was recruited from 2 diabetes outpatient clinics of a regional hospital in Taiwan. Data were analyzed using structural equation modeling. A more recent diagnosis of diabetes, more depressive symptoms, and lower sleep quality were related to higher fatigue. Higher fatigue correlated with less performance in diabetes self-management. Fatigue mediated the relationship between depressive symptoms, sleep quality, and diabetes self-management. Fatigue had a mediating effect on the link between psychological influencing factors and diabetes self-management. Future development of fatigue interventions integrating depressive symptoms and sleep management will likely increase the performance of diabetes self-management and improve the health outcomes in adults with type 2 diabetes. The study tested the theory of unpleasant symptoms using empirical data and will assist in building theory-guided fatigue interventions to improve diabetes self-management in people with type 2 diabetes.

#6834 PREVALENCE, ETIOLOGY AND CLINICAL CHARACTERISTICS OF BIOPSY PROVEN NON-DIABETIC RENAL DISEASE: 10 YEARS OF BIOPSES IN DIABETIC PATIENTS

Abstract Background and Aims Diabetic nephropathy (DN) is the major cause of kidney disease in diabetic patients. However, a significant proportion of diabetic patients may actually have nondiabetic renal disease (NDRD). Therefore, it is important to identify patients who can benefit from a renal biopsy in order to establish the correct diagnosis. Our study aims to determine the prevalence and etiology of biopsy proven NDRD and to explore the clinical differences encountered in the diabetic patient with NDRD. Method Retrospective study of the medical records of all diabetic patients who underwent a renal biopsy due to suspicion of NDRD from January 2012 to December 2022 at Nephrology department Collected data comprised demographic information, indication and result of renal biopsy, lab results (serum creatinine, Hb1Ac, proteinuria, albuminemia, hematuria, presence of active urinary sediment and presence of auto antibodies) and disease's characteristics (duration of diabetes, presence of diabetic retinopathy). Categorical variables are presented as frequencies and percentages, continuous variables as means and standard deviations, or medians and interquartile ranges (IQR) for variables with skewed distributions. A p-value&amp;lt;0.05 was considered statistically significant. Statistical analysis was performed using SPSS version 28.1 for Mac OS X. Results 57 patients, 33.3% (n=19) were females, the medium age was 64.9 $\langle {{\rm{italic}}} \rangle \pm \langle {/{\rm{italic}}} \rangle $ 12.1. The most frequent indication for renal biopsy was acute kidney injury (26.3%), followed by rapidly progressive renal failure and nephrotic syndrome (22.8%). In our population, 22.9% had DN and 77.4% had NDRD. Pauciimune Glomerulonephritis (14%) and Membranous Nephropathy (10.5%) were the most common causes of NDRD. A chi-square test was performed to examine the relation between the two groups (ND vs NDRD) and the presence of diabetic retinopathy. There was a statistically significant association between the two variables ($\langle {{\rm{italic}}} \rangle {{\rm{X}}}^2\langle {/{\rm{italic}}} \rangle $= 11.778, p&amp;lt;0.01). Mann-Whitney test was performed to compare the median of duration the diabetes and Hb1Ac in two groups. That showed a statistically significant difference (U = 357, P = .018 and U=335.5 P = .013 respectively). Conclusion Since renal biopsy is critical to establish the correct diagnosis and provide an appropriate treatment, it should be performed in patients with high suspicion of NRDN, especially in patients with a recent diagnosis of diabetes, good metabolic control and the absence of diabetic retinopathy.

1229-P: Participation of Hispanic (Hisp) and African-American (AA) Youth in an Observational Study in Diabetes

Background and Aim: Suboptimal representation of race/ethnic minorities in clinical research contributes to critical gaps in our knowledge of diabetes in these populations. We aimed to evaluate the participation of AA and Hisp youth in an observational study in diabetes to assess factors impacting participation. Methods: We studied 92 participants in the Diabetes Study in Children of Diverse Ethnicity and Race (DISCOVER) that is currently enrolling youth (age 0-yrs) with non-secondary diabetes for collection of data and blood samples. We compared racial/ethnic distribution of actual vs. target enrollment and refusal rates by race/ethnicity. We analyzed qualitative data on reasons for study refusal. Results: The racial/ethnic distribution of participants was 60.9% Hisp, 27.2% AA, 12.0% non-Hispanic white [NHW] and 0% other, vs. enrollment targets of 35.3% Hisp, 31.8% AA, 29.9% NHW and 3% other (p=0.001) . In the population of eligible candidates, 31.1% of the children were Hisp, 18.8% AA, 42.2% NHW and 7.9% other. Refusal rates were 20.0%, 16.7%, 38.9% and 100%, respectively, for Hisp, AA, NHW and other (p=0.072) . Among those who refused, the reasons noted were no interest in research (44.4% overall, 80% in AA youth) , blood draw (29.6% overall, 42.6% in Hisp youth) , no direct benefit to the participant (11.1%) , and being too busy (18.5%) or overwhelmed by the recent diabetes diagnosis (11.1%) . NHW youth cited the first 3 reasons, with similar frequency, for refusal. Conclusions: Refusal rates were not elevated in AA and Hisp children compared with NHW. Actual enrollment was statistically different from the target, with over-representation of Hisp youth and underrepresentation of NHW youth. Facilitators of racial/ethnic minority participation in research studies may include diverse racial/ethnic distribution in the population where the study is conducted, a trusted environment, race/ethnicity concordance with research team members, and a minimally invasive study protocol. Disclosure M.J. Redondo: Advisory Panel; Provention Bio, Inc. M. Tosur: Advisory Panel; Provention Bio, Inc. A.B. Muir: None. S. Iftekhar: None. S. Deen: None. D.J. Perry: None. D.H. Glueck: None. K. Vehik: None. R.A. Oram: Consultant; Janssen Research &amp; Development, LLC. Research Support; Randox R &amp; D. W. Hagopian: Research Support; Janssen Research &amp; Development, LLC. D. Dabelea: None. M.A. Atkinson: None. Funding NIH NIDDK RDK124395

Energy-restricted interventions are effective for the remission of newly diagnosed type 2 diabetes: A systematic review of the evidence base.

BackgroundType 2 diabetes (T2D) is a chronic, progressive disease. Caloric restriction and subsequent weight loss have been associated with both improvements and, in some cases, remission of T2D.AimTo systematically review the safety and effectiveness of calorie‐restricted diets on weight change and the remission of T2D.MethodsElectronic databases were searched. Intervention trials including a calorie restriction, published between 2010 and 2020, evaluating the remission of T2D (HbA1c <6.5% without diabetes medication) were selected. Risk of bias was assessed.ResultsEight trials met inclusion criteria including four randomized controlled and four single‐arm trials. Three controlled trials found greater remission in the calorie‐restricted arm (p < 0.05). A recent diagnosis of diabetes was associated with higher remission rates (75%–80%) with an inverse association between duration of diabetes and rate of remission (r = −0.94). A higher level of remission was observed with greater calorie restriction in non‐new diagnosis studies. Greater weight loss was associated with increasing rates of remission (r = 0.83). No reported adverse events led to withdrawal from trials. There was great heterogeneity in study design.ConclusionRemission rate of T2D achieved through calorie restriction is high and similar to that reported in the bariatric surgery literature. Remission should be the aim at diagnosis and calorie restriction could be used to achieve this. The target weight loss should be >10% body weight in people with obesity. More research is needed into the optimum level of calorie restriction and the support required for long‐term remission. National guidelines should be updated to reflect recent evidence.

Costs implications of pneumococcal vaccination of adults aged 30–60 with a recent diagnosis of diabetes

ObjectiveThe 23-valent pneumococcal polysaccharide vaccine is routinely recommended for adults with diabetes, but little is known about adherence to this recommendation and how vaccination of these adults affects costs related to pneumococcal disease. Research design and methodsWe used data from a commercial insurance claims dataset to examine a cohort of non-elderly adults with a new diagnosis of diabetes and adults with no diagnosis of diabetes from 2005 to 2014. We examined rates of pneumococcal polysaccharide vaccination and the relationship between vaccination and pneumococcal disease costs, comparing results for persons with a diagnosis of diabetes and those with no diagnosis of diabetes. ResultsOverall rates of pneumococcal polysaccharide vaccination among adults 30–60 years old were <1%/year. Rates of pneumococcal polysaccharide vaccination were higher for adults with diabetes. Pneumococcal polysaccharide vaccination rates more than doubled from 2.9% per year in 2005 to 6.0% per year in 2014 for adults vaccinated during the same year as their diabetes diagnosis. Using a two-part differences-in-differences model on a propensity-score matched dataset, pneumococcal polysaccharide vaccination may reduce average annual per-person pneumococcal disease costs by $90.54 [95% CI: $183.59, -$2.49, (p = 0.056)] in persons with diabetes from two years before to two years after vaccination. ConclusionsNon-elderly adults with diabetes have low but rising rates of pneumococcal polysaccharide vaccination. Pneumococcal polysaccharide vaccination has a modest impact reducing overall costs of pneumococcal disease in this population.

New-Onset Diabetes, Longitudinal Trends in Metabolic Markers, and Risk of Pancreatic Cancer in a Heterogeneous Population

Observational studies of predominantly white populations have found new-onset diabetes to be associated with increased risk of pancreatic cancer. We sought to determine whether this relationship applies to other races or ethnicities and to identify metabolic profiles associated with increased risk of pancreatic cancer. We conducted a population-based cohort study of Asian, black, Hispanic and white patients from Kaiser Permanente Southern California from 2006 through 2016 (n = 1,499,627). Patients with diabetes were identified based on glucose and hemoglobin A1c (HbA1c) measurements. We used Cox regression to assess the relationship between diabetes status and duration and pancreatic cancer. For patients with recent diagnoses of diabetes (1 year or less) we compared longitudinal changes in glucose, HbA1c, and weight, from time of diabetes diagnosis through 3years prior to the diagnosis, in patients with vs without pancreatic cancer. We identified 2,002 incident cases of pancreatic cancer from nearly 7.5 million person-years of follow-up. Compared to patients without diabetes, individuals who received a recent diagnosis of diabetes had an almost 7-fold increase in risk of pancreatic cancer (relative risk, 6.91; 95% CI, 5.76-8.30). Among patients with a recent diagnosis of diabetes, those who developed pancreatic cancer had more rapid increases in levels of glucose (Δslope: cases, 37.47 mg/dL vs non-cases, 27.68 mg/dL) and HbA1c (Δslope: cases, 1.39% vs non-cases, 0.86%) in the month preceding the diagnosis of diabetes, and subtle weight loss in the prior years (slope: cases -0.18 kg/interval vs non-cases 0.33 kg/interval). These longitudinal changes in markers of metabolism were stronger for specific race and ethnic groups. In a study of a large ethnically diverse population, we found risk of pancreatic cancer to be increased among patients with a diagnosis of diabetes in the past year among different races and ethnicities. Weight loss and rapid development of poor glycemic control were associated with increased risk of pancreatic cancer in multiple races.

Pilot randomized controlled trial of a complex intervention for diabetes self-management supported by volunteers, technology, and interprofessional primary health care teams

BackgroundMost health care for people with diabetes occurs in family practice, yet balancing the time and resources to help these patients can be difficult. An intervention empowering patients, leveraging community resources, and assisting self-management could benefit patients and providers. Thus, the feasibility and potential for effectiveness of “Health Teams Advancing Patient Experience, Strengthening Quality through Health Connectors for Diabetes Management” (Health TAPESTRY-HC-DM) as an approach supporting diabetes self-management was explored to inform development of a future large-scale trial.MethodsFour-month pilot randomized controlled trial (RCT), sequential explanatory qualitative component. Participants—patients of an interprofessional primary care team—were over age 18 years, diagnosed with diabetes and hypertension, and had Internet access and one of the following: uncontrolled HbA1c, recent diabetes diagnosis, end-stage/secondary organ damage, or provider referral. The Health TAPESTRY-HC-DM intervention focused on patient health goals/needs, integrating community volunteers, eHealth technologies, interprofessional primary care teams, and system navigation. Pilot outcomes included process measures (recruitment, retention, program participation), perceived program feasibility, benefits and areas for improvement, and risks or safety issues. The primary trial outcome was self-efficacy for managing diabetes. There were a number of secondary trial outcomes.ResultsOf 425 eligible patients invited, 50 signed consent (11.8%) and 35 completed the program (15 intervention, 20 control). Volunteers (n = 20) met 28 clients in 234 client encounters (home visits, phone calls, electronic messages); 27 reports were sent to the interprofessional team. At 4 months, controlling for baseline, most outcomes were better in the intervention compared to control group; physical activity notably better. The most common goal domains set were physical activity, diet/nutrition, and social connection. Clients felt the biggest impact was motivation toward goal achievement. They struggled with some of the technologies. Several participants perceived that the program was not a good fit, mostly those that felt they were already well-managing their diabetes.ConclusionsHealth TAPESTRY-HC-DM was feasible; a large-scale randomized controlled trial seems possible. However, further attention needs to be paid to improving recruitment and retention. The intervention was well received, though was a better fit for some participants than others.Trial registrationClinicalTrials.gov, NCT02715791. Registered 22 March 2016—retrospectively registered.

HNF1β Diabetes or Maturity-Onset Diabetes of the Young Type 5 With Rare HNF1β Mutation: A Case Report.

A 7-year-old girl presented to the endocrinology office for a second opinion regarding her recent diabetes diagnosis. Four months before arriving in our office, she had been to an urgent care facility for nausea and vomiting with much of her family, who had been experiencing the same symptoms, presumed to be viral gastroenteritis. Testing revealed that the patient had ketones and glucose in her urine, and her blood glucose was 240 mg/dL (13.32 mmol/L). The patient’s family followed up with her pediatrician and were referred to a pediatric endocrinology clinic, where she was given a 2-hour 75-g oral glucose tolerance test, causing her blood glucose to rise to >200 mg/dL (>11 mmol/L). According to her mother, the pediatric facility tested for type 1 diabetes antibodies, which were negative. The patient’s blood glucose readings were high after eating and came back down without treatment, so the pediatric endocrinologist ordered testing for maturity-onset diabetes of the young (MODY). The mother reported that the sample was insufficient to complete the MODY test. Because of the way her blood glucose levels reacted to meals and the MODY suspicion, the family was advised to control the patient’s diabetes with her diet, so her mother had been restricting her carbohydrate intake to <65 g per meal and monitoring her blood glucose. Her mother was uncomfortable with this plan and felt like no one was listening to them. The patient’s mother reported a family history of type 2 diabetes in the patient’s maternal grandmother. The patient denied any change in her weight in the last year. On physical examination, her weight was 24.4 kg, her height was 1.4 m, and her BMI was 12.4 kg/m2, which was in the 1st percentile (healthy weight is 5th to 85th percentile). Her A1C was 5.2%. Initially, the patient …

Identification of nephropathy predictors in urine from children with a recent diagnosis of type 1 diabetes

Despite research progresses, the chance to accurately predict the risk for diabetic nephropathy (DN) is still poor. So far, the first evidence of DN is micro-albuminuria, which is detected only 10–20 years after the onset of diabetes.Our goal is to develop new predictive tools of nephropathy starting from urine, which can be easily obtained using noninvasive procedures and it is directly related to kidney. Since it is reasonable to suppose that, in predisposed patients, the mechanisms leading to nephropathy start acting since the diabetes onset, urine from children with recent diagnosis of type 1 diabetes was subjected to proteomic analysis in comparison to age-matched controls. Targeted confirmation was performed on children with a longer history of diabetes using Western Blotting and applying a urinary lipidomic approach. To definitively understand whether the observed alterations could be related to diabetic nephropathy, urine from diabetic adults with or without albuminuria was also examined.For the first time, lipid metabolisms of prostaglandin and ceramide, which are significantly and specifically modified in association with DN, are shown to be already altered in children with a recent diabetes diagnosis. Future studies on larger cohorts are needed to improve the validity and generalizability of these findings.Data are available via ProteomeXchange with identifier PXD011183Submission details:Project Name: Urinary proteomics by 2DE and LC-MS/MS.Project accession: PXD011183Project DOI: https://doi.org/10.6019/PXD011183 SignificanceNephropathy is a very common diabetic complication. Once established, its progression can only be slowed down but full control or remission is achieved in very few cases, thus posing a large burden on worldwide health. The first evidence of diabetic nephropathy (DN) is micro-albuminuria, but only 30% of patients with micro-albuminuria progress to proteinuria, while in some patients it spontaneously reverts to normo-albuminuria. Thus, there is clear need for biomarkers that can accurately predict the risk to develop DN. Herein, by applying proteomic and lipidomic approaches on urine samples, we show that alteration of prostaglandin and ceramide metabolisms specifically occurs in association with DN. Interestingly, we demonstrate that the modification of these metabolic pathways is an early event in diabetic patients, suggesting the identified changed proteins as possible predictive biomarkers of diabetes-induced renal function decline.

Factors associated with self-care practice among adult diabetes patients in West Shoa Zone, Oromia Regional State, Ethiopia

BackgroundDiabetes, a rising global health problem, requires continuous self-care practice to prevent acute and chronic complications. However, studies show that few diabetes patients practice the recommended self-care in Ethiopia. The aim of this study was to assess factors associated with self-care practice among adult diabetes patients in public hospitals of West Shoa Zone, Oromia Regional State, Ethiopia.MethodsIn this cross-sectional study, 257 diabetes patients (mean age 42.9 ± 14.6 years, 54.1% male) completed the survey in Afan Oromo and Amharic languages. A questionnaire consisting standardized tools was used to collect the data. Descriptive and logistic regression analyses were conducted using SPSS version 21.ResultsThe mean score for diabetes self-care was 39.8 ± 9.5 and 45.5% of the participants scored below the mean. Multiple logistic regression analysis revealed that having higher diabetes knowledge (AOR = 2.42, 95% CI = 1.22, 4.80), self-efficacy (AOR = 3.30, 95% CI = 1.64, 6.62), social support (AOR = 2.86, 95% CI = 1.37, 5.96), secondary school education (AOR = 6.0, 95% CI = 1.90, 18.85), and longer duration of diabetes (AOR = 5.55, 95% CI = 2.29, 13.44) were important predictors of good diabetes self-care practice.ConclusionThe diabetes education programs should use strategies that enhance patients’ diabetes knowledge, self-efficacy, and social support. Patients with recent diabetes diagnosis need special attention as they may relatively lack knowledge and skills in self-care. Further studies are needed to elucidate pathways through which diabetes knowledge, self-efficacy, social support, and health literacy affect diabetes self-care.

Racial Variation in the Relationship of Diabetes with Pancreatic Cancer Risk

Pancreatic cancer is one of the most fatal malignancies, with a 5-year survival of &amp;lt;8% and is the 4th leading cause of cancer death. It is also one of the cancers most tightly linked to diabetes even when recent diabetes diagnosis and reverse causation are ruled out. The highest rates of pancreatic cancer are found among blacks in the U.S., yet despite nearly twice the prevalence of diabetes among blacks compared to whites, as well as blacks’ increased prevalence of obesity, another key risk factor, little is known about the interrelationship between diabetes and pancreatic cancer among blacks and whether this accounts for the observed racial disparity. We tested the relationship of diabetes with the incidence of pancreatic cancer and whether this relationship varied between blacks and whites. Our null hypothesis was that diabetes would not differentially increase risk among blacks compared to whites. Using the Southern Community Cohort Study, we conducted a cancer follow-up (2002-2015) of a cohort of mostly low income black and white participants aged 40-79 with (n=17,644) and without diabetes (n=64,870) at cohort entry. Mean age and diabetes duration of those with diabetes was 55.0 and 9.5 years, respectively. Mean age of those without diabetes was 51.6 years. Logistic regression was used. A total of 307 incident cases of pancreatic cancer were observed. In analysis controlling for age, sex, race, current and former smoking, and BMI, diabetes was a significant risk factor for pancreatic cancer (OR=1.48, 95% CI= 1.13-2.94). In race-stratified analyses, the increases associated with diabetes were seen both among blacks (OR= 1.46, 95% CI=1.06-2.02) and whites (OR=1.60, 95% CI= 0.95-2.67). After control for diabetes, the black excess in risk of pancreatic cancer was attenuated (OR=1.25, 95% CI=0.96-1.64). The findings suggest that diabetes affects pancreas cancer risk regardless of race, but that the higher prevalence of diabetes among blacks contributes to their elevated risk of pancreatic cancer. Disclosure B. Conway: None. W.J. Blot: None.

Quantifying usability: an evaluation of a diabetes mHealth system on effectiveness, efficiency, and satisfaction metrics with associated user characteristics.

Objective Mobile health (mHealth) systems are becoming more common for chronic disease management, but usability studies are still needed on patients’ perspectives and mHealth interaction performance. This deficiency is addressed by our quantitative usability study of a mHealth diabetes system evaluating patients’ task performance, satisfaction, and the relationship of these measures to user characteristics. Materials and Methods We used metrics in the International Organization for Standardization (ISO) 9241-11 standard. After standardized training, 10 patients performed representative tasks and were assessed on individual task success, errors, efficiency (time on task), satisfaction (System Usability Scale [SUS]) and user characteristics. Results Tasks of exporting and correcting values proved the most difficult, had the most errors, the lowest task success rates, and consumed the longest times on task. The average SUS satisfaction score was 80.5, indicating good but not excellent system usability. Data trends showed males were more successful in task completion, and younger participants had higher performance scores. Educational level did not influence performance, but a more recent diabetes diagnosis did. Patients with more experience in information technology (IT) also had higher performance rates. Discussion Difficult task performance indicated areas for redesign. Our methods can assist others in identifying areas in need of improvement. Data about user background and IT skills also showed how user characteristics influence performance and can provide future considerations for targeted mHealth designs. Conclusion Using the ISO 9241-11 usability standard, the SUS instrument for satisfaction and measuring user characteristics provided objective measures of patients’ experienced usability. These could serve as an exemplar for standardized, quantitative methods for usability studies on mHealth systems.

Health and social correlates of Internet use for diabetes information: findings from Australia's Living with Diabetes Study.

This study investigated the relationship between online information seeking and a broad range of health and social characteristics among a large sample of Australian adults with type 2 diabetes. One in four participants used the Internet for diabetes-related purposes and Internet searching was associated with high patient activation, poor metabolic control, signs of peripheral nerve damage, a recent diagnosis of diabetes and poorer patient-assessed coordination of care. No relationship was found between Internet use and treatment complexity and the presence of comorbid conditions. The findings underline the importance of providing better online health resources and support to diabetes patients, and of targeting potential intervention points where services and information may be particularly beneficial.

Reply to: Diabetes and risk of Parkinson's disease

We thank Cereda et al. for including our study1 in their updated meta-analysis of diabetes and Parkinson disease (PD) published in Movement Disorders. There were only 4 prospective studies available at the time of publication of the original meta-analysis and inclusion of our investigation substantially increased the number of PD cases from 3284 in the original meta-analysis to 3940 in the updated version. Overall, this addition changed the pooled relative risk estimate for diabetes from 1.37 (95% confidence interval [CI], 1.21–1.55) to 1.25 (95% CI, 1.03–1.55), but with significant heterogeneity between studies. A key question is: what are the sources of this heterogeneity? An important difference among the studies included in this meta analysis are the methods of PD ascertainment. Those studies that relied on register data (Hu et al.)2 or unconfirmed self-report (Driver et al.),3 may have included as incident PD cases individuals with vascular Parkinsonism. The potential bias from this source was reduced in the study by Xu et al.,4 who were able to obtain confirmation from the treating neurologist of about two-thirds of the incident PD cases, and minimized in the studies by Simon et al.,5 and Palacios et al.,1 which included only neurologist-confirmed incident PD cases. Vascular parkinsonism may contribute to explain the fact that the strongest association between diabetes and PD was found in Finland (Hu et al.),2 which has relatively high rates of cardiovascular disease. Another important difference is residual confounding. For example, adjustment for changes in smoking behavior was only implemented in Simon et al.,5 and Palacios et al.;1 in the remaining studies, a spurious positive association between diabetes and PD could have resulted if individuals with diabetes were more likely to quit smoking (a negative risk factor for PD)6–8 during the follow-up than those without diabetes. Finally, losses to follow-up may contribute to bias—because only about 63% of the participants in the cohort studied by Xu et al. responded to the PD survey, a higher response rate among diabetics could induce a spurious positive association between diabetes and PD. As Cereda et al. acknowledge, it is not possible to take these differences into account in the meta-analysis. The results from the meta-analysis should therefore be considered with caution. A close analysis of the results of the studies that report a positive association between diabetes and PD raises further doubt on whether such association truly reflects an increased PD risk among diabetics The 2 U.S. studies that reported a positive association are in conflict as to the timing of diabetes prior to onset of PD. Xu et al. found an overall increased risk of PD associated with diabetes within the National Institutes of Health and AARP (formerly the American Association of Retired Persons) (NIH-AARP) cohort, but most of the risk was attributed to patients with 10 or more years of diabetes at baseline. At the same time, in the other positive study, by Driver et al., the increase in PD risk was restricted to patients with <10 years of diabetes at baseline, and a 7-fold increase in risk was reported among individuals with a recent diagnosis of diabetes. The authors of the latter study acknowledged that their results were most likely due to ascertainment bias or reverse causation. Thus, pooling the relative risk estimates from these 2 studies does not have a biological rationale. Overall, in spite of the interesting work by Cereda et al, we believe that there is little evidence that PD risk is increased among individuals with diabetes in the United States. The possibility of an association in Finland remains open. Obesity has also been found to be associated with an increased PD risk in Finland,9 but not in the United States,1,10 and it remains possible that genetic or lifestyle differences between the Finnish and the U.S. population may explain this apparent discrepancy.

Health investment decisions in response to diabetes information in older Americans

Diabetes is a very common and serious chronic disease, and one of the fastest growing disease burdens in the United States. Further, health behaviors, such as exercise, smoking, drinking, as well as weight status, are instrumental to diabetes management and the reduction of its medical consequences. Nine waves of the Health and Retirement Study are used to model the role of a recent diabetes diagnosis and medication on present and subsequent weight status, exercise, drinking and smoking activity. Several non-linear dynamic population average probit models are estimated. Results suggest that compared to non-diagnosed individuals at risk for high blood sugar, diagnosed diabetics respond initially in terms of increasing exercise, losing weight, and curbing smoking and drinking behavior, but the effect diminishes after diagnosis. Evidence of recidivism is also found in these outcomes, especially weight status and physical activity, suggesting that some behavioral responses to diabetes may be short-lived.

Determinants of uncontrolled hypertension in adult type 2 diabetes mellitus: an analysis of the Malaysian diabetes registry 2009

BackgroundUncontrolled blood pressure (BP) is a significant contributor of morbidity and even mortality in type 2 diabetes (T2D) patients. This study was done to determine the significant determinants of uncontrolled blood pressure in T2D patients in Malaysia.MethodsBetween 1st January 2009 to 31st December 2009, data from 70 889 patients with Type 2 diabetes was obtained from the Adult Diabetes Control and Management Registry for analysis; 303 centers participated in the study. Their demographic characteristics, the nature of their diabetes, their state of hypertension, treatment modalities, risk factors, and complications are described. Based on their most recent BP values, subjects were divided into controlled BP and uncontrolled BP and their clinical determinants compared. Independent determinants were identified using multivariate logistic regression.ResultsThe mean age of patients at diagnosis of diabetes was 52.3 ± 11.1 years old. Most were women (59.0 %) and of Malay ethnicity (61.9 %). The mean duration of diabetes was 5.9 ± 5.6 years. A total of 57.4 % were hypertensive. Of the 56 503 blood pressure (BP) measured, 13 280 (23.5 %) patients had BP <130/80 mmHg. Eighteen percent was on > two anti-hypertensive agents. Health clinics without doctor, older age (≥ 50 years old), shorter duration of diabetes (< 5 years), Malay, overweight were determinants for uncontrolled blood pressure (BP ≥130/80 mmHg). Patients who were on anti-hypertensive agent/s were 2.7 times more likely to have BP ≥130/80 mmHg. Type 2 diabetes patients who had ischaemic heart disease or nephropathy were about 20 % and 15 % more likely to have their blood pressure treated to target respectively.ConclusionsMajor independent determinants of uncontrolled BP in our group of T2D patients were Malay ethnicity, older age, recent diagnosis of diabetes, overweight and follow-up at health clinics without a doctor and possibly the improper use of anti hypertensive agent. More effort, education and resources, especially in the primary health care centres are needed to improve hypertensive care among our patients with diabetes.

Diabetic retinopathy screening in patients with diabetes mellitus in primary care: Incentives and barriers to screening attendance

AimAlthough diabetic retinopathy (DR) screening is a basic component of diabetes care, uptake of screening programs is less than optimal. Because attendance rates and reasons for non-attendance in an unselected diabetes population are unknown, this study examines incentives and barriers to attend DR-screening. MethodFour focus groups provided patient-related themes concerning individual decision-making regarding attendance at DR-screening. A questionnaire measuring attendance rates and the influence of several factors was sent to 3236 diabetes patients (>18 years) in 20 Dutch general practices, of which 2363 (73%) responded. ResultsIn the past 3 years, 81% of the patients had attended DR-screening. Patients not attending had lower levels of education, a more recent diagnosis of diabetes, and less frequently used insulin. There was no difference in DM types 1 and 2 patients regarding attendance. Patients attending more often visited health-care providers. Patients reported ‘knowledge of detrimental effects of DR on visual acuity’, ‘sense of duty’ and ‘fear of impaired vision’ as main incentives. The main barrier was the absence of a recommendation by the health-care provider. ConclusionKnowledge about detrimental effects of DR on visual acuity and recommendation by health-care providers are important, possibly modifiable, factors in the attendance to DR screening.

Sociodemographic differences in diabetic retinopathy screening; using patient-level primary care data for health equity audit

Sociodemographic differences in diabetic retinopathy screening; using patient-level primary care data for health equity audit Simon DS Fraser1, GE Watkinson2, CA Rennie3, D King2, H Sanderson2, L Edwards4, P Roderick1 1Public Health Sciences and Medical Statistics, University of Southampton, Southampton General Hospital, Southampton, 2NHS Southampton City, Southampton, 3Southampton Eye Unit, Southampton General Hospital, Southampton, 4NHS Hampshire, Eastleigh, Hampshire, UK Background: The prevalence of diabetes is increasing worldwide and there is inequality in the distribution of diabetic complications. Diabetic retinopathy is the leading cause of blindness in adults of working age in the UK, and certain risk factors are recognized. Retinopathy screening in the UK involves annual digital retinal photography and image grading. Auditing equity in retinopathy screening poses unique challenges, and screening program data are often incomplete for variables relevant to equity. Using two sources of patient-level primary care data, we conducted a health equity audit comparing the access and uptake of screening between groups of people with diabetes in each of three screening programs covering this area of southern England. Methods: A patient-level dataset using data from general practices and a combined health record was used to compare dimensions of equity (gender, age, length of time since diabetes diagnosis, type of diabetes, presence of hypertension, socioeconomic deprivation, ethnicity, and screening program) between people with and without a record of retinopathy screening within three years in Hampshire and the Isle of Wight, UK. Results: Anonymized data for 70,004 people with diabetes were obtained from 205 (88%) general practices. In total, 62,836 people (89.8%) had a record of screening within three years and 7168 (10.2%) did not. Lower uptake of screening was independently associated with the youngest and oldest age groups (compared with 50&ndash;79-year-olds), recent diabetes diagnosis, and deprived areas. Diagnosed hypertension was positively associated with screening. Conclusion: Evaluating equity in screening programs is important to help reduce inequalities. We found evidence of inequity in access and uptake of retinopathy screening. Primary care data contained more information than screening program data. Using a combined health record was more efficient than obtaining data directly from general practices, but data were incomplete for deprivation measures at the time of this audit. Our audit informed subsequent efforts to improve equity in local diabetic retinopathy screening services. Keywords: inequality, diabetes, eye, complications, screening

Learning to live with illness: experiences of persons with recent diagnoses of diabetes mellitus

The process of learning to live with an illness is complex. By better understanding the learning process for persons with diabetes in the early stage of the illness, the role of the health care can be shown. To reach an understanding of how learning to live with diabetes is experienced in the first 2 months after diagnosis. A qualitative descriptive design was used, and interviews were conducted. Thirteen participants with a recent diagnosis of diabetes were included and asked to narrate about their experience of living with diabetes. Qualitative inductive content analysis was used. Four themes emerged: 'taken over by a new reality', 'the body plays a role in life', 'different ways of learning' and 'the healthcare service as a necessary partner'. People with short-term experience of the illness gained knowledge through personal resources such as their own experience and self-reflection. The learning process includes an inner dialogue between the self, the body and the life. Participants were concerned with grasping a new reality and understanding a different self and body where lifestyle changes and uncertainty were present. When health care was accessible and sensitive to their needs, those with short-term experience of diabetes chose the staff as key players in the early stages of their life with diabetes.