Curr Diab Rep. 2007 Dec;7(6):416-9. Lavery LA, Armstrong DG. Department of Surgery, Texas A&M University College of Medicine, Scott and White Hospital, Round Rock, TX 78633, USA.

Preventing foot complications in high-risk patients with diabetes is often overlooked. Assessing risk factors and providing standard preventative care is low tech and relatively inexpensive. The objective of this article is to discuss standard screening and prevention practices and using temperature as a self-assessment and monitoring tool. There are a number of studies that demonstrate the impact of screening and prevention; three randomized clinical trials report a three- to 10-fold reduction in foot ulcerations among high-risk patients.

Foot Temperature in Type 2 Diabetic Patients with or without Peripheral Neuropathy

Exp Clin Endocrinol Diabetes 2009; 117(1): 44-47 N. Papanas1, K. Papatheodorou1, D. Papazoglou1, C. Monastiriotis1, E. Maltezos1 Outpatient Clinic of the Diabetic Foot at the Second Department of Internal Medicine, Democritus University of Thrace, Greece

The aim of this study was to evaluate foot temperature in type 2 diabetic patients with vs. without peripheral neuropathy.

The study included 30 patients (group A: 16 men, mean age 63.23±7.02 years) with peripheral neuropathy and 30 patients (group B: 17 men, mean age 62.37±6.73 years) without peripheral neuropathy. Neuropathy was diagnosed by the Diabetic Neuropathy Index (DNI). Foot temperature was measured with a handheld infrared thermometer (KM 814, Kane-May, UK) on the mid-dorsal aspect of the foot (dorsal temperature) and on the plantar aspect of the foot at the level of the first metatarsal head (plantar temperature).

Dorsal temperature was significantly higher in group A than in group B (right foot 32.89±1.02°C vs. 31.2±1.07°C, p<0.001). The same significant difference was observed for the plantar temperature (32.2±0.94°C vs. 30.7±1.07°C, p<0.001). In both groups, a significant positive correlation was observed between dorsal and plantar temperature (group A: rs=0.913, p<0.001; group B: rs=0.956, p<0.001). Finally, in group A, DNI score showed a significant positive correlation with dorsal temperature (rs=0.856, p<0.001), as well as plantar temperature (rs=0.859, p<0.001).

Conclusions: Foot temperature is significantly higher in type 2 diabetic patients with neuropathy as compared to those without neuropathy. In patients with neuropathy, a significant positive correlation is observed between foot temperature and clinical severity of neuropathy.

Type 2 diabetes impairs pulmonary function in morbidly obese women: a case-control study.

Diabetologia. 2010 Jun;53(6):1210-6. Lecube A, Sampol G, Muñoz X, Hernández C, Mesa J, Simó R. CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Diabetes and Metabolism Research Unit, Institut de Recerca Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035 Barcelona, Spain

AIMS/HYPOTHESIS: To determine whether the presence of type 2 diabetes and the degree of metabolic control are related to reduced pulmonary function in obese individuals.

METHODS: Seventy-five morbidly obese women (25 with type 2 diabetes [cases]--and 50 without diabetes [controls]) with a history of non-smoking and without prior cardiovascular or respiratory disease were prospective recruited for a case-control study in the outpatient obesity unit of a referral centre. Both groups were closely matched by age, BMI and waist circumference. Pulmonary function test included forced spirometry and static pulmonary volume measurements.

RESULTS: Type 2 diabetic patients showed lower forced expiratory volume at 1 s (FEV1) (mean difference -11.6% of predicted [95% CI -20.4 to -2.8]; p = 0.011), and FEV1/forced vital capacity (FEV1/FVC) ratio (mean difference -4.4% [95% CI -8.1 to -0.7]; p = 0.049), but a greater residual volume (RV) (mean difference 19.5% of predicted [95% CI 10.8-28.3]; p < 0.001). In addition, an obstructive ventilatory pattern was more frequent in diabetic patients. Significant negative correlations between FEV1 and fasting glucose, HbA1c and HOMA insulin resistance (HOMA-IR) were detected. By contrast, RV was positively correlated with fasting glucose, HbA1c and HOMA-IR. Multiple linear regression analyses showed that fasting glucose and HbA1c independently predicted FEV1 and RV.

CONCLUSIONS/INTERPRETATION: The presence of diabetes and the degree of glycaemic control are related to respiratory function impairment in morbidly obese women. Therefore, the impact of type 2 diabetes on pulmonary function should be taken into consideration by those providing care for obese people.

Patients diagnosed with diabetes are at increased risk for asthma, chronic obstructive pulmonary disease, pulmonary fibrosis, and pneumonia but not lung cancer.

Diabetes Care. 2010 Jan;33(1):55-60. Epub 2009 Oct 6. Ehrlich SF, Quesenberry CP Jr, Van Den Eeden SK, Shan J, Ferrara A. Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.

OBJECTIVE: There are limited data on the risk of pulmonary disease in patients with diabetes. The aim of this study was to evaluate and compare the incidence of asthma, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, pneumonia, and lung cancer in patients with and without a diagnosis of diabetes.

RESEARCH DESIGN AND METHODS: We conducted a retrospective, longitudinal cohort study using the electronic records of a large health plan in northern California. Age and sex data were available for all cohort members (n = 1,811,228). Data on confounders were available for a subcohort that responded to surveys (n = 121,886), among whom Cox proportional hazards regression models were fit.

RESULTS: Age- and sex-adjusted incidence rates and 95% CIs were calculated for members with and without diabetes in the full cohort and the subcohort. No difference was observed for lung cancer, but the incidence of asthma, COPD, fibrosis, and pneumonia was significantly higher in those members with a diagnosis of diabetes. These differences remained significant in regression models adjusted for age, sex, race/ethnicity, smoking, BMI, education, alcohol consumption, and outpatient visits (asthma hazard ratio [HR] 1.08 [95% CI 1.03-1.12], COPD HR 1.22 [1.15-1.28], pulmonary fibrosis HR 1.54 [1.31-1.81], and pneumonia HR 1.92 [1.84-1.99]). The risk of pneumonia and COPD increased significantly with increasing A1C.

CONCLUSIONS: Individuals with diabetes are at increased risk of several pulmonary conditions (asthma, COPD, fibrosis, and pneumonia) but not lung cancer. This increased risk may be a consequence of declining lung function in patients with diabetes

Cost-effectiveness of diabetes self-management programs in community primary care settings.

Diabetes Educ. 2009 Sep-Oct;35(5):761-9. Epub 2009 Jul 21. Brownson CA, Hoerger TJ, Fisher EB, Kilpatrick KE. National Program Office, Robert Wood Johnson Foundation Diabetes Initiative, Division of Health Behavior Research, Washington University School of Medicine, St Louis, MO 63108-2212, USA.

PURPOSE: The purpose of this study is to estimate the cost-effectiveness of diabetes self-management programs in real-world community primary care settings. Estimates incorporated lifetime reductions in disease progression, costs of adverse events, and increases in quality of life.

METHODS: Clinical results and costs were based on programs of the Diabetes Initiative of the Robert Wood Johnson Foundation, implemented in primary care and community settings in disadvantaged areas with notable health disparities. Program results were used as inputs to a Markov simulation model to estimate the long-term effects of self-management interventions. A health systems perspective was adopted.

RESULTS: The simulation model estimates that the intervention does reduce discounted lifetime treatment and complication costs by $3385, but this is more than offset by the $15,031 cost of implementing the intervention and maintaining its effects in subsequent years. The intervention is estimated to reduce long-term complications, leading to an increase in remaining life-years and quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio is $39,563/QALY, well below a common benchmark of $50,000/QALY. Sensitivity analyses tested the robustness of the model's estimates under various alternative assumptions. The model generally predicts acceptable cost-effectiveness ratios.

CONCLUSIONS: Self-management programs for type 2 diabetes are cost-effective from a health systems perspective when the cost savings due to reductions in long-term complications are recognized. These findings may justify increased reimbursement for effective self-management programs in diverse settings.

Diabetes and incident heart failure in hypertensive and normotensive participants of the Strong Heart Study.

J Hypertens. 2009 Oct 19. de Simone G, Devereux RB, Chinali M, Lee ET, Galloway JM, Barac A, Panza JA, Howard BV. aWeill Cornell Medical College, New York, USA bFederico II University, Naples, Italy cCenter for American Indian Health Research, University of Oklahoma, Oklahoma City, Oklahoma, USA dUniversity of Arizona, Tucson, Arizona, USA eMedstar Research Institute, Washington, District of Columbia, USA.

OBJECTIVES: Type 2 diabetes is accepted as a cause of heart failure, but direct cause-effect evidence independent of incident myocardial infarction (MI), hypertension and other coexisting risk factors is less well studied. We tested the hypothesis that diabetes predisposes to heart failure independently of hypertension and intercurrent MI.

METHODS: We evaluated 12-year incident heart failure in 2740 participants (1781 women) without prevalent cardiovascular or severe kidney disease, at the time of the first exam of the Strong Heart Study cohort. Intercurrent MI was censored as a competing risk event.

RESULTS: Diabetes was present in 1206 individuals (44%), and impaired fasting glucose (IFG) in 391 (14%). Diabetic participants more frequently had hypertension and/or central obesity (both P < 0.0001). Incident heart failure was ascertained in 64 participants with normal fasting glucose (NFG; 6%), 26 (7%) with IFG and 201 with diabetes (17%, hazard ratio = 4.04 vs. NFG, P < 0.0001). In Cox analysis adjusting for age, sex, obesity, central fat distribution, hypertension, antihypertensive medications, prevalent atrial fibrillation, glomerular filtration rate, urinary albumin/creatinine ratio, plasma cholesterol, Hb1Ac, smoking habit, alcohol use, educational level and physical activity, diabetes was associated with a two-fold greater risk of incident heart failure than NFG (hazard ratio = 2.45, P < 0.0001). Diabetes maintained 1.5-fold greater risk of heart failure than NFG (P < 0.03) even when intercurrent MI (n = 221) was censored as a competing risk event, similar to the adjusted hazard ratio for heart failure in hypertension.

CONCLUSION: Type 2 diabetes is a potent, independent risk factor for heart failure. Risk of heart failure in diabetic patients cannot be fully explained by incident MI and coexisting cardiovascular risk factors. Mechanisms directly related to diabetes and impairing cardiac function should be studied and identified.

Cost-effectiveness of Diabetes Self-management Programs in Community Primary Care Settings

Diabetes Educ. 2009 Jul 21. Brownson CA, Hoerger TJ, Fisher EB, Kilpatrick KE. Washington University School of Medicine, St Louis, Missouri.

Purpose: The purpose of this study is to estimate the cost-effectiveness of diabetes self-management programs in real-world community primary care settings. Estimates incorporated lifetime reductions in disease progression, costs of adverse events, and increases in quality of life.

Methods: Clinical results and costs were based on programs of the Diabetes Initiative of the Robert Wood Johnson Foundation, implemented in primary care and community settings in disadvantaged areas with notable health disparities. Program results were used as inputs to a Markov simulation model to estimate the long-term effects of self-management interventions. A health systems perspective was adopted.

Results: The simulation model estimates that the intervention does reduce discounted lifetime treatment and complication costs by $3385, but this is more than offset by the $15 031 cost of implementing the intervention and maintaining its effects in subsequent years. The intervention is estimated to reduce long-term complications, leading to an increase in remaining life-years and quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio is $39 563/QALY, well below a common benchmark of $50 000/QALY. Sensitivity analyses tested the robustness of the model's estimates under various alternative assumptions. The model generally predicts acceptable cost-effectiveness ratios.

Conclusions: Self-management programs for type 2 diabetes are cost-effective from a health systems perspective when the cost savings due to reductions in long-term complications are recognized. These findings may justify increased reimbursement for effective self-management programs in diverse settings.

Cost impact of self-measurement of blood glucose on complications of type 2 diabetes: the spanish perspective.

Diabetes Technol Ther. 2009 Aug;11(8):509-16. Neeser K, Weber C. Institute for Medical Informatics and Biostatistics , Basel, Switzerland .

Abstract: Background: Despite the increasing prevalence of type 2 diabetes, its financial burden on the Spanish healthcare system remains unclear. This study was conducted to determine the cost share of self-measurement of blood glucose (SMBG) by comparing the direct costs of reduced complications of diabetes in SMBG users versus nonusers in the Spanish statutory health insurance system.

Methods: Matched-pair analysis was done of the average annual total direct cost of diabetes monitoring, treatment-related services, complications, and follow-up in the RetrOlective Study Self-Monitoring of Blood Glucose and Outcome in Patients with Type 2 Diabetes (ROSSO) study cohort, updated to 2008 from the year of occurrence or diagnosis of diabetes.

Results: In patients treated with oral antidiabetes drugs (OADs) only, total annual costs were euro1,934 in SMBG users and euro1,982 in nonusers. In those treated with OADs plus insulin, total annual costs were euro3,451 and euro4,167, respectively. By increasing the number of patients using SMBG, the Spanish statutory health insurance system might save several million Euros annually.

Conclusions: The analysis showed that the promotion of SMBG in patients with type 2 diabetes is associated with considerable cost savings for the Spanish healthcare system.

Risks of cardiovascular events and effects of routine blood pressure lowering among patients with type 2 diabetes and atrial fibrillation: results of the ADVANCE study.

Eur Heart J. 2009 May;30(9):1128-35. Du X, Ninomiya T, de Galan B, Abadir E, Chalmers J, Pillai A, Woodward M, Cooper M, Harrap S, Hamet P, Poulter N, Lip GY, Patel A; ADVANCE Collaborative Group. The George Institute for International Health, University of Sydney, Level 10, King George V Building, Royal Prince Alfred Hospital, PO Box M201, Missenden Road, Camperdown, Sydney, NSW 2050, Australia.

AIMS: The aim of this study was to investigate serious clinical outcomes associated with atrial fibrillation (AF) and the effects of routine blood pressure lowering on such outcomes in the presence or absence of AF, among individuals with type 2 diabetes.

METHODS AND RESULTS: About 11 140 patients with type 2 diabetes (7.6% of whom had AF at baseline) were randomized to a fixed combination of perindopril and indapamide or placebo in the Action in Diabetes and Vascular Disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE) study. We compared total mortality and cardiovascular disease outcomes and effects of randomized treatment for 4.3 years on such outcomes between patients with and without AF at baseline. After multiple adjustments, AF was associated with a 61% (95% confidence interval 31-96, P < 0.0001) greater risk of all-cause mortality and comparable higher risks of cardiovascular death, stroke, and heart failure (all P < 0.001). Routine treatment with a fixed combination of perindopril and indapamide produced similar relative, but greater absolute, risk reductions for all-cause and cardiovascular mortalities in patients with AF, compared with those without AF. The number of patients needed to be treated with perindopril-indapamide for 5 years to prevent one cardiovascular death was 42 for patients with AF and 120 for patients without AF at baseline.

CONCLUSION: Atrial fibrillation is relatively common in type 2 diabetes and is associated with substantially increased risks of death and cardiovascular events in patients with type 2 diabetes. This arrhythmia identifies individuals who are likely to obtain greater absolute benefits from blood pressure-lowering treatment. Atrial fibrillation in diabetic patients should be regarded as a marker of particularly adverse outcome and prompt aggressive management of all risk factors.

Identification of an increased short-term blood pressure variability on ambulatory blood pressure monitoring as a coronary risk factor in diabetic hypertensives.

Clin Exp Hypertens. 2009 May;31(3):259-70 Ozawa M, Tamura K, Okano Y, Matsushita K, Yanagi M, Tsurumi-Ikeya Y, Oshikawa J, Hashimoto T, Masuda S, Wakui H, Shigenaga A, Azuma K, Ishigami T, Toya Y, Ishikawa T, Umemura S. Department of Medical Science and Cardiorenal Medicine, Yokohama City University, Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.

We examined risk factors for coronary heart disease (CHD) by ambulatory blood pressure (BP) monitoring in 72 diabetic hypertensives who were hospitalized for the educational program.

The patients were divided into two groups (CHD group, 19 subjects; and non-CHD group, 53 subjects) along with or without co-existing CHD.

On ambulatory BP monitoring, no significant differences were found between the groups regarding BP values through the day. However, the CHD group had a significantly greater BP variability than non-CHD group.

The result of logistic regression analysis demonstrated that nighttime systolic BP variability was an independent risk factor for CHD.

Increased long-term risk of new-onset diabetes mellitus in white-coat and masked hypertension.

J Hypertens. 2009 May 4. Mancia G, Bombelli M, Facchetti R, Madotto F, Quarti-Trevano F, Grassi G, Sega R. aClinica Medica, Dipartimento di Medicina Clinica, Prevenzione e Biotecnologie Sanitarie, Università Milano-Bicocca, Ospedale San Gerardo, Monza, Italy bIstituto Auxologico Italiano, Italy cIstituto Scientifico Multimedica, IRCCS, Sesto San Giovanni, Milan, Italy.

OBJECTIVE: A sustained blood pressure elevation is associated with an increased risk of new-onset diabetes mellitus. Whether this is the case also in white-coat and masked hypertension is unknown.

METHODS: In 1412 individuals of the Pressioni Arteriose Monitorate E Loro Associazioni study stratified for sex and age decades, we measured office, home and 24-h ambulatory blood pressure together with fasting plasma glucose and other metabolic variables. This allowed to identify patients with white-coat, masked, sustained hypertension and true normotension.

RESULTS: Over a 10-year period, the increase in plasma glucose and the incidence of new-onset diabetes (plasma glucose >/=126 mg/dl or use of antidiabetic drugs) was significantly greater in individuals with white-coat and masked hypertension than in those with 'true' normotension (age and sex-adjusted risk 2.9 and 2.7, respectively), the increase being similar to that of sustained hypertensive individuals. The adjusted risk showed a marked increase when development of an impaired fasting glucose condition was also considered, and the results were similar when individuals reporting antihypertensive drug treatment were excluded or white-coat and masked hypertension were identified by office versus home blood pressure. The increased risk of new-onset diabetes become no more significant when data were adjusted for initial blood glucose and BMI, which, at a multivariate analysis, were the most significant predictors of this condition, with only a small although significant contribution of the initial blood pressure.

CONCLUSION: Thus, white-coat and masked hypertension are associated with a long-term greater progression of blood glucose abnormalities and an increased risk of developing diabetes. This is largely accounted for by the metabolic abnormalities that are frequent components of these conditions.

"Diabetes in Germany"(DIG) study. A prospective 4-year-follow-up study on the quality of treatment for type 2 diabetes in daily practice

Dtsch Med Wochenschr. 2009 Feb;134(7):291-7 Ott P, Benke I, Stelzer J, Köhler C, Hanefeld M. Weisseritzel-Kliniken, Freital/Dippoldiswalde, Freital.

INTRODUCTION: The efficacy of a multifactorial intervention with antihypertensive drugs, statins and acetylsalicylic acid was shown in the STENO 2 trial of diabetic patients with microalbuminuria. But how good is clinical practice in Germany? The DIG (Diabetes in Germany) study was an prospective survey, analysing the quality of risk factor control and treatment patterns of type 2 diabetics over 4 years between 2002 and 2007.

METHODS: A total of 4020 type 2 diabetics (aged 35 - 80 years) were recruited by 238 physicians across Germany. Their medical history, risk factor profile and clinical data were recorded. The quality of control of diabetes, hypertension or hyperlipidemia and the use of aspirin were assessed in 2914 patients at baseline and after 3,7 years.

RESULTS: The mean HbA (1c) value was 6,98 % at baseline and 7,03 at the study end. 42,9 % at the beginning vs. 36,9 % at follow-up had HbA (1c) values above the target level of 6,5 %. Mean blood pressure was 139,3/80.0 compared with 137,3/79.9 mm Hg (p < 0,01), while 24,1 % and 27,0 %, respectively had values above the target level. Mean LDL-cholesterol levels were 3,23 mmol/l and 2,93 mmol/l, respectively, but only 23,2 % and 30,4 % of patients, respectively, reached target levels. There was a significant increase in the use of antihypertensive drugs, statins and acetylsalicylic acid over the four-year period.

CONCLUSION: Type 2 diabetics in Germany received an acceptable level of treatment for hyperglycaemia, but still more than 60 % of the patients have HbA (1c) values higher than 6,5 %. There are serious deficits in the management of hypertension, hypercholesterolemia and the use of aspirin. Because intensive, multifactorial care of type 2 diabetics leads to reduced rates of death and cardiovascular disorders, these results indicate that the early and meticulous implementation of current treatment guidelines remains a major challenge.

Night time blood pressure variability is a strong predictor for cardiovascular events in patients with type 2 diabetes.

Am J Hypertens. 2009 Jan;22(1):46-51. Eguchi K, Ishikawa J, Hoshide S, Pickering TG, Schwartz JE, Shimada K, Kario K. Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University, Tochigi, Japan.

BACKGROUND: We aimed this study to test the hypothesis that short-term blood pressure (BP) variability and abnormal patterns of diurnal BP variation, evaluated by ambulatory BP (ABP), predicts risk of incident cardiovascular disease (CVD) in patients with type 2 diabetes (T2DM).

METHODS: ABP monitoring (ABPM) was performed in 300 patients with uncomplicated T2DM without known CVD and without BP medications, who were followed for 54 +/- 20 months. The relationships of different measures of BP variability, the presence of abnormal patterns of diurnal BP variation (nondipper, riser, or morning BP surge) and the standard deviations of awake and asleep ABP were determined. Cox proportional hazards models were used to estimate hazard ratios (HRs) and their 95% confidence intervals (CIs) before and after controlling for various covariates.

RESULTS: The mean age was 67.8 +/- 9.6 years, 48% were male, 253 (84%) had a diagnosis of hypertension, and the mean of the standard deviations of awake systolic BP/diastolic BP (SBP/DBP) were 18 +/- 6/11 +/- 4 mm Hg, and those of sleep SBP/DBP were 13 +/- 5/9 +/- 3 mm Hg. During follow-up, there were 29 cardiovascular events. In multivariable analyses, the standard deviations of sleep SBP (HR = 1.08; 95% CI, 1.01-1.16, P < 0.05) and sleep DBP (HR = 1.13; 1.04-1.23, P < 0.01) were independently associated with incident CVD. Neither the nondipper and riser patterns nor the morning BP surge were associated with incident CVD events independently of clinic and 24-h BP levels.

CONCLUSIONS: Abnormal diurnal BP variation was not a predictor of CVD in patients with T2DM. Night time BP variability was an independent predictor of future incidence of CVD, suggesting that this measure could reflect pathophysiology of T2DM.

Interactive effect of central obesity and hypertension on cognitive function in older out-patients with Type 2 diabetes.

Diabet Med. 2008 Dec;25(12):1440-6. Kim E, Cho MH, Cha KR, Park JS, Ahn CW, Oh BH, Kim CH. Institute of Behavioural Science in Medicine, College of Medicine, Yonsei University, Seoul, Korea.

Aim: Central obesity, hypertension and diabetes mellitus have been related individually to cognitive dysfunction. We aimed to study the interactive effects of these co-occurring risk factors on cognitive decline, which remain unclear in older patients with diabetes.

Methods: We assessed metabolic profiles and neuropsychological functions in 60 older out-patients with Type 2 diabetes to examine the associations of central obesity with cognitive functions, while controlling for other confounding factors in these subjects.

Results: Waist circumference was associated with poor performance in digits forward (r(2) = 0.11, P = 0.02), choice reaction time (r(2) = 0.08, P = 0.04) and cognitive reaction time (r(2) = 0.07, P < 0.05) even after adjustment for potential confounders including age, gender, education and HbA(1c). There were also significant interactions between central obesity and hypertension with respect to performance of digits forward (P = 0.04) and delayed verbal cued recall (P = 0.03).

Conclusion: Our findings suggest that, in addition to glycaemic control, central obesity and hypertension influence cognitive functions, such as attention and psychomotor speed in older patients with Type 2 diabetes.

Characteristics of Diabetics with Poor Glycemic Control Who Achieve Good Control

The Journal of the American Board of Family Medicine 21 (6): 490-496 (2008) Michal Shani, MD, MPH, Tomas R. Taylor, MD, PhD, Shlomo Vinker, MD, Alexander Lustman, MD, Rina Erez, MD, Asher Elhayany, MD, MPA and Amnon Lahad, MD, MPH Department of Family Medicine, Central District, Clalit Health Service (MS, AL, RE, AE), Rehovot Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University (MS, SV), Israel Department of Family Medicine, University of Washington, Seattle (TRT) Department of Family Medicine, Hadassah Medical School, Hebrew University, Jerusalem, Israel

Objective: To find the characteristics of diabetics with poorly controlled diabetes that became well controlled compared with the patients with poorly controlled diabetes that remained poorly controlled.

Methods: The sample included diabetic patients, aged 40 years and older, from the Central district of Clalit Health Service in Israel, with at least one HbA1c measure greater than 9.5 mg% during 2001. They were divided into 2 categories according to their HbA1c levels in 2003, well controlled (HbA1c <7.5 mg%) and poorly controlled (HbA1c >9.5 mg%). Patients with 7.5< HbA1c <9.5 in 2003 were excluded from analysis.

Results: Two thousand sixty-two diabetic patients met the inclusion criteria and care was provided by one of 249 primary care physicians. Of these patients, 1232 (41.6%) had well-controlled diabetes and 1760 (58.4%) had poorly controlled diabetes in 2003. The well-controlled group had fewer patients with low socioeconomic status (30.3% vs 41.9%; P < .001) and more men (52% vs 43.8%; P < .001). The individual primary care physician was the most significant predictor of good glycemic control. Total patient costs in 2004 were 8% lower among the group with well-controlled diabetes.

Conclusion: The primary care physician has an important role in the patient's chances of achieving glycemic control. Further investigation of how and why some primary care physicians achieve better diabetes control in their patients would be worthwhile.

Relation of the number of metabolic syndrome risk factors with all-cause and cardiovascular mortality

Am J Cardiol. 2008 Sep 15;102(6):689-92. Ho JS, Cannaday JJ, Barlow CE, Mitchell TL, Cooper KH, FitzGerald SJ. Cooper Clinic, Dallas, Texas, USA

The metabolic syndrome (MS) is a constellation of risk factors associated with diabetes and cardiovascular disease. This syndrome consists of at least 3 parameters assessing central obesity, hypertension, high-density lipoprotein cholesterol, triglycerides, and impaired glucose metabolism. Whether persons with 4 or 5 risk factors are at higher risk than those with 3 risk factors is unclear. Also unclear is whether those without the MS but with 1 or 2 risk factors warrant therapy. We assessed cardiovascular and all-cause mortality as a function of the number of these risk factors. We followed 30,365 men for a median follow-up of 13.6 years. During follow-up, 1,449 participants died, 527 from cardiovascular causes. All of the individual parameters defining the MS were significantly associated with both all-cause and cardiovascular mortality (p <0.001). After adjustment for age and the other MS variables, hypertension was the most potent risk factor whereas central obesity and hypertriglyceridemia remained associated with both all-cause and cardiovascular mortality. A highly significant trend was also noted between both all-cause or cardiovascular mortality and the number of risk factors (p <0.001 for trend). Risk increased incrementally, beginning at 1 risk factor for cardiovascular mortality and at 2 risk factors for all-cause mortality.

In conclusion, there is a continuum of risk as the number of metabolic syndrome risk factors increases. These findings add to the growing evidence that central obesity can independently and adversely affect health.

Insulin therapy, hyperglycemia, and hypertension in type 1 diabetes mellitus

Arch Intern Med. 2008 Sep 22;168(17):1867-73 de Boer IH, Kestenbaum B, Rue TC, Steffes MW, Cleary PA, Molitch ME, Lachin JM, Weiss NS, Brunzell JD; Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Study Research Group. Division of Nephrology, University of Washington, Box 356521, 1959 NE Pacific St, Seattle, WA 98117, USA.

BACKGROUND: Diabetes mellitus and hypertension are closely linked, but the long-term blood pressure effects of glucose-lowering therapy and hyperglycemia are not clear.

METHODS: We examined the effects of intensive insulin therapy and hyperglycemia on the development of hypertension in the Diabetes Control and Complications Trial (DCCT) and its observational follow-up, the Epidemiology of Diabetes Intervention and Complications (EDIC) study. Incident hypertension was defined as 2 consecutive study visits with a systolic blood pressure of 140 mm Hg or higher, a diastolic blood pressure of 90 mm Hg or higher, or use of antihypertensive medications to treat high blood pressure.

RESULTS: Participants were enrolled from August 23, 1983, through June 30, 1989. During a 15.8-year median follow-up, 630 of 1441 participants developed hypertension. During the DCCT, the incidence of hypertension was similar comparing participants assigned to intensive vs conventional therapy. However, intensive therapy during the DCCT reduced the risk of incident hypertension by 24% during EDIC study follow-up (hazard ratio, 0.76; 95% confidence interval [CI], 0.64-0.92). A higher hemoglobin A(1c) level, measured at baseline or throughout follow-up, was associated with increased risk for incident hypertension (adjusted hazard ratios, 1.11 [95% CI, 1.06-1.17] and 1.25 [95% CI, 1.14-1.37], respectively, for each 1% higher hemoglobin A(1c) level), and glycemic control appeared to mediate the antihypertensive benefit of intensive therapy. Older age, male sex, family history of hypertension, greater baseline body mass index, weight gain, and greater albumin excretion rate were independently associated with increased risk of hypertension.

CONCLUSIONS: Hyperglycemia is a risk factor for incident hypertension in type 1 diabetes, and intensive insulin therapy reduces the long-term risk of developing hypertension.

Impact of White-coat Hypertension on Microvascular Complications in Type 2 Diabetes Mellitus.

Diabetes Care. 2008 Sep 3 Kramer CK, Leitão CB, Canani LH, Gross JL. Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.

Objective: To determine the impact of white-coat hypertension (WCH) on microvascular complications in type 2 diabetes mellitus (DM).

Research Design and Methods: A cross-sectional study was conducted in normotensive and WCH subjects selected from a cohort of 319 type 2 DM patients. Normotension was defined by office blood pressure (BP) <140/90 mmHg and daytime BP in ambulatory BP monitoring (ABPM) <135/85 mmHg. WCH was defined as office BP >/=140/90 mmHg and daytime BP on ABPM <135/85 mmHg. Subjects were evaluated for diabetic nephropathy (DN; 24 h urinary albumin excretion rate) and diabetic retinopathy (DR; classified according to the Global Diabetic Retinopathy Group)

Results: Forty-six type 2 DM patients had WCH (14.4%; age 56.6; 45.3% men) and 117, normotension (36.6%; age 55.8; 37.5% men). These groups did not differ in clinical and main laboratory characteristics. Systolic ABPM (24-h: 124.7+/-6.7 vs. 121.0+/-8.5 mmHg, P=0.01 and daytime: 126.6+/-7.2 vs. 123.2+/-8.2 mmHg, P=0.01) and BP loads were higher in WCH subjects than in the normotensive ones. WCH was associated with an increased risk for macroalbuminuria (OR 4.9, 95%CI 1.3-18.7, P=0.01). On multivariate analysis models, WCH was associated with macroalbuminuria (OR 2.0 95%CI 1.3-3.2, P=0.02) and increased the risk for both non-proliferative and proliferative DR (OR 2.7, 95%CI 1.2-6.6, P=0.02 for any degree of DR) after adjustments for confounding factors.

Conclusions: Type 2 DM patients with WCH have an increased risk for DR and DN. Therefore, WCH should not be considered a harmless condition and treatment should be considered.

Prevalence of type 2 diabetes among patients with hypertension under the care of 30 Italian clinics of hypertension: results of the (Iper)tensione and (dia)bete study.

J Hypertens. 2008 Sep;26(9):1801-1808 Lonati C, Morganti A, Comarella L, Mancia G, Zanchetti A; on behalf of the IPERDIA Study Group. aUnità Operativa di Medicina Interna e Centro Ipertensione Arteriosa, Ospedale San Giuseppe Milano Cuore, Italy bUnità Operativa di Medicina Interna e Centro Ipertensione Arteriosa, Ospedale San Giuseppe Milano Cuore, and Centro Interuniversitario di Fisiologia Clinica e Ipertensione, University of Milan, Milan, Italy cContract Research Organisation Statistics and Data Management, CROS NT, Verona, Italy dDepartment of Clinical Medicine and Prevention, University of Milan Bicocca, and Centro Interuniversitario di Fisiologia Clinica e Ipertensione, University of Milan, Milan, Italy eCentro Interuniversitario di Fisiologia Clinica e Ipertensione, Università diMilano and Istituto Auxologico Italiano, Milan, Italy.

BACKGROUND AND PURPOSE: Hypertension is known to be highly prevalent among patients with diabetes and associated with an increased risk of cardiovascular damage. In contrast, relatively few investigations have addressed the prevalence of diabetes among patients with hypertension. The purpose of the present study was to examine the prevalence of type 2 diabetes, the effectiveness of hypertension and diabetes control and the association with other cardiovascular risk factors and previous cardiovascular diseases in a cohort of patients with hypertension referred to 30 hospital outpatient clinics for the treatment of hypertension.

METHODS AND PATIENTS: Patients were considered as having diabetes if they were already on an antidiabetic treatment either with diet or medications. All other patients had fasting plasma glucose measured on two separate occasions and were classified as having diabetes if both values were at least 140 mg/dl (7.8 mmol/l) and as not having diabetes if both values were less than 110 mg/dl (6.1 mmol/l). In patients with a single determination of at least 110 mg/dl, the final diagnosis of diabetes was established according to the result of an oral glucose tolerance test. A secondary definition of diabetes was also used, that is two fasting plasma glucose values of at least 126 mg/dl (7.0 mmol/l). In all patients, serum total, high-density lipoprotein cholesterol and low-density lipoprotein cholesterol, fasting serum triglycerides, serum creatinine and urinary albumin were also evaluated.

RESULTS AND CONCLUSION: Among the 1397 recruited patients, 242 (17.3%) were diagnosed as having diabetes according to the primary definition and 244 (17.5%) according to the secondary definition. In 195 out of the 242 (14%), the diagnosis was already known whereas, in the remaining 47 (3.3%), it was made de novo. In 61.4% of those already having diabetes, plasma glucose was at least 140 mg/dl (7.8 mmol/l), whereas only in 8.4% of them was it less than 110 mg/dl (6.1 mmol/l). Patients with diabetes were older, heavier and with a greater familiar predisposition. Patients with diabetes had higher values of systolic blood pressure than individuals without diabetes (150 +/- 17 vs. 144 +/- 16 mmHg, respectively; P < 0.001), lower high-density lipoprotein cholesterol and higher triglycerides and microalbuminuria. Overall, among patients with hypertension and diabetes, only 3% had blood pressure and HbA1c within the recommended limits. The prevalence of previous cardiovascular disorders was two to three times higher than among individuals without diabetes.

Obesity and intermediate clinical outcomes in diabetes: evidence of a differential relationship across ethnic groups

Diabet Med. 2008 Jun;25(6):685-91 Millett C, Khunti K, Gray J, Saxena S, Netuveli G, Majeed A. Wandsworth Primary Care Research Centre, Wandsworth PCT, Imperial College, London.

AIM: To examine associations between obesity, ethnicity and intermediate clinical outcomes in diabetes.

METHODS: Population-based, cross-sectional study using electronic primary care medical records of 7300 people with diabetes from White, Black and south Asian ethnic groups.

RESULTS: The pattern of obesity differed within ethnic groups, with rates significantly higher in younger when compared to older Black (women, 63% vs. 44%, P = 0.002; men, 37% vs. 20%, P = 0.005) and south Asian (women, 47% vs. 27%, P = 0.01; men, 21% vs. 13%, P = 0.05) people. Obese people with diabetes were significantly less likely to achieve an established target for blood pressure control (adjusted odds ratio 0.50, 95% confidence interval 0.42, 0.59). Differences in mean systolic blood pressure in obese and normal weight persons were significant in the White group but not in the Black groups or south Asian groups (6.9 mmHg, 1.9 mmHg and 2.7 mmHg, respectively). Differences in mean diastolic blood pressure between obese and normal weight persons were 4.8 mmHg, 3.6 mmHg and 3.4 mmHg in the White, Black and south Asian groups. Mean HbA(1c) and achievement of an established treatment target did not differ significantly with obesity in any ethnic group.

CONCLUSIONS: Obesity is more prevalent amongst younger people than older people with diabetes in ethnic minority groups. The relationship between obesity and blood pressure control in diabetes differs markedly across ethnic groups. Major efforts must be implemented, especially in young people, to reduce levels of obesity in diabetes and improve long-term outcomes.

Relationship of elevated casual blood glucose level with coronary heart disease, cardiovascular disease and all-cause mortality in a representative sample of the Japanese population.

Diabetologia. 2008 Apr;51(4):575-82. Kadowaki S, Okamura T, Hozawa A, Kadowaki T, Kadota A, Murakami Y, Nakamura K, Saitoh S, Nakamura Y, Hayakawa T, Kita Y, Okayama A, Ueshima H; NIPPON DATA Research Group. Department of Health Science, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu 520-2192, Japan.

AIMS/HYPOTHESIS: High fasting blood glucose is one of the well-known risk factors for CHD. However, in certain settings, patients cannot always be expected to fast. For example, community screenings for cardiovascular disease (CVD) risk factors in Japan are performed under non-fasting conditions to achieve high participation rates. Thus, we examined a representative cohort of the Japanese population (n=9,444, follow-up period 17.3 years) to clarify whether high casual blood glucose (CBG) can predict CVD mortality.

METHODS: We defined CBG groups as follows: high CBG >or= 11.1 mmol/l or participants with a history of diabetes mellitus; borderline high, 7.77 <or= CBG<11.1 mmol/l; higher normal, 5.22 <or= CBG<7.77 mmol/l); and lower normal, CBG<5.22 mmol/l. The multivariate-adjusted hazard ratios (HRs) for CHD, CVD and all-cause mortality were calculated.

RESULTS: The crude CHD mortality rate was 0.84 per 1,000 person-years. Age- and sex-adjusted HRs for CHD mortality were high among participants with CBG levels >or= 7.77 mmol/l, regardless of time since last meal. Multivariate-adjusted HRs (95% CI) of CHD mortality in high and borderline high CBG groups were 2.62 (1.46-4.67) and 2.43 (1.29-4.58), respectively. Similar results were observed for both CVD and all-cause mortality. Even within the normal blood glucose range, each 1 mmol/l increase in CBG was associated with a statistically significant increase in the HR for CVD mortality (1.12, 95% CI 1.02-1.22). Population-attributable fractions of the combined groups of high and borderline high CBG for CHD, CVD and all-cause mortality were 12.0, 4.9 and 3.5%, respectively.

CONCLUSIONS/INTERPRETATION: Increases in CBG, even within the normal range, predict CVD mortality

Blood pressure means rather than nocturnal dipping pattern are related to complications in Type 2 diabetic patients

Diabet Med. 2008 Mar;25(3):308-13. Leitão CB, Canani LH, Kramer CK, Moehlecke M, Pinto LC, Ricardo ED, Pinotti AF, Gross JL. Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.

AIM: To determine whether systolic and diastolic blood pressure (BP) means, during ambulatory BP monitoring (ABPM), are more strongly correlated with microvascular complications and echocardiographic structural alterations than night-time/daytime (N/D) BP ratio.

METHODS: A cross-sectional study was conducted in 270 Type 2 diabetes mellitus (DM) outpatients who underwent clinical and laboratory investigations, urinary albumin excretion rate (UAER) determination, echocardiography, office and 24-h ABPM (Spacelabs 90207).

RESULTS: UAER, after multivariate adjustments, was associated with office BP (systolic: R(2)(a) 0.162, P < 0.001; diastolic: R(2)(a) 0.124, P < 0.001) and ABPM (24-h systolic: R(2)(a) 0.195, P < 0.001; 24-h diastolic: R(2)(a) 0.197, P < 0.001) but not with N/D BP ratios (systolic: R(2)(a) 0.062, P = 0.080; diastolic: R(2)(a) 0.063, P = 0.069). Similar results were observed for echocardiographic parameters. The presence of retinopathy was associated only with night-time BP values [systolic means: odds ratio (OR) 1.13, 95% confidence interval (CI) 1.03-1.24 and diastolic means: OR 1.21, CI 1.04-1.40 and N/D diastolic BP ratio > 0.90, OR 3.21, CI 1.65-6.25].

CONCLUSIONS: UAER and echocardiographic structural alterations had more consistent correlations of a greater magnitude with systolic BP means than with N/D BP ratios. The nocturnal BP values appear to be more relevant for diabetic retinopathy. BP measurement in patients with Type 2 DM should take into account the 24-h period rather than focusing on a specific time span of BP homeostasis.

Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes

N Engl J Med 2008;358(24):2560-2572, The ADVANCE Collaborative Group

Background: In patients with type 2 diabetes, the effects of intensive glucose control on vascular outcomes remain uncertain.

Methods: We randomly assigned 11,140 patients with type 2 diabetes to undergo either standard glucose control or intensive glucose control, defined as the use of gliclazide (modified release) plus other drugs as required to achieve a glycated hemoglobin value of 6.5% or less. Primary end points were composites of major macrovascular events (death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke) and major microvascular events (new or worsening nephropathy or retinopathy), assessed both jointly and separately.

Results: After a median of 5 years of follow-up, the mean glycated hemoglobin level was lower in the intensive-control group (6.5%) than in the standard-control group (7.3%). Intensive control reduced the incidence of combined major macrovascular and microvascular events (18.1%, vs. 20.0% with standard control; hazard ratio, 0.90; 95% confidence interval [CI], 0.82 to 0.98; P=0.01), as well as that of major microvascular events (9.4% vs. 10.9%; hazard ratio, 0.86; 95% CI, 0.77 to 0.97; P=0.01), primarily because of a reduction in the incidence of nephropathy (4.1% vs. 5.2%; hazard ratio, 0.79; 95% CI, 0.66 to 0.93; P=0.006), with no significant effect on retinopathy (P=0.50). There were no significant effects of the type of glucose control on major macrovascular events (hazard ratio with intensive control, 0.94; 95% CI, 0.84 to 1.06; P=0.32), death from cardiovascular causes (hazard ratio with intensive control, 0.88; 95% CI, 0.74 to 1.04; P=0.12), or death from any cause (hazard ratio with intensive control, 0.93; 95% CI, 0.83 to 1.06; P=0.28). Severe hypoglycemia, although uncommon, was more common in the intensive-control group (2.7%, vs. 1.5% in the standard-control group; hazard ratio, 1.86; 95% CI, 1.42 to 2.40; P<0.001).

Conclusions: A strategy of intensive glucose control, involving gliclazide (modified release) and other drugs as required, that lowered the glycated hemoglobin value to 6.5% yielded a 10% relative reduction in the combined outcome of major macrovascular and microvascular events, primarily as a consequence of a 21% relative reduction in nephropathy

Excess risk of diabetes in persons with hypertension.

J Diabetes Complications. 2008 May 28. Weycker D, Nichols GA, O'Keeffe-Rosetti M, Edelsberg J, Vincze G, Khan ZM, Oster G. Policy Analysis Inc. (PAI), Brookline, MA, USA.

PROBLEM: Persons with hypertension appear to be at increased risk of diabetes, an important predictor of cardiovascular disease. Whether, and to what extent, this risk may vary across subgroups defined on the basis of important clinical characteristics has not been well characterized.

METHODS: Study population included members of Kaiser Permanente Northwest Region, a large health maintenance organization, aged >/=35 years and free of diabetes in 1998. Persons in the study population were stratified based on whether or not they had hypertension, and onset of diabetes was ascertained over a 6-year period beginning January 1999. Excess risk of diabetes was characterized in terms of risk differences between persons with and without hypertension, and was estimated on an overall basis and for subgroups defined on the basis of age, sex, and body mass index (BMI).

RESULTS: Study population totaled 104,368; 44% had hypertension. Relative risk (RR) of developing diabetes was 2.7 (95% CI: 2.6-2.8) for those with vs. without hypertension [21.0 (95% CI: 20.7-21.4) vs. 7.8 (95% CI: 7.6-8.0) per 1000 person-years, respectively]. Adjusted for age, sex, and BMI, RR of diabetes was 1.8 (95% CI: 1.7-1.9). With one exception (men, aged >/=75 years), risk of diabetes was higher across all age and BMI strata for both men and women with vs. without hypertension; differences in risk were greatest among those with high BMI (>/=35 kg/m(2)). Across BMI strata, RR of developing diabetes was generally higher at younger ages.

CONCLUSION: All persons with hypertension, irrespective of age, sex, and BMI, are at elevated risk of developing diabetes. Men and women with hypertension who are overweight or obese are at substantially elevated risk of diabetes, regardless of age, and should be monitored especially closely for the development of this disease.

Screening for Type 2 Diabetes Mellitus in Adults: U.S. Preventive Services Task Force Recommendation Statement

Annals of Internal Medicine 148(11):846-854, 3 June 2008 U.S. Preventive Services Task Force

Description: Updated U.S. Preventive Services Task Force (USPSTF) recommendation about screening for type 2 diabetes mellitus in adults.

Methods: To estimate the balance of benefits and harms of screening, the USPSTF updated its 2003 evidence review, adding evidence from new trials as well as updates on earlier studies. The review for this current recommendation focused on evidence that early treatment prevented long-term adverse outcomes of diabetes, including cardiovascular events, visual impairment, renal failure, and amputation.

Recommendations: Screen for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. (B recommendation)

Current evidence is insufficient to assess the balance of benefits and harms of routine screening in asymptomatic adults with blood pressure of 135/80 mm Hg or lower. (I statement)

Can metabolic syndrome usefully predict cardiovascular disease and diabetes? Outcome data from two prospective studies

The Lancet published online 22 May 2008 Prof Naveed Sattar et al.

Background: Clinical use of criteria for metabolic syndrome to simultaneously predict risk of cardiovascular disease and diabetes remains uncertain. We investigated to what extent metabolic syndrome and its individual components were related to risk for these two diseases in elderly populations.

Methods : We related metabolic syndrome (defined on the basis of criteria from the Third Report of the National Cholesterol Education Program) and its five individual components to the risk of events of incident cardiovascular disease and type 2 diabetes in 4812 non-diabetic individuals aged 70–82 years from the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER). We corroborated these data in a second prospective study (the British Regional Heart Study [BRHS]) of 2737 non-diabetic men aged 60–79 years.

Findings : In PROSPER, 772 cases of incident cardiovascular disease and 287 of diabetes occurred over 3•2 years. Metabolic syndrome was not associated with increased risk of cardiovascular disease in those without baseline disease (hazard ratio 1•07 [95% CI 0•86–1•32]) but was associated with increased risk of diabetes (4•41 [3•33–5•84]) as was each of its components, particularly fasting glucose (18•4 [13•9–24•5]). Results were similar in participants with existing cardiovascular disease. In BRHS, 440 cases of incident cardiovascular disease and 105 of diabetes occurred over 7 years. Metabolic syndrome was modestly associated with incident cardiovascular disease (relative risk 1•27 [1•04–1•56]) despite strong association with diabetes (7•47 [4•90–11•46]). In both studies, body-mass index or waist circumference, triglyceride, and glucose cutoff points were not associated with risk of cardiovascular disease, but all five components were associated with risk of new-onset diabetes.

Interpretation : Metabolic syndrome and its components are associated with type 2 diabetes but have weak or no association with vascular risk in elderly populations, suggesting that attempts to define criteria that simultaneously predict risk for both cardiovascular disease and diabetes are unhelpful. Clinical focus should remain on establishing optimum risk algorithms for each disease.

Trends in Diabetes, high cholesterol, and hypertension in Chronic Kidney Disease among US adults: 1988-1994 through 1999-2004.

Diabetes Care. 2008 Apr 24 Fox CS, Muntner P. The National Heart, Lung and Blood Institute's Framingham Heart Study (CSF), Framingham, Massachusetts; Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, Harvard Medical School, Boston MA (CSF) and Mt Sinai School of Medicine (PM), New York, NY.

Objective: The prevalence of chronic kidney disease (CKD) increased among US adults from 1988-1994 through 1999-2004. We sought to explore the importance of trends in risk factors for CKD over time.

Research Design and Methods: The prevalence of cigarette smoking, obesity, hypertension, high cholesterol, and diabetes among US adults with stage-3 CKD (estimated GFR <60 ml/min/1.73m(2)) and albuminuria (urinary albumin to creatinine ratio >/=30 mg/g), separately, were determined for 1988-1994 and 1999-2004 using data from serial National Health and Nutrition Examination Surveys. The prevalence ratio (PR) for stage-3 CKD and albuminuria by the presence of these risk factors were compared across survey periods.

Results: The PR for CKD declined between 1988-1994 and 1999-2004 for obesity (PR=1.51 and 1.14 for 1988-1994 and 1999-2004, respectively; p-value for change=0.010), hypertension (PR=2.60 and 1.70; p-value for change=0.005) and high cholesterol (PR=1.58 and 1.20; p-value for change=0.028). However, for diagnosed diabetes, the prevalence ratio remained unchanged (1.64 in NHANES III and 1.62 in NHANES 1999-2004; p-value for change=0.898). Similar results were observed for undiagnosed diabetes: the prevalence ratio of CKD was 1.38 and 1.50 in NHANES III and NHANES 1999-2004; p=0.373). The association of cigarette smoking was similar in each time period. Besides obesity, for which the association remained stable over time, similar patterns were observed for the PR of albuminuria.

Conclusions: In terms of CKD, improvements in hypertension and high cholesterol management have been offset by both diagnosed and undiagnosed diabetes. Further increases in CKD may occur if diabetes continues to increase.

Improving Hypertension Control in Diabetes Mellitus. The Effects of Collaborative and Proactive Health Communication.

Circulation. 2008 Mar 3 Naik AD, Kallen MA, Walder A, Street RL Jr. Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VA Medical Center, Houston, Tex; Sections of Health Services Research and Geriatrics, Baylor College of Medicine, Houston, Tex; Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Tex; and Department of Communication, Texas A&M University, College Station, Tex.

Background - Communication between patients and clinicians using collaborative goals and treatment plans may overcome barriers to achieving hypertension control in routine diabetes mellitus care. We assessed the interrelation of patient-clinician communication factors to determine their independent associations with hypertension control in diabetes care.

Methods and Results - We identified 566 older adults with diabetes mellitus and hypertension at the DeBakey VA Medical Center in Houston, Tex. Clinical and pharmacy data were collected, and a patient questionnaire was sent to all participants. A total of 212 individuals returned surveys. Logistic regression analyses were performed to assess the effect of patient characteristics, self-management behaviors, and communication factors on hypertension control. Three communication factors had significant associations with hypertension control. Two factors, patients' endorsement of a shared decision-making style (odds ratio 1.61, 95% confidence interval 1.01 to 2.57) and proactive communication with one's clinician about abnormal results of blood pressure self-monitoring (odds ratio 1.89, 95% confidence interval 1.10 to 3.26), had direct, independent associations in multivariate regression. Path analysis was used to investigate the direct and indirect effects of communication factors and hypertension control. Decision-making style (beta=0.20, P<0.01) and proactive communication (beta=0.50, P<0.0001) again demonstrated direct effects on hypertension control. A third factor, clinicians' use of collaborative communication when setting treatment goals, had a total effect on hypertension control of 0.16 (P<0.05) through its direct effects on decision-making style (beta=0.28, P<0.001) and proactive communication (beta=0.22, P<0.01).

Conclusions - Three communication factors were found to have significant associations with hypertension control. Patient-clinician communication that facilitates collaborative blood pressure goals and patients' input related to the progress of treatment may improve rates of hypertension control in diabetes care independent of medication adherence.

Impact of New-Onset Diabetes Mellitus on Development of Atrial Fibrillation and Heart Failure in High-Risk Hypertension (from the VALUE Trial).

Am J Cardiol. 2008 Mar 1;101(5):634-8. Aksnes TA, Schmieder RE, Kjeldsen SE, Ghani S, Hua TA, Julius S. Department of Cardiology, Ullevaal University Hospital, Oslo, Norway.

Hypertension and diabetes mellitus (DM) are known risk factors for atrial fibrillation (AF). We investigated the influence of new-onset DM on developing AF in the VALUE trial population of high-risk hypertensive patients. Five thousand two hundred fifty patients of the 15,245 participants in the VALUE trial had DM at baseline and 1,298 of the initially nondiabetic patients developed DM during the average 4.2-year follow-up. The presence of AF was determined by central analyzed electrocardiograms at baseline and changes were assessed yearly. Patients without AF at baseline and with any AF by later electrocardiograms were defined as patients with new-onset AF. Patients with new-onset and baseline DM were compared with patients without DM by a Cox regression model with adjustment for prespecified covariates. Five hundred fifty-one patients developed new-onset AF during the trial. Patients with new-onset DM had a significantly higher event rate of new-onset AF with a hazard ratio of 1.49 (1.14 to 1.94, p = 0.0031) compared with patients without DM, and there was a trend toward more AF in patients with DM at baseline. Patients with new-onset DM had also more persistent AF (hazard ratio 1.87, 1.28 to 2.74, p = 0.0014). Patients with new-onset DM and AF had a hazard ratio of 3.56 for heart failure (2.86 to 4.44, p <0.0001) compared with patients with new-onset DM without AF.

In conclusion, hypertensive patients who developed DM during the VALUE trial had more AF than did patients without DM, and this may explain some of their concomitant high risk of hospitalization for heart failure.

Predictors of mortality in patients with type 2 diabetes with or without diabetic nephropathy: a follow-up study.

J Hypertens. 2007 Dec;25(12):2479-85. Astrup AS, Nielsen FS, Rossing P, Ali S, Kastrup J, Smidt UM, Parving HH. Steno Diabetes Center, Gentofte, Denmark.

OBJECTIVE: To evaluate the prognostic significance of cardiovascular risk factors including 24-h ambulatory blood pressure level and rhythm for all-cause mortality in type 2 diabetic patients.

METHODS: In a prospective observational study, 104 patients with type 2 diabetes were followed: 51 patients with diabetic nephropathy and 53 patients with persistent normoalbuminuria. At baseline, 24-h ambulatory blood pressure, left ventricular hypertrophy, glomerular filtration rate and cardiac autonomic neuropathy were measured. Blood samples were taken and patients answered a World Health Organization questionnaire. Dipping was calculated as the average nocturnal reduction in systolic and diastolic blood pressure.

RESULTS: Mean follow-up was 9.2 years (range 0.5-12.9). During follow-up, 54 of 104 patients died. Sixteen patients (15%) had higher blood pressure at night than during the day (reversed pattern); 14 of these patients died (88%), compared to 40 of 88 patients (45%) with reduced dipping or normal dipping; log rank P = 0.001. In a Cox regression analysis, predictors of all-cause mortality were: age, male sex, presence of left ventricular hypertrophy, glycated haemoglobin A1c (HbA1c), daytime systolic blood pressure, cardiac autonomic neuropathy, glomerular filtration rate and dipping (1% increase; hazard ratio 0.97, 95% confidence interval 0.94-0.998, P = 0.033).

CONCLUSION: Type 2 diabetes patients with non-dipping of night blood pressure were at higher risk of death as compared to dippers, independent of known cardiovascular risk factors. Since non-dipping has a high prevalence in patients with diabetic nephropathy, 24-h ambulatory blood pressure should be used to assess a full risk profile and blood pressure-lowering therapy in these patients

Joint effects of history of hypertension at baseline and type 2 diabetes at baseline and during follow-up on the risk of coronary heart disease.

Eur Heart J. 2007 Nov 2
Hu G, Jousilahti P, Tuomilehto J.
Department of Health Promotion and Chronic Diseases Prevention, National Public Health Institute, Helsinki, Finland.

Aims
To evaluate the joint associations of history of hypertension at baseline and type 2 diabetes at baseline and during follow-up on the incidence of coronary heart disease (CHD) and CHD mortality.

Methods and results
Study cohorts included 49 775 Finnish subjects aged 25-74 without history of CHD and stroke. The multivariable-adjusted hazard ratios (HRs) of CHD incidence were 1.25, 1.69, 1.25, 1.83, 1.85, 2.39, 2.15, and 3.31 (P-value for trend <0.001), respectively, among men with hypertension I (blood pressure 140-159/90-94 mmHg or using antihypertensive drugs at baseline but blood pressure <160/95 mmHg) only, with hypertension II (blood pressure >/=160/95 mmHg) only, with incident diabetes during follow-up only, with both hypertension I and incident diabetes, with both hypertension II and incident diabetes, with history of diabetes at baseline only, with both hypertension I and history of diabetes, and with both hypertension II and history of diabetes compared with men without either of these diseases. The corresponding HRs of CHD incidence among women were 1.52, 2.37, 2.45, 3.78, 4.56, 5.63, 6.10, and 7.41 (P-value for trend <0.001), respectively. The impact on CHD mortality associated with the different strata of hypertension and diabetes was almost the same or a little stronger compared with that on the CHD incidence.

Conclusion
Hypertension and type 2 diabetes increase the CHD risk independently, and their combination increases the risk dramatically, particularly in women.

End-digit preference and the quality of blood pressure monitoring in diabetic adults.

Diabetes Care. 2007 Aug;30(8):1959-63
Kim ES, Samuels TA, Yeh HC, Abuid M, Marinopoulos SS, McCauley JM, Brancati FL.
Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.

OBJECTIVE: Although tight blood pressure (BP) control is proven to reduce diabetes-related cardiovascular risk, it has been difficult to achieve in practice, perhaps in part because of low-quality monitoring data. We hypothesized that low-quality BP data, reflected in end-digit preference (EDP), remains common in primary care of diabetic adults.

RESEARCH DESIGN AND METHODS: Data were abstracted from the charts of 404 adults with type 2 diabetes seen at 16 academically affiliated clinics from 1999 to 2001. End-digits of systolic and diastolic BPs taken with nonautomated sphygmomanometers were extracted, and prevalence of EDP for zero was calculated. Associations between EDP and selected patient characteristics were determined using multiple logistic regressions.

RESULTS: EDP was highly prevalent in the BP measurements taken by nonphysicians (4,333 BPs; 50% of systolic, 50% of diastolic readings ended in zero; P < 0.001) and physicians (1,347 BPs; 69% of systolic, 64% of diastolic readings ended in zero; P < 0.001). In multivariate analysis, nonphysicians showed greater EDP for systolic BP in older patients (odds ratio [OR] 1.07 per 5 years) and women (OR 1.36 vs. men) and for diastolic BP in African-Americans (OR 1.25 vs. whites; all P < 0.05); physicians showed greater EDP for diastolic BP in less obese patients (OR 0.97 per 5 kg/m2 increment in BMI; P = 0.02).

CONCLUSIONS: Low-quality BP measurement is common in primary care of diabetic adults. Procedural and technological improvements to BP measurement deserve attention as part of an overall strategy to tighten BP control and reduce cardiovascular risk.

Effects of Aerobic Training, Resistance Training, or Both on Glycemic Control in Type 2 Diabetes

A Randomized Trial

Ann Intern Med 18 September 2007, 147:357-369.
Ronald J. Sigal, MD, MPH; Glen P. Kenny, PhD; Normand G. Boulé, PhD; George A. Wells, PhD; Denis Prud'homme, MD, MSc; Michelle Fortier, PhD; Robert D. Reid, PhD, MBA; Heather Tulloch, MSc; Douglas Coyle, PhD; Penny Phillips, MA; Alison Jennings, MA; and James Jaffey, MSc

Background: Previous trials have evaluated the effects of aerobic training alone and of resistance training alone on glycemic control in type 2 diabetes, as assessed by hemoglobin A1c values. However, none could assess incremental effects of combined aerobic and resistance training compared with either type of exercise alone.

Objective: To determine the effects of aerobic training alone, resistance training alone, and combined exercise training on hemoglobin A1c values in patients with type 2 diabetes.

Design: Randomized, controlled trial.

Setting: 8 community-based facilities.

Patients: 251 adults age 39 to 70 years with type 2 diabetes. A negative result on a stress test or clearance by a cardiologist, and adherence to exercise during a 4-week run-in period, were required before randomization.

Interventions: Aerobic training, resistance training, or both types of exercise (combined exercise training). A sedentary control group was included. Exercise training was performed 3 times weekly for 22 weeks (weeks 5 to 26 of the study).

Measurements: The primary outcome was the change in hemoglobin A1c value at 6 months. Secondary outcomes were changes in body composition, plasma lipid values, and blood pressure.

Results: The absolute change in the hemoglobin A1c value in the combined exercise training group compared with the control group was –0.51 percentage point (95% CI, –0.87 to –0.14) in the aerobic training group and –0.38 percentage point (CI, –0.72 to –0.22) in the resistance training group. Combined exercise training resulted in an additional change in the hemoglobin A1c value of –0.46 percentage point (CI, –0.83 to –0.09) compared with aerobic training alone and –0.59 percentage point (CI, –0.95 to –0.23) compared with resistance training alone. Changes in blood pressure and lipid values did not statistically significantly differ among groups. Adverse events were more common in the exercise groups.

Limitations: The generalizability of the results to patients who are less adherent to exercise programs is uncertain. The participants were not blinded, and the total duration of exercise was greater in the combined exercise training group than in the aerobic and resistance training groups.

Conclusion: Either aerobic or resistance training alone improves glycemic control in type 2 diabetes, but the improvements are greatest with combined aerobic and resistance training.

Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community.

Circulation. 2007 Jul 31;116(5):480-8
Dhingra R, Sullivan L, Jacques PF, Wang TJ, Fox CS, Meigs JB, D'Agostino RB, Gaziano JM, Vasan RS.
Framingham Heart Study, 73 Mount Wayte Ave, Suite 2, Framingham, MA 01702-5803, USA.

BACKGROUND: Consumption of soft drinks has been linked to obesity in children and adolescents, but it is unclear whether it increases metabolic risk in middle-aged individuals.

METHODS AND RESULTS: We related the incidence of metabolic syndrome and its components to soft drink consumption in participants in the Framingham Heart Study (6039 person-observations, 3470 in women; mean age 52.9 years) who were free of baseline metabolic syndrome. Metabolic syndrome was defined as the presence of > or = 3 of the following: waist circumference > or = 35 inches (women) or > or = 40 inches (men); fasting blood glucose > or = 100 mg/dL; serum triglycerides > or = 150 mg/dL; blood pressure > or = 135/85 mm Hg; and high-density lipoprotein cholesterol < 40 mg/dL (men) or < 50 mg/dL (women). Multivariable models included adjustments for age, sex, physical activity, smoking, dietary intake of saturated fat, trans fat, fiber, magnesium, total calories, and glycemic index. Cross-sectionally, individuals consuming > or = 1 soft drink per day had a higher prevalence of metabolic syndrome (odds ratio [OR], 1.48; 95% CI, 1.30 to 1.69) than those consuming < 1 drink per day. On follow-up (mean of 4 years), new-onset metabolic syndrome developed in 765 (18.7%) of 4095 participants consuming < 1 drink per day and in 474 (22.6%) of 2059 persons consuming > or = 1 soft drink per day. Consumption of > or = 1 soft drink per day was associated with increased odds of developing metabolic syndrome (OR, 1.44; 95% CI, 1.20 to 1.74), obesity (OR, 1.31; 95% CI, 1.02 to 1.68), increased waist circumference (OR, 1.30; 95% CI, 1.09 to 1.56), impaired fasting glucose (OR, 1.25; 95% CI, 1.05 to 1.48), higher blood pressure (OR, 1.18; 95% CI, 0.96 to 1.44), hypertriglyceridemia (OR, 1.25; 95% CI, 1.04 to 1.51), and low high-density lipoprotein cholesterol (OR, 1.32; 95% CI 1.06 to 1.64).

CONCLUSIONS: In middle-aged adults, soft drink consumption is associated with a higher prevalence and incidence of multiple metabolic risk factors.

Microvascular function: a potential link between salt sensitivity, insulin resistance and hypertension.

J Hypertens. 2007 Sep;25(9):1887-1893.
de Jongh RT, Serné EH, Ijzerman RG, Stehouwer CD.
aDepartment of Internal Medicine and Institute for Cardiovascular Research – Vrije Universiteit, VU University Medical Center, Amsterdam bDepartment of Internal Medicine and Cardiovascular Research Institute, Maastricht University Hospital, Maastricht, The Netherlands.

OBJECTIVE: Generalized microvascular dysfunction may contribute to the development of salt sensitivity, insulin resistance and hypertension, and may thus link these cardiovascular risk factors. To test this hypothesis, we examined skin microvascular function, salt sensitivity, insulin sensitivity and blood pressure in 27 normotensive and 26 hypertensive individuals.

METHODS: Capillary density was examined by videomicroscopy during venous congestion and postocclusive reactive hyperaemia. Endothelium-(in)dependent vasodilation was assessed by iontophoresis of acetylcholine and sodium nitroprusside and by laser Doppler flowmetry. Salt sensitivity was determined as the difference in mean arterial pressure (MAP) between a 1-week high-salt diet ( approximately 235 mmol NaCl/day) versus low-salt diet ( approximately 55 mmol NaCl/day). Insulin sensitivity was measured with the hyperinsulinaemic, euglycaemic clamp, and blood pressure was assessed by 24-h ambulatory blood pressure monitoring.

RESULTS: Salt sensitivity of blood pressure was inversely associated with postocclusive capillary recruitment and endothelium-dependent vasodilation (r = -0.67, P < 0.001 and r = -0.60, P < 0.01, respectively), but not with capillary density during venous congestion or endothelium-independent vasodilation. Salt sensitivity was negatively associated with insulin sensitivity (r = -0.55, P < 0.001) and positively with MAP (r = 0.58, P < 0.001). Multiple regression analyses suggested that associations between salt sensitivity and both insulin sensitivity and MAP were dependent on microvascular function.

CONCLUSION: Our results suggest a close inverse association between skin microvascular function and salt sensitivity and a role for generalized microvascular defects as a link between salt sensitivity, insulin resistance and hypertension.

Hypertension, hypercholesterolemia, diabetes, and risk of Parkinson disease.

Neurology. 2007 Aug 29
Simon KC, Chen H, Schwarzschild M, Ascherio A.
From the Departments of Epidemiology (K.C.S., A.A.) and Nutrition (A.A.), Harvard School of Public Health, Boston, MA; Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC (H.C.); Department of Neurology, Massachusetts General Hospital, Boston, MA (M.S.); and Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (A.A.).

ABSTRACT OBJECTIVE: To determine whether history of hypertension, hypercholesterolemia, or diabetes is associated with risk of Parkinson disease (PD).

METHODS: Prospective study among participants in two large cohorts: the Nurses' Health Study (121,046 women) and the Health Professionals Follow-up Study (50,833 men). Mean duration of follow-up was 22.9 years in women, aged 30 to 55 years at baseline, and 12.6 years in men, aged 40 to 75 years at baseline. Relative risks (RRs) of PD were estimated from a Cox proportional hazards model adjusting for potential confounders.

RESULTS: We identified a total of 530 incident cases of PD during the follow-up. Risk of PD was not associated with self-reported history of hypertension (RR = 0.96, 95% CI = 0.80 to 1.15), high cholesterol (RR = 0.98, 95% CI = 0.82 to 1.19), or diabetes (RR = 1.04, 95% CI = 0.74 to 1.46), after adjusting for age and smoking in pack-years. Risk of PD decreased modestly with increasing levels of self-reported total cholesterol (RR for a 50-mg/dL increase in total cholesterol = 0.86, 95% CI = 0.78 to 0.95, p for trend = 0.02), but use of cholesterol-lowering drugs was not associated with PD risk (RR comparing users with nonusers = 0.85, 95% CI = 0.59 to 1.23). Among individuals with PD, systolic blood pressure was similar to noncases up to the time of diagnosis but declined afterward.

CONCLUSIONS: Results of this large prospective study suggest that Parkinson disease risk is not significantly related to history of hypertension, hypercholesterolemia, or diabetes but may modestly decline with increasing blood cholesterol levels.

Short-Term Risk for Stroke Is Doubled in Persons With Newly Treated Type 2 Diabetes Compared With Persons Without Diabetes

A Population-Based Cohort Study

Stroke. 2007;38:1739-1743. June 2007
Thomas Jeerakathil, MD, MSc; Jeffrey A. Johnson, PhD; Scot H. Simpson, PharmD, MSc Sumit R. Majumdar, MD, MPH
From the Division of Neurology (T.J.); the Department of Medicine, Faculty of Medicine and Dentistry (T.J., S.R.M., J.A.J.); the School of Public Health (J.A.J., S.R.M.), and the Faculty of Pharmacy and Pharmaceutical Services (S.H.S.), University of Alberta, and the Institute of Health Economics (J.A.J., S.R.M., S.H.S.), Edmonton, Canada.

Background and Purpose— Cardiovascular risk factors are suboptimally treated in diabetes, possibly because of the impression that there is a long delay between diagnosis and the development of macrovascular complications such as stroke. We determined the incidence of stroke in people newly treated for type 2 diabetes.

Methods— We conducted an inception cohort study with the use of linked administrative databases from Saskatchewan Health. Subjects entered the type 2 diabetes cohort on receipt of their first prescription for an oral antidiabetic drug. We defined incident stroke as any hospital admission with International Classification of Diseases, Ninth Revision, codes 430 to 438 inclusive. Age-standardized incidence rates were compared between the diabetes cohort and the general population.

Results— There were 12 272 subjects in the diabetes cohort, the mean±SD age was 64±13.6 years, and 55% were male. During a mean 5-year follow-up, 9.1% of the diabetes cohort had a stroke. The age-standardized incidence rate for stroke was 642 per 100 000 person-years in subjects with diabetes, compared with 313 per 100 000 person-years in the general population (rate ratio=2.1, 95% CI=1.8 to 2.3). The relative short-term risk for stroke in the diabetes cohort compared with the general population ranged from 1.8 (95%=CI 1.6 to 1.9) in persons >75 years to 5.6 (95% CI=2.5 to 9.3) in the 30- to 44-year category.

Conclusions— The risk of stroke is high within 5 years of treatment for type 2 diabetes and more than double the rate for the general population. This further supports the need for aggressive early cardiovascular risk factor management in type 2 diabetes.

Diabetes in treated hypertension is common and carries a high cardiovascular risk: results from a 28-year follow-up.

J Hypertens. 2007 Jun;25(6):1311-1317.
Almgren T, Wilhelmsen L, Samuelsson O, Himmelmann A, Rosengren A, Andersson OK.
aDepartments of Internal Medicine bNephrology cClinical Pharmacology, Sahlgrenska University Hospital, Goteborg dDepartment of Medicine, Sahlgrenska University Hospital, Ostra, Goteborg eSection of Preventive Cardiology, the Cardiovascular Unit, Goteborg University, Goteborg, Sweden.

OBJECTIVE: The objective of this study was to analyse predictive factors for development of type 2 diabetes during life-long therapy for hypertension and the alleged additional cardiovascular risk this constitutes.

METHODS: The study group (n = 754) comprised the hypertensive subgroup of a randomized population sample of 7500 men, aged 47-54 years, screened for cardiovascular risk factors and followed for 25-28 years. The patients were treated with thiazide diuretics and beta-adrenergic blocking drugs with the addition of hydralazin during the first decade. Calcium antagonists were substituted for hydralazin and, if needed, angiotensin-converting enzyme inhibitors were added when these drugs became available.

RESULTS: A total of 148 (20.4%) treated hypertensive patients developed diabetes during 25 years, and in multivariate Cox regression analysis body mass index, serum triglycerides and treatment with beta-blockers were positively related with this complication. New-onset diabetes implied a significantly increased risk for stroke [hazard ratio (HR): 1.67; 95% confidence interval (95% CI): 1.1-2.6; P < 0.05], myocardial infarction (OR: 1.66; 95% CI: 1.1-2.5; P < 0.05) and mortality (OR: 1.42; 95% CI: 1.1-1.9; P < 0.05). The greatest risk for stroke was new-onset diabetes, followed by smoking (OR: 1.46; 95% CI: 1-2.2; P = 0.07) and the greatest risk for myocardial infarction was new-onset diabetes, followed by smoking (HR: 1.64; 95% CI: 1.1-2.4; P < 0.01). The greatest risk for mortality was smoking (HR: 1.73; 95% CI: 1.3-2.2; P < 0.005). Achieved systolic and diastolic blood pressure were not predictive of cardiovascular complications or death. The mean observation time from onset of diabetes mellitus to a first stroke was 9.1 years and to a first myocardial infarction 9.3 years.

CONCLUSION: Diabetes in treated hypertensive patients is alarmingly common and carries a high risk for cardiovascular complications and mortality.

Television viewing is associated with prevalence of metabolic syndrome in Hispanic elders.

Diabetes Care. 2007 Mar;30(3):694-700.
Gao X, Nelson ME, Tucker KL.
Jean Mayer USDA HNRCA at Tufts University, 711 Washington St., Boston, MA 02111-1524, USA.

OBJECTIVE: We examined associations between television viewing and prevalence of the metabolic syndrome among a representative sample of Caribbean-origin Hispanic elders living in Massachusetts.

RESEARCH DESIGN AND METHODS: We conducted a cross-sectional analysis of 350 Puerto Rican and 105 Dominican elders (> or = 60 years). Information on television viewing hours was collected by a questionnaire. The metabolic syndrome was defined by using the definition from the National Cholesterol Education Program.

RESULTS: Prevalences for the metabolic syndrome were 50.1 and 56.9% among Puerto Ricans and Dominicans, respectively. Of the subjects, 82.6% had high blood pressure and 61.4% had high fasting glucose. Prevalence of the syndrome was significantly associated with television viewing. Each additional hour of television viewing was associated with a 19% greater likelihood of having the metabolic syndrome (odds ratio [OR] 1.19, 95% CI 1.1-1.3, P for trend 0.002), after adjusting for age, sex, ethnicity, BMI, education, alcohol use, smoking, household arrangement, physical activity, intake of energy and fat, and activities-of-daily-living score. We did not observe significant interactions of television viewing with sex, smoking status, alcohol use, or BMI (P for interaction > 0.15 for all) in relation to presence of the metabolic syndrome.

CONCLUSIONS: A high prevalence of the metabolic syndrome in a representative sample of Caribbean-origin Hispanic elders was associated with prolonged television viewing, independent of physical activity and energy intake. Longitudinal studies are needed to clarify the causality of this relationship.

Blood pressure, antihypertensive treatment and factors associated with good blood pressure control in hypertensive diabetics: the Tarmidas study.

J Hum Hypertens. 2007 Apr 26;
de Pablos-Velasco P, Gonzalez-Albarran O, Estopinan V, Khanbhai A.
Department of Endocrinology, Hospital General de Gran Canaria Doctor Negrin, Las Palmas de Gran Canaria, Spain.

Numerous population studies confirm the high prevalence of hypertension in type II diabetic (DM2) subjects and that intensive antihypertensive treatment is more beneficial to diabetic than to nondiabetic hypertensive subjects, yet not many of these are specific to Spain.

To assess the degree of blood pressure (BP) control and the effects of antihypertensive drugs in the medical management of hypertension in diabetic patients in specialist care centres throughout Spain, we studied the socio-demographic, clinical and relevant laboratory parameters of 796 hypertensive patients with DM2 (mean age 66.09 (95% confidence interval (CI): 64.08-68.10).

The percentage of diabetic patients responding positively to BP control measures was lower when compared to the nondiabetic population in both Spain and Europe. The degree of control was poorer for systolic than for diastolic BP, yet 40.6% of the patients were only on monotherapy. The fact that antihypertensive treatment was modified in only 40% of the poorly controlled patients was also highly significant and could be attributed to a nonstringent use of clinical guidelines. Among the other differences between well-controlled and poorly controlled patients, we found that well-controlled patients presented with lower levels of cholesterol and triglycerides, a lower prevalence of excess weight/obesity, and a greater prevalence of cardiovascular and/or cerebrovascular disease despite having a greater percentage of patients on antiplatelet therapy.

Better application of therapeutic guidelines and the prevention and treatment of compounding factors could improve the response rate to BP control measures in poorly controlled patients.

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