RESUMO
AIMS: To examine whether the development of obesity with age was different for individuals with and without a spouse with diabetes. METHODS: We analysed data from the English Longitudinal Study of Ageing [n= 7123, median (interquartile range) age 59 (53-67) years, 51% men], which included four clinical examination waves between 1998 and 2012. The main exposure was having a spouse with diabetes. Outcomes of interest were BMI and waist circumference. We fitted quadratic age-related trajectories using mixed-effect models stratified by sex and adjusted for education, smoking and the corresponding interaction terms between age and spousal diabetes status. RESULTS: The baseline spousal diabetes prevalence was 4.4%. Men with a wife with diabetes experienced a steeper increase in BMI (1.6 kg/m2 ) between ages 50 to 65 years than men with a wife without diabetes (0.9 kg/m2 ). Women with a husband with diabetes had a similarly shaped BMI trajectory to women with a husband without diabetes, but their average BMI levels were higher between ages 55 and 65 years. Waist circumference trajectories showed a similar shape by spousal diabetes status for men and women, although individuals with a spouse with diabetes had higher waist circumference values throughout follow-up. CONCLUSIONS: We found a positive association between spousal diabetes status and obesity development, which differed by sex among middle-aged individuals. Evidence from couple-based interventions is needed to test whether the latter could improve the current individual-focused public health strategies for obesity prevention.
Assuntos
Envelhecimento , Diabetes Mellitus Tipo 2/epidemiologia , Promoção da Saúde , Obesidade/epidemiologia , Cônjuges/estatística & dados numéricos , Idoso , Estudos Transversais , Diabetes Mellitus Tipo 2/etiologia , Diabetes Mellitus Tipo 2/fisiopatologia , Inglaterra/epidemiologia , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Obesidade/fisiopatologia , Prevalência , Fatores de Risco , Circunferência da CinturaRESUMO
BACKGROUND: It is unclear whether cardiovascular risk factor modification influences the development of renal disease in people with type 2 diabetes identified through screening. We determined predictors of albuminuria 5 years after a diagnosis of screen-detected diabetes within the ADDITION-Europe study, a pragmatic cardiovascular outcome trial of multifactorial cardiovascular risk management. METHODS: In 1826 participants with newly diagnosed, screen-detected diabetes without albuminuria, we explored associations between risk of new albuminuria (≥2.5 mg mmol-1 for males and ≥3.5 mg mmol-1 for females) and (1) baseline cardio-metabolic risk factors and (2) changes from baseline to 1 year in systolic blood pressure (ΔSBP) and glycated haemoglobin (ΔHbA1c ) using logistic regression. RESULTS: Albuminuria developed in 268 (15%) participants; baseline body mass index and active smoking were independently associated with new onset albuminuria in 5 years after detection of diabetes. In a model adjusted for age, gender, baseline HbA1c and blood pressure, a 1% decrease in HbA1c and 5-mm Hg decrease in SBP during the first year were independently associated with lower risks of albuminuria (odds ratio), 95% confidence interval: 0.76, 0.62 to 0.91 and 0.94, 0.88 to 1.01, respectively. Further adjustment did not materially change these estimates. There was no interaction between ΔSBP and ΔHbA1c in relation to albuminuria risk, suggesting likely additive effects on renal microvascular disease. CONCLUSIONS: Baseline measurements and changes in HbA1c and SBP a year after diagnosis of diabetes through screening independently associate with new onset albuminuria 4 years later. Established multifactorial treatment for diabetes applies to cases identified through screening.
Assuntos
Albuminúria/epidemiologia , Doenças Cardiovasculares/etiologia , Diabetes Mellitus Tipo 2/fisiopatologia , Nefropatias Diabéticas/epidemiologia , Idoso , Albuminúria/fisiopatologia , Pressão Sanguínea/fisiologia , Diabetes Mellitus Tipo 2/complicações , Nefropatias Diabéticas/fisiopatologia , Feminino , Hemoglobinas Glicadas/análise , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
AIM: To assess the prospective association between objectively measured physical activity and kidney function over 4 years in people with Type 2 diabetes. METHODS: Individuals (120 women and 206 men) participating in the ADDITION-Plus trial underwent assessment of sedentary time (SED-time), time spent in moderate-to-vigorous-intensity physical activity (MVPA) and total physical activity energy expenditure (PAEE) using a combined heart rate and movement sensor, and kidney function [estimated glomerular filtration rate (eGFR), serum creatinine and urine albumin-to-creatinine ratio (ACR)] at baseline and after 4 years of follow-up. Multivariate regression was used to quantify the association between change in SED-time, MVPA and PAEE and kidney measures at four-year follow-up, adjusting for change in current smoking status, waist circumference, HbA1c , systolic blood pressure, triglycerides and medication usage. RESULTS: Over 4 years, there was a decline in eGFR values from 87.3 to 81.7 ml/min/1.73m(2) (P < 0.001); the prevalence of reduced eGFR (eGFR < 60 ml/min/1.73m(2) ) increased from 6.1 to 13.2% (P < 0.001). There were small increases in serum creatinine (median: 81-84 µmol/l, P < 0.001) and urine ACR (median: 0.9-1.0 mg/mmol, P = 0.005). Increases in SED-time were associated with increases in serum creatinine after adjustment for MVPA and cardiovascular risk factors (ß = 0.013, 95% CI: 0.001, 0.03). Conversely, increases in PAEE were associated with reductions in serum creatinine (ß = -0.001, 95% CI: -0.003, -0.0001). CONCLUSION: Reducing time spent sedentary and increasing overall physical activity may offer intervention opportunities to improve kidney function among individuals with diabetes. (Trial Registry no. ISRCTN 99175498).
Assuntos
Diabetes Mellitus Tipo 2/metabolismo , Metabolismo Energético , Exercício Físico , Taxa de Filtração Glomerular , Insuficiência Renal Crônica/metabolismo , Comportamento Sedentário , Adulto , Idoso , Albuminúria/urina , Estudos de Coortes , Creatinina/sangue , Creatinina/urina , Diabetes Mellitus Tipo 2/tratamento farmacológico , Progressão da Doença , Feminino , Seguimentos , Humanos , Hipoglicemiantes/uso terapêutico , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Prospectivos , Fatores de TempoRESUMO
OBJECTIVE: The objective of this study is to examine the independent associations of time spent in moderate-to-vigorous physical activity (MVPA) and sedentary (SED-time), with total and abdominal body fat (BF), and the bidirectionality of these associations in adults at high risk of type 2 diabetes. DESIGN AND SUBJECTS: We measured MVPA (min per day) and SED-time (h per day) by accelerometry, and indices of total (body weight, fat mass (FM), BF% and FM index) and abdominal BF (waist circumference (WC)) using standard procedures in 231 adults (41.3 ± 6.4 years) with parental history of type 2 diabetes (ProActive UK) at baseline, 1-year and 7-year follow-up. Mixed effects models were used to quantify the independent associations (expressed as standardised ß-coefficients (95% confidence interval (CI))) of MVPA and SED-time with fat indices, using data from all three time points. All models were adjusted for age, sex, intervention arm, monitor wear time, follow-up time, smoking status, socioeconomic status and MVPA/SED-time. RESULTS: MVPA was inversely and independently associated with all indices of total BF (for example, 1 s.d. higher MVPA was associated with a reduction in FM, ß = -0.09 (95% CI: -0.14, -0.04) s.d.) and abdominal BF (for example, WC: ß = -0.07 (-0.12, -0.02)). Similarly, higher fat indices were independently associated with a reduction in MVPA (for example, WC: ß = -0.25 (-0.36, -0.15); FM: ß = -0.27 (-0.36, -0.18)). SED-time was positively and independently associated with most fat indices (for example, WC: ß = 0.03 (-0.04, 0.09); FM: ß = 0.10 (0.03, 0.17)). Higher values of all fat indices independently predicted longer SED-time (for example, WC: ß = 0.10 (0.02, 0.18), FM: ß = 0.15 (0.07, 0.22)). CONCLUSIONS: The associations of MVPA and SED-time with total and abdominal BF are bidirectional and independent among individuals at high risk for type 2 diabetes. The association between BF and MVPA is stronger than the reciprocal association, highlighting the importance of considering BF as a determinant of decreasing activity and a potential consequence. Promoting more MVPA and less SED-time may reduce total and abdominal BF.
Assuntos
Doenças Cardiovasculares/prevenção & controle , Diabetes Mellitus Tipo 2/prevenção & controle , Exercício Físico , Obesidade/prevenção & controle , Comportamento Sedentário , Aumento de Peso , Acelerometria , Adiposidade , Adulto , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/metabolismo , Estudos de Coortes , Diabetes Mellitus Tipo 2/etiologia , Diabetes Mellitus Tipo 2/metabolismo , Medicina Baseada em Evidências , Feminino , Seguimentos , Conhecimentos, Atitudes e Prática em Saúde , Promoção da Saúde , Humanos , Masculino , Obesidade/complicações , Obesidade/metabolismo , Fatores de Risco , Fatores de Tempo , Circunferência da CinturaRESUMO
BACKGROUND: Interventions that improve HbA1c levels do not necessarily improve health-related quality of life (QoL). This issue may be particularly relevant in asymptomatic diabetes patients detected earlier in the course of the disease. METHODS: HbA1c , diabetes-specific QoL (ADDQoL) and health status were measured in 510 screen-detected diabetes patients from the ADDITION-Cambridge trial at 1 and 5 years post diagnosis. Multivariable logistic/linear regression was used to quantify the longitudinal association between change in HbA1c from 1 to 5 years and ADDQoL and health status at 5 years, adjusting for age, sex, education and trial group; alcohol consumption, smoking, physical activity, plasma vitamin C, HbA1c , ADDQoL or health status at 1 year, and glucose-lowering medication at 5 years. RESULTS: From 1 to 5 years, median HbA1c interquartile range increased from 6.3% (5.9-6.8) to 6.8% (6.4-7.4); the median ADDQoL score and mean health status physical health summary score decreased from -0.4 (-1 to -0.08) to -0.5 (-1.08 to -0.09) (suggesting an adverse impact of diabetes on QoL) and by -0.79 (8.94) points, respectively. Increases in HbA1c were independently associated with reporting a negative impact of diabetes on QoL (OR = 1.38, 95% CI: 1.03 to 1.85) but not with the health status summary scores. CONCLUSIONS: Increases in HbA1c from 1 to 5 years post-diagnosis were independently associated with increased odds of reporting a negative impact of diabetes on QoL. While our results suggest that efforts to reduce HbA1c do not adversely affect health-related QoL, large numbers of participants still report a negative impact of diabetes on their QoL 5 years post-diagnosis.
Assuntos
Glicemia/metabolismo , Diabetes Mellitus Tipo 2/sangue , Nível de Saúde , Qualidade de Vida , Adulto , Idoso , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Perfil de Impacto da DoençaRESUMO
AIMS: To examine the short- and long-term cost-effectiveness of intensive multifactorial treatment compared with routine care among people with screen-detected Type 2 diabetes. METHODS: Cost-utility analysis in ADDITION-UK, a cluster-randomized controlled trial of early intensive treatment in people with screen-detected diabetes in 69 UK general practices. Unit treatment costs and utility decrement data were taken from published literature. Accumulated costs and quality-adjusted life years (QALYs) were calculated using ADDITION-UK data from 1 to 5 years (short-term analysis, n = 1024); trial data were extrapolated to 30 years using the UKPDS outcomes model (version 1.3) (long-term analysis; n = 999). All costs were transformed to the UK 2009/10 price level. RESULTS: Adjusted incremental costs to the NHS were £285, £935, £1190 and £1745 over a 1-, 5-, 10- and 30-year time horizon, respectively (discounted at 3.5%). Adjusted incremental QALYs were 0.0000, - 0.0040, 0.0140 and 0.0465 over the same time horizons. Point estimate incremental cost-effectiveness ratios (ICERs) suggested that the intervention was not cost-effective although the ratio improved over time: the ICER over 10 years was £82,250, falling to £37,500 over 30 years. The ICER fell below £30 000 only when the intervention cost was below £631 per patient: we estimated the cost at £981. CONCLUSION: Given conventional thresholds of cost-effectiveness, the intensive treatment delivered in ADDITION was not cost-effective compared with routine care for individuals with screen-detected diabetes in the UK. The intervention may be cost-effective if it can be delivered at reduced cost.
Assuntos
Complicações do Diabetes/prevenção & controle , Diabetes Mellitus Tipo 2/economia , Diabetes Mellitus Tipo 2/terapia , Assistência Centrada no Paciente , Idoso , Análise por Conglomerados , Estudos de Coortes , Terapia Combinada/economia , Análise Custo-Benefício , Complicações do Diabetes/economia , Complicações do Diabetes/epidemiologia , Complicações do Diabetes/terapia , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/diagnóstico , Feminino , Custos de Cuidados de Saúde , Humanos , Incidência , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Educação de Pacientes como Assunto/economia , Assistência Centrada no Paciente/economia , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Risco , Fatores de Tempo , Reino Unido/epidemiologiaRESUMO
OBJECTIVE: To examine the association between meeting behavioural goals and diabetes incidence over 10 years in a large, representative Swedish population. METHODS: Population-based prospective cohort study of 32,120 individuals aged 35 to 55 years participating in a health promotion intervention in Västerbotten County, Sweden (1990 to 2013). Participants underwent an oral glucose tolerance test, clinical measures, and completed diet and activity questionnaires. Poisson regression quantified the association between achieving six behavioural goals at baseline - body mass index (BMI) <25 kg/m(2), moderate physical activity, non-smoker, fat intake <30% of energy, fibre intake ≥15 g/4184 kJ and alcohol intake ≤20 g/day - and diabetes incidence over 10 years. RESULTS: Median interquartile range (IQR) follow-up time was 9.9 (0.3) years; 2211 individuals (7%) developed diabetes. Only 4.4% of participants met all 6 goals (n=1245) and compared to these individuals, participants meeting 0/1 goals had a 3.74 times higher diabetes incidence (95% confidence interval (CI)=2.50 to 5.59), adjusting for sex, age, calendar period, education, family history of diabetes, history of myocardial infarction and long-term illness. If everyone achieved at least four behavioural goals, 14.1% (95% CI: 11.7 to 16.5%) of incident diabetes cases might be avoided. CONCLUSION: Interventions promoting the achievement of behavioural goals in the general population could significantly reduce diabetes incidence.
Assuntos
Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/prevenção & controle , Comportamentos Relacionados com a Saúde , Adulto , Índice de Massa Corporal , Estudos de Coortes , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Atividade Motora , Análise de Regressão , Fatores de Risco , Fumar/epidemiologia , Inquéritos e Questionários , Suécia/epidemiologiaRESUMO
OBJECTIVES: To describe perceptions of chronic care among diabetes patients 6 years after diagnosis by screening and to examine the impact of intensive treatment on patients' perceptions of chronic care. METHODS: The ADDITION-Denmark (2001-2006) trial compared the effects of intensive multifactorial therapy (IT) with routine care (RC) among individuals with screen-detected diabetes. Perceptions of chronic care were assessed using the Patient Assessment of Chronic Illness Care (PACIC) measure after 6-year follow-up (n = 937). Analysis was by intention-to-treat, accounting for clustering by general practice. RESULTS: The mean (SD) summary PACIC score was 2.4 (0.79) in the RC and 2.4 (0.82) in the IT group. The highest mean (SD) PACIC subscale score was for Delivery System Design/Decision Support [RC: 3.2 (0.95), IT: 3.3 (0.91)] and the lowest was for Follow-up/Coordination [RC: 2.1 (0.84), IT: 2.1 (0.87)]. Perceptions of chronic care did not differ between trial groups. CONCLUSIONS: Compared to RC, an intensive multifactorial intervention was not associated with differences in perceptions of chronic care among patients with screen-detected diabetes after 6 years. Intensive treatment does not adversely affect perceptions of chronic care early in the course of the disease. However, there is potentially room for improvement in some aspects of chronic care.
Assuntos
Diabetes Mellitus Tipo 2/terapia , Satisfação do Paciente , Adulto , Idoso , Dinamarca , Diabetes Mellitus Tipo 2/psicologia , Dietoterapia/psicologia , Feminino , Humanos , Hipoglicemiantes/uso terapêutico , Estilo de Vida , Masculino , Pessoa de Meia-Idade , Fatores SocioeconômicosRESUMO
AIM: To assess whether a 12-week participant-driven health education programme offered to individuals with screening-detected hyperglycaemia in Danish primary care would lead to improvements in cardiovascular risk factors, health behaviour and patient-reported outcomes after 3 years. METHODS: We conducted a randomized controlled trial in 509 patients with screening-detected hyperglycaemia (impaired fasting glucose, impaired glucose tolerance or type 2 diabetes) from 33 general practices in Denmark. Individuals were pre-randomized to receive (i) routine care (n = 187), or (ii) an invitation to participate in the Ready to Act health education programme (n = 322). The programme was delivered over 12 weeks in primary care and focused on motivation, action experience, informed decision-making and social involvement to promote health behaviour change. The primary outcome was 10-year modelled cardiovascular risk. RESULTS: Of 322 individuals, 123 (38%) received the intervention and 436/509 individuals (86%) returned for follow-up assessment. There was no difference between the trial groups in modelled cardiovascular risk at 3 years (relative difference: 1.01; 95% CI: 0.84 to 1.23). Total cholesterol was lower (-0.24mmol/l, 95% CI: -0.45 to -0.03, P = 0.027), and patient activation was higher in the intervention than in the control group (5.3, 95% CI: 0.97 to 9.7). No other between-group differences were observed for any cardiovascular risk factor, health behaviour or patient-reported outcome variables. Subgroup analyses suggested that the intervention was more beneficial in those with impaired fasting glucose/impaired glucose tolerance than in those with type 2 diabetes. CONCLUSION: For patients with screening-detected hyperglycaemia, a participant-driven health education programme was not associated with improvements in most clinical, behavioural and patient-reported outcomes after 3 years of follow-up.
Assuntos
Doenças Cardiovasculares/prevenção & controle , Diabetes Mellitus Tipo 2/terapia , Intolerância à Glucose/terapia , Educação de Pacientes como Assunto , Medicina de Precisão , Estado Pré-Diabético/terapia , Atenção Primária à Saúde , Adulto , Idoso , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/etiologia , Terapia Combinada , Dinamarca/epidemiologia , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/diagnóstico , Angiopatias Diabéticas/complicações , Angiopatias Diabéticas/prevenção & controle , Cardiomiopatias Diabéticas/complicações , Cardiomiopatias Diabéticas/prevenção & controle , Feminino , Seguimentos , Intolerância à Glucose/sangue , Intolerância à Glucose/diagnóstico , Intolerância à Glucose/fisiopatologia , Comportamentos Relacionados com a Saúde , Humanos , Hipercolesterolemia/complicações , Hipercolesterolemia/etiologia , Hipercolesterolemia/prevenção & controle , Estilo de Vida , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Estado Pré-Diabético/sangue , Estado Pré-Diabético/diagnóstico , Estado Pré-Diabético/fisiopatologia , Fatores de RiscoRESUMO
AIMS: To examine variation between general practices in the prescription of lipid-lowering treatment to people with screen-detected Type 2 diabetes, and associations with practice and participant characteristics and risk of cardiovascular events and all-cause mortality. METHODS: Observational cohort analysis of data from 1533 people with screen-detected Type 2 diabetes aged 40-69 years from the ADDITION-Denmark study. One hundred and seventy-four general practices were cluster randomized to receive: (1) routine diabetes care according to national guidelines (623 individuals), or (2) intensive multifactorial target-driven management (910 individuals). Multivariable logistic regression was used to quantify the association between the proportion of individuals in each practice who redeemed prescriptions for lipid-lowering medication in the two years following diabetes diagnosis and a composite cardiovascular disease (CVD) outcome, adjusting for age, sex, prevalent chronic disease, baseline CVD risk factors, smoking and lipid-lowering medication, and follow-up time. RESULTS: The proportion of individuals treated with lipid-lowering medication varied widely between practices (0-100%). There were 118 CVD events over 9431 person-years of follow-up. For the whole trial cohort, the risk of CVD was significantly higher in practices in the lowest compared with the highest quartile for prescribing lipid-lowering medication [adjusted odds ratio (OR) 3.4, 95% confidence interval (CI) 1.6-7.3]. Similar trends were found for all-cause mortality. CONCLUSIONS: More frequent prescription of lipid-lowering treatment was associated with a lower incidence of CVD and all-cause mortality. Improved understanding of factors underlying practice variation in prescribing may enable more frequent use of lipid-lowering treatment. The results highlight the benefits of intensive treatment of people with screen-detected diabetes (Clinical Trials Registry No; NCT 00237549).
Assuntos
Doenças Cardiovasculares/epidemiologia , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipolipemiantes/uso terapêutico , Padrões de Prática Médica/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Adulto , Idoso , Doenças Cardiovasculares/mortalidade , Estudos de Coortes , Dinamarca/epidemiologia , Diabetes Mellitus Tipo 2/diagnóstico , Gerenciamento Clínico , Feminino , Humanos , Incidência , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Mortalidade , Fatores de RiscoRESUMO
AIMS: To describe change in self-reported diet and plasma vitamin C, and to examine associations between change in diet and cardiovascular disease risk factors and modelled 10-year cardiovascular disease risk in the year following diagnosis of Type 2 diabetes. METHODS: Eight hundred and sixty-seven individuals with screen-detected diabetes underwent assessment of self-reported diet, plasma vitamin C, cardiovascular disease risk factors and modelled cardiovascular disease risk at baseline and 1 year (n = 736) in the ADDITION-Cambridge trial. Multivariable linear regression was used to quantify the association between change in diet and cardiovascular disease risk at 1 year, adjusting for change in physical activity and cardio-protective medication. RESULTS: Participants reported significant reductions in energy, fat and sodium intake, and increases in fruit, vegetable and fibre intake over 1 year. The reduction in energy was equivalent to an average-sized chocolate bar; the increase in fruit was equal to one plum per day. There was a small increase in plasma vitamin C levels. Increases in fruit intake and plasma vitamin C were associated with small reductions in anthropometric and metabolic risk factors. Increased vegetable intake was associated with an increase in BMI and waist circumference. Reductions in fat, energy and sodium intake were associated with reduction in HbA1c , waist circumference and total cholesterol/modelled cardiovascular disease risk, respectively. CONCLUSIONS: Improvements in dietary behaviour in this screen-detected population were associated with small reductions in cardiovascular disease risk, independently of change in cardio-protective medication and physical activity. Dietary change may have a role to play in the reduction of cardiovascular disease risk following diagnosis of diabetes.
Assuntos
Doenças Cardiovasculares/etiologia , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/terapia , Comportamento Alimentar , Adulto , Idoso , Doenças Cardiovasculares/epidemiologia , Estudos de Coortes , Inglaterra/epidemiologia , Feminino , Humanos , Estilo de Vida , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Fatores de Risco , Padrão de Cuidado , Resultado do TratamentoRESUMO
AIMS: Little is known about the long-term effects of intensive multifactorial treatment early in the diabetes disease trajectory. In the absence of long-term data on hard outcomes, we described change in 10-year modelled cardiovascular risk in the 5 years following diagnosis, and quantified the impact of intensive treatment on 10-year modelled cardiovascular risk at 5 years. METHODS: In a pragmatic, cluster-randomized, parallel-group trial in Denmark, the Netherlands and the UK, 3057 people with screen-detected Type 2 diabetes were randomized by general practice to receive (1) routine care of diabetes according to national guidelines (1379 patients) or (2) intensive multifactorial target-driven management (1678 patients). Ten-year modelled cardiovascular disease risk was calculated at baseline and 5 years using the UK Prospective Diabetes Study Risk Engine (version 3ß). RESULTS: Among 2101 individuals with complete data at follow up (73.4%), 10-year modelled cardiovascular disease risk was 27.3% (sd 13.9) at baseline and 21.3% (sd 13.8) at 5-year follow-up (intensive treatment group difference -6.9, sd 9.0; routine care group difference -5.0, sd 12.2). Modelled 10-year cardiovascular disease risk was lower in the intensive treatment group compared with the routine care group at 5 years, after adjustment for baseline cardiovascular disease risk and clustering (-2.0; 95% CI -3.1 to -0.9). CONCLUSIONS: Despite increasing age and diabetes duration, there was a decline in modelled cardiovascular disease risk in the 5 years following diagnosis. Compared with routine care, 10-year modelled cardiovascular disease risk was lower in the intensive treatment group at 5 years. Our results suggest that patients benefit from intensive treatment early in the diabetes disease trajectory, where the rate of cardiovascular disease risk progression may be slowed.
Assuntos
Diabetes Mellitus Tipo 2/prevenção & controle , Angiopatias Diabéticas/prevenção & controle , Adulto , Idoso , Terapia Combinada/estatística & dados numéricos , Diagnóstico Precoce , Métodos Epidemiológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Cardiovasculares , Resultado do TratamentoRESUMO
AIMS/HYPOTHESIS: HbA1c is an important risk factor for cardiovascular disease (CVD), with 1% higher HbA1c levels associated with a 10-20% increased risk of CVD. Little is known about the association between change in HbA1c over time and cardiovascular risk in non-diabetic populations. This study examined the association between change in HbA1c over time and cardiovascular risk in a non-diabetic British population. METHODS: We used data on HbA1c collected at baseline and at a second health examination 3 years later among a population of 5,790 non-diabetic men and women who participated in the European Prospective Investigation of Cancer (EPIC)-Norfolk. The association between change in HbA1c over 3 years and incident cardiovascular events over the following 8 years was examined using multivariate Cox regression. We also examined whether information on change in HbA1c over time improved prediction of cardiovascular events over a single measure of HbA1c by comparing the area under the receiver operating characteristic curves (aROC) and computing the net reclassification improvement. RESULTS: The mean change (SD) in HbA1c over 3 years was 0.13% (0.52). During 44,596 person-years of follow-up, 529 cardiovascular events occurred (incidence 11.9 per 1,000 person-years). Each 0.5% rise in HbA1c over 3 years was associated with a 9% increase in risk of a cardiovascular event (HR 1.09; 95% CI 1.01, 1.18) after adjustment for baseline HbA1c and other major cardiovascular risk factors. However, change in HbA1c was not associated with cardiovascular risk after adjustment for HbA1c at follow-up. Multivariate models with and without information on change in HbA1c over time showed a similar aROC of 0.78. Adding change in HbA1c to the model with HbA1c at follow-up did not improve risk classification. CONCLUSIONS/INTERPRETATION: Addition of information on change in HbA1c over 3 years did not improve the prediction of CVD over and above information on HbA1c and other major cardiovascular risk factors from a single time point.
Assuntos
Doenças Cardiovasculares/etiologia , Hemoglobinas Glicadas/análise , Hiperglicemia/fisiopatologia , Modelos Biológicos , Adulto , Idoso , Doenças Cardiovasculares/epidemiologia , Estudos de Coortes , Análise Discriminante , Inglaterra/epidemiologia , Feminino , Seguimentos , Humanos , Hiperglicemia/sangue , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Curva ROC , Fatores de RiscoRESUMO
AIMS: To describe change in physical activity over 1 year and associations with change in cardiovascular disease risk factors in a population with screen-detected Type 2 diabetes. METHODS: Eight hundred and sixty-seven individuals with screen-detected diabetes underwent measurement of self-reported physical activity, cardiovascular disease risk factors and modelled cardiovascular disease risk at baseline and 1 year (n = 736) in the ADDITION-Cambridge trial. Multiple linear regression was used to quantify the association between change in different physical activity domains and cardiovascular disease risk factors at 1 year. RESULTS: There was no change in self-reported physical activity over 12 months. Even relatively large changes in physical activity were associated with relatively small changes in cardiovascular disease risk factors after allowing for changes in self-reported medication and diet. For every 30 metabolic equivalent-h increase in recreational activity (equivalent to 10 h/brisk walking/week), there was an average reduction of 0.1% in HbA(1c) in men (95% CI -0.15 to -0.01, P = 0.021) and an average reduction of 2 mmHg in systolic blood pressure in women (95% CI -4.0 to -0.05, P = 0.045). CONCLUSIONS: Few associations were observed between change in different physical activity domains and cardiovascular disease risk factors in this trial cohort. Cardiovascular disease risk reduction appeared to be driven largely by factors other than changes in self-reported physical activity in the first year following diagnosis.
Assuntos
Glicemia/metabolismo , Doenças Cardiovasculares/epidemiologia , Diabetes Mellitus Tipo 2/epidemiologia , Angiopatias Diabéticas/epidemiologia , Exercício Físico , Hemoglobinas Glicadas/metabolismo , Adulto , Idoso , Índice de Massa Corporal , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/prevenção & controle , Estudos de Coortes , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/prevenção & controle , Angiopatias Diabéticas/sangue , Angiopatias Diabéticas/prevenção & controle , Dieta , Inglaterra/epidemiologia , Feminino , Promoção da Saúde , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Modelos Cardiovasculares , Fatores de Risco , Comportamento de Redução do Risco , Inquéritos e QuestionáriosRESUMO
AIMS: There are continuing uncertainties about how much screening for type 2 diabetes brings forward the clinical diagnosis and the impact that earlier diagnosis has on health outcomes. We compared the duration of diabetes and health outcomes in a population invited for diabetes screening at 5-yearly intervals from 1990 (screened population) with those in a similar population not invited for screening (unscreened population). METHODS: This was a parallel-group, cohort study of people aged 40-65 years, free of known diabetes, identified from the population register of a general practice in Ely, Cambridgeshire, UK (n = 4,936). In 1990-1992, one-third (n = 1,705), selected randomly, received an invitation for screening for diabetes and cardiovascular risk factors at 5-yearly intervals (screened population). From the remainder of the sampling frame, 1,705 randomly selected individuals were invited to diabetes screening 10 years later (unscreened population). Patients with diabetes from both populations were invited for a health assessment, including biochemical, anthropometric and questionnaire measures, and testing for the presence of diabetic complications RESULTS: Of the 199 eligible individuals with diabetes diagnosed during follow-up, 152 (76%) attended for health assessment. The median duration of clinically recognised diabetes was significantly longer in cases arising in the screened (5.0 years) compared with the unscreened population (1.7 years; p = 0.006). Clinical measures, prescribed medication and functional status were similar between screened and unscreened populations. CONCLUSIONS: Diabetes screening resulted in cases being identified on average 3.3 years earlier, a difference significantly shorter than previous estimates. Earlier diagnosis did not appear to impact on health outcomes. Further evidence is needed to justify the introduction of population-based screening.
Assuntos
Diabetes Mellitus Tipo 2/diagnóstico , Programas de Rastreamento/estatística & dados numéricos , Adulto , Idoso , Estudos de Coortes , Diagnóstico Precoce , Feminino , Humanos , Masculino , Programas de Rastreamento/economia , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/economia , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricosRESUMO
AIMS: There is continuing uncertainty regarding the overall net benefits of population-based screening for Type 2 diabetes. We compared clinical measures, prescribed medication, cardiovascular morbidity and self-rated health in individuals without diabetes in a screened vs. an unscreened population. METHODS: A parallel-group, cohort study of people aged 40-65 years, free of known diabetes, identified from the population register of a general practice in Ely, Cambridgeshire (n = 4936). In 1990-1992, one third (n = 1705), selected randomly, received an invitation for screening for diabetes and cardiovascular risk factors at 5-yearly intervals (screened population). From the remainder of the sampling frame, 1705 randomly selected individuals were invited to diabetes screening 10 years later (unscreened population). Patients without known diabetes from both populations were invited for a health assessment. RESULTS: Of 3390 eligible individuals without diabetes, 1442 (43%) attended for health assessment, with no significant difference in attendance between groups. Thirteen years after the commencement of screening, self-rated functional health status and health utility were identical between the screened and unscreened populations. Clinical measures, self-reported medication and cardiovascular morbidity were similar between the two groups. CONCLUSIONS: Screening for diabetes is not associated with long-term harms at the population level. However, screening has limited long-term impact on those testing negative; benefits may largely be restricted to those whose diabetes is detected early through screening.
Assuntos
Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiologia , Angiopatias Diabéticas/diagnóstico , Angiopatias Diabéticas/epidemiologia , Adulto , Idoso , Doenças Cardiovasculares/prevenção & controle , Estudos de Coortes , Atenção à Saúde/estatística & dados numéricos , Diabetes Mellitus Tipo 2/prevenção & controle , Angiopatias Diabéticas/prevenção & controle , Diagnóstico Precoce , Feminino , Seguimentos , Teste de Tolerância a Glucose , Nível de Saúde , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Fatores de Risco , Fatores de Tempo , Reino Unido/epidemiologiaRESUMO
BACKGROUND: Diabetes risk assessment has been proposed as part of the National Health Service Health Checks programme, and HbA(1c) has recently been recommended as a diagnostic test for diabetes at a threshold of 48 mmol/mol (6.5%). We estimated the potential population impact of different stepwise screening strategies to identify individuals at high risk who might be offered preventive interventions. METHODS: Using data from 5910 participants in the European Prospective Investigation of Cancer (EPIC)-Norfolk cohort with HbA(1c) measurements, we modelled different stepwise screening strategies for identifying and treating individuals at high risk of Type 2 diabetes using different HbA(1c) cut-off points with and without a stage of prestratification. For each strategy, we estimated the number needed to have a diagnostic test, the number needed to treat to prevent one new case of Type 2 diabetes, and the number of new cases that could be prevented in the population over 3 years. Relative risk reductions for estimated effects of intensive lifestyle intervention were derived from the US Diabetes Prevention Program. RESULTS: Compared with inviting all individuals in an average primary care trust for a diagnostic test, a stepwise screening approach using simple routine data such as age and anthropometric indices could prevent a slightly lower number (lower-upper estimates) of new cases of Type 2 diabetes over 3 years (224 [130-359] and 193 [109-315] cases respectively) but would only require half the population to be invited for a diagnostic blood test. A total of 162 (88-274) cases could be prevented by inviting individuals with a Cambridge risk score of ≥ 0.15, with only 40% of the total population requiring diagnostic blood tests. Using a participant completed questionnaire for risk assessment (FINDRISC) was less effective, mainly relating to the questionnaire response rate. Providing preventive interventions to those with a lower HbA(1c) of 37-< 48 mmol/mol (5.5-< 6.5%) could prevent more cases but with a disproportionately higher workload, compared with using the recommended HbA(1c) threshold of 42-< 48 mmol/mol (6.0-< 6.5%). CONCLUSIONS: Compared with mass screening, an approach using routine data for risk stratification followed by an HbA(1c) test with a threshold of 42-< 48 mmol/mol (6.0-< 6.5%) for identifying individuals suitable for preventive interventions might prevent slightly fewer cases of Type 2 diabetes but with potential cost-savings.
Assuntos
Doenças Cardiovasculares/epidemiologia , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/epidemiologia , Programas de Rastreamento/estatística & dados numéricos , Programas Nacionais de Saúde/organização & administração , Adulto , Idoso , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/prevenção & controle , Diabetes Mellitus Tipo 2/prevenção & controle , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Prevenção Primária , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Inquéritos e Questionários , Reino Unido/epidemiologiaRESUMO
AIMS: To investigate validity of waist circumference measurements obtained by self-report and self-measurement with non-verbal pictorial instructions among a multi-ethnic population. METHODS: Five hundred and twenty-six individuals aged 40-75 years (91 South Asian, 430 White European and five other), who attended a screening programme for Type 2 diabetes, estimated their waist circumference and measured their waist with a paper tape measure. Participants were also provided with simple pictorial instructions for measurement of waist circumference in their preferred language and remeasured their waist circumference. We calculated 95% limits of agreement with measures undertaken by a healthcare professional unaware of prior measures. RESULTS: Mean age was 56.8 years (sd 9.0), mean BMI 30.0 kg/m(2) (sd 5.6) and mean waist circumference 98.4 cm (sd 14.1). Seventy-nine per cent had high waist circumference according to International Diabetes Federation criteria. The mean of participants' self-reported value was 6.8 cm lower than the healthcare professional measure (sd 8.8; 95% limits of agreement -10.4 to 24.0 cm), with significant differences by sex and ethnicity (South Asian men 7.5 cm, South Asian women 0.1 cm, White European men 7.8 cm, White European women 7.0 cm, P < 0.001). Compared with healthcare professional measures, mean self-measured waist circumference was very similar, both with instructions (0.4 cm higher; sd 5.5 cm; -11.1 to 10.4 cm) and without instructions (0.5 cm lower; sd 5.6; -10.4 to 11.4 cm), but with significant differences by sex and ethnicity (P < 0.001). CONCLUSIONS: There was systematic underestimation of self-reported waist circumference in this multi-ethnic UK population. The magnitude of underestimation might reduce the performance of risk scores; however, this can be corrected through self-measurement with pictorial instructions.
Assuntos
Diabetes Mellitus Tipo 2/epidemiologia , Obesidade/epidemiologia , Circunferência da Cintura , Adulto , Idoso , Índice de Massa Corporal , Diabetes Mellitus Tipo 2/etnologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/etnologia , Cooperação do Paciente , Educação de Pacientes como Assunto , Reprodutibilidade dos Testes , Autorrelato , Reino Unido/epidemiologia , Reino Unido/etnologiaRESUMO
AIMS: To describe the total cardiovascular burden (cardiovascular morbidity or mortality, revascularization or non-traumatic amputation) in individuals with screen-detected diabetes in the ADDITION-Europe trial and to quantify the impact of the intervention on multiple cardiovascular events over 5 years. METHODS: In a pragmatic, cluster-randomized, parallel-group trial in four centres (Denmark; Cambridge, UK; the Netherlands; and Leicester, UK), 343 general practices were randomized to screening plus routine care (n = 1379 patients), or screening and promotion of target-driven, intensive treatment of multiple risk factors (n = 1678). We estimated the effect of the intervention on multiple cardiovascular events after diagnosis of diabetes using the Wei, Lin and Weissfeld method. RESULTS: Over 5.3 years, 167 individuals had exactly one cardiovascular event, 53 exactly two events, and 18 three or more events. The incidence rates (95% CI) of first events and any event per 1000 person-years were 14.6 (12.8-16.6) and 20.4 (18.2-22.6), respectively. There were non-significant reductions in the risk of a first (hazard ratio 0.83, 95% CI 0.65-1.05) and second primary endpoint (hazard ratio 0.70, 95% CI 0.43-1.12). The overall average hazard ratio for any event was 0.77 (95% CI 0.58-1.02). CONCLUSIONS: Early intensive multifactorial treatment was not associated with a significant reduction in total cardiovascular burden at 5 years. Focusing on first events in cardiovascular disease prevention trials underestimates the total cardiovascular burden to patients and the health service.
Assuntos
Amputação Cirúrgica/estatística & dados numéricos , Doenças Cardiovasculares/epidemiologia , Diabetes Mellitus Tipo 2/epidemiologia , Angiopatias Diabéticas/epidemiologia , Adulto , Idoso , Doenças Cardiovasculares/fisiopatologia , Doenças Cardiovasculares/prevenção & controle , Análise por Conglomerados , Dinamarca/epidemiologia , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/fisiopatologia , Diabetes Mellitus Tipo 2/prevenção & controle , Angiopatias Diabéticas/fisiopatologia , Angiopatias Diabéticas/prevenção & controle , Feminino , Hemoglobinas Glicadas/metabolismo , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Fatores de Risco , Reino Unido/epidemiologiaRESUMO
AIMS/HYPOTHESIS: Non-diabetic hyperglycaemia is usually not considered at all or is viewed as a binary risk category in isolation from other factors when quantifying cardiovascular risk. We argue that hyperglycaemia should be considered as a continuous risk factor and only in the context of other vascular risk factors. To examine the potential impact of hyperglycaemia on cardiovascular disease (CVD) risk, we calculated the absolute CVD risk in groups defined by different levels of HbA(1c) and other CVD risk factors. METHODS: We used data on 10,144 men and women from the European Prospective Investigation of Cancer-Norfolk cohort to calculate CVD rates across levels of HbA(1c) in groups characterised by different levels of traditional risk factors. RESULTS: We found significant differences in CVD rates across levels of HbA(1c) in groups defined by different levels of the other risk factors. CVD rates for non-diabetic individuals with an HbA(1c) of <5.5% increased from 0.6 (95% CI 0.3-1.2) to 29.6 (95% CI 14.8-59.1) per 1,000 person-years when traditional CVD risk factors were added sequentially to the lowest risk reference group. In most cases, non-diabetic individuals with an HbA(1c) of <5.5% and high values for all other CVD risk factors had substantially higher absolute CVD rates than those with an HbA(1c) of 6.0% to 6.4% but with no other raised CVD risk factors (29.6 [95% CI 14.8-59.1] and 2.5 [95% CI 0.4-18.1], respectively). A history of diabetes significantly increased CVD risk over the non-diabetic hyperglycaemia range. Comparisons of CVD rates across tertiles of total cholesterol:HDL-cholesterol ratio or mean systolic blood pressure in groups characterised by different levels of other risk factors showed similar findings. CONCLUSIONS/INTERPRETATION: In people with non-diabetic hyperglycaemia, cardiovascular risk is highly dependent on the presence of other CVD risk factors. Attention should be given not to whether an individual has 'pre-diabetes', 'hypertension' or 'hypercholesterolaemia', but to an integrated assessment of CVD risk, based on the combination of risk factors present and potential benefits of treatment.