The prevalence of vitamin D deficiency and relationship with fracture risk in older women presenting in Australian general practice.

AIM: To investigate vitamin D status among older women and to explore relationships between vitamin D and fracture risk and vertebral fractures. METHODS: A total of 267 general practitioners recruited 2466 women aged >70 years with no known osteoporosis or fragility fracture. Serum 25-hydroxy vitamin D (25(OH)D), bone mineral density by dual-energy X-ray absorptiometry (DXA) and vertebral fracture on thoracolumbar X-ray were determined. RESULTS: A total of 2368 women, median age 76 years, provided data and of these 13% were on vitamin D supplements. 25(OH)D levels were available for 907 (44.1%) of those not taking vitamin D. 88.3% of these had a level below 75 nmol/L. Serum 25(OH)D was negatively associated with age (P = 0.003) and body mass index (P < 0.001), and positively associated with lower latitude, femoral neck DXA T-score (P = 0.044) and being Caucasian (P < 0.001). CONCLUSIONS: The vitamin D status of community-dwelling older Australian women is inadequate, yet the use of supplements is low.

In patients with chronic stable angina, secondary prevention appears better in the very old compared to younger patients: the Coronary Artery Disease in gENeral practiCE (CADENCE) Substudy.

BACKGROUND: With our aging communities and the increased prevalence of coronary heart disease (CAD) with age, the impact of this disease in the very old warrants further investigation. OBJECTIVE: To assess health outcomes and the attainment of guideline-based secondary prevention targets in the very old (>80 years, n=482) as compared to young (<65 years, n=582) and elderly (between 65 and 80 years, n=932) patients, all of whom had chronic stable angina. DESIGN: The coronary artery disease in general practice (CADENCE) study was a cluster-stratified cross-sectional survey. This study reports on health outcomes quantitated using the Seattle Angina Questionnaire and guideline targets achieved for blood pressure, smoking, lipids, diabetic control and body habitus. SETTINGS AND PARTICIPANTS: 2031 stable angina patients were recruited from 207 primary care practices. RESULTS: Despite similar angina frequency scores, the very old were more physically impaired by their angina than both the young and elderly [76±25 (Young) vs. 70±26 (Elderly) vs. 63±28 (Very old), p<0.05 for both comparisons]. However, the very old had better quality of life scores than young stable angina patients [72±24 vs. 65±25, p<0.05] and were similar to the elderly [72±24 vs. 72±23, p>0.05]. Also blood pressure, lipid, diabetic and body habitus targets were more often achieved in the very old and elderly patients compared to young stable angina patients. CONCLUSION: Despite similar symptomatic status and greater physical limitations, the very old reported a better quality of life and more often achieved treatment targets than young stable angina patients. Failure to improve secondary prevention measures in younger age groups may potentially contribute to increased morbidity in older age, and failure to achieve 'Healthy Ageing'.

Quality of life of patients with peripheral arterial disease and chronic stable angina.

The Coronary Artery Disease in gENeral practiCE (CADENCE) study examined chronic stable angina (CSA). This further analysis examined atherosclerotic risk factors, symptomatic status, clinical management, and quality of life in patients with CSA with and without peripheral arterial disease (PAD). The CADENCE study involved 207 Australian general practitioners (GPs) recruiting 10 to 15 consecutively presenting patients with CSA (n = 2031). General practitioners completed a 2-page case report form, detailing demographic data, cardiovascular status, risk factors, and GP perception of control. Patients completed the Seattle Angina Questionnaire. Patients with coexisting CSA and PAD (17%) were more likely to be older and had more comorbidities than patients with CSA without coexisting PAD. Patients with peripheral arterial disease had a longer history of heart disease and were more likely to experience angina on a weekly basis. Patients with peripheral arterial disease had poorer quality-of-life indices.

Disparities between prescribing of secondary prevention therapies for stroke and coronary artery disease in general practice.

BACKGROUND: Extensive evidence exists regarding the effectiveness of secondary prevention measures in patients with cardiovascular disease. AIM: We aimed to examine the management and risk perceptions of cardiovascular events in people with established cardiovascular disease. METHODS: We analyzed data on 1453 patients, ≥55 year old, with a history of cardiovascular disease, from the Australian Hypertension and Absolute Risk Study. RESULTS: Compared with those 533 patients with stroke/transient ischemic attack, the 743 patients with coronary artery disease were twice as likely to have been prescribed secondary prevention therapies even after adjustment for potential confounding variables (adjusted relative risks 1·85; 95% confidence interval 1·56-2·19, 42% vs. 73% for use of the combination of blood pressure-lowering, lipid-lowering and antiplatelet therapies) and to have better control of lipid and blood pressure levels. General practitioners estimated that only 27% of patients with stroke/transient ischemic attack - 38% of those with coronary artery disease and 41% of those with both conditions - were at a high risk (≥15%) of a recurrent event. Patients similarly underestimated their risk of recurrent cardiovascular events, with only 8% of stroke/transient ischemic attack, 11% of coronary and 15% of combination disease patients rating themselves at 'high' or 'very-high' risk. CONCLUSIONS: This study reaffirms the large treatment gap in the uptake of secondary prevention for cardiovascular disease in primary care settings, being much greater for patients with cerebral compared with cardiac cardiovascular disease. This appears to be related to differential perceptions of cardiovascular risk across different vascular territories in both patients and doctors.

Cardiovascular risk management in chronic kidney disease in general practice (the AusHEART study).

BACKGROUND: Chronic kidney disease (CKD) is common and increasing in prevalence. Adverse outcomes of CKD can be prevented through early detection and treatment. There is limited data on the awareness of CKD and the quality of care offered to patients with CKD in the primary care setting. The objectives of this study were to assess the prevalence, general practitioner (GP) awareness and extent of current evidence-practice gaps in the management of CKD in Australian primary care. METHODS: The Australian Hypertension and Absolute Risk Study (AusHEART) was a nationally representative, cluster stratified, cross-sectional survey among 322 GPs. Each GP was asked to provide data for 15-20 consecutive patients (age ≥ 55 years) who presented between April and June, 2008. The main outcome measures were CKD prevalence based on proteinuria and decreased estimated glomerular filtration rate. Evidence-practice gaps in management of patients with CKD were identified. RESULTS: Among a total of 4966 patients with kidney function test data, 1845 (37%) had abnormal kidney function. Of the 1312 patients with abnormal kidney function known to the GP at the time of visit, only 235 were correctly identified as having CKD. GPs under-estimated cardiovascular (CV) risks in patients with CKD when compared with the prevailing guidelines at the time of survey and the recent national guidelines, particularly in later stages of CKD. Among CKD patients not prescribed blood pressure-lowering agents or lipid-lowering agents, treatment was indicated as per relevant guidelines in 51 and 46%, respectively. For CKD patients who were already prescribed blood pressure-lowering and lipid-lowering agents, 61 and 50%, respectively, did not meet the treatment targets recommended by the relevant guidelines. CONCLUSIONS: CKD is common, significantly under-recognized and under-treated in primary care. Effort to increase awareness and provide opportunities for improved screening and assessment should improve the management and outcome of these patients at high risk of CV disease.

Gender disparities in the assessment and management of cardiovascular risk in primary care: the AusHEART study.

AIMS: Studies indicate ongoing gender-based differences in the prevention, detection and management of cardiovascular disease. The aims of this study were to determine whether there are differences in general practitioners' (GPs') perceptions of a patient's cardiovascular risk compared with the patient's estimated risk and in the patient's subsequent medical management according to patient sex. METHODS: The Australian Hypertension and Absolute Risk Study (AusHEART) was a nationally representative, cluster-stratified, cross-sectional survey among 322 GPs. Each GP was asked to collect data on cardiovascular disease risk factors and their management in 15-20 consecutive patients (age ≥55 years) who presented between April and June, 2008. They were also asked to estimate each patient's absolute risk of a cardiovascular event in the next five years. The main outcomes were the Adjusted Framingham risk, GP estimated risk and proportion of patients receiving blood pressure-lowering, statin and antiplatelet therapy. RESULTS: A total of 5293 patients were recruited to the study, of whom 2968 (56%) were women. Among patients without established cardiovascular disease, the level of agreement between the GP estimated risk and the Adjusted Framingham risk was poor (<50%) and was similarly so for men (kappa coefficient 0.18; 95% confidence interval (CI) 0.14-0.21) and women (0.19; 95% CI 0.16-0.22; P homogeneity = 0.57). For patients with established cardiovascular disease, however, women were more likely to be assigned by the GP to a lower risk category (66% vs. 54%, P < 0.001) and less likely to be prescribed combination (blood pressure-lowering, statin and antiplatelet) (44% vs. 56%, P < 0.001) therapy compared with men, even after adjusting for patient age. CONCLUSIONS: Cardiovascular risk is underrecognized and undertreated in Australian primary care patients, with women apparently disproportionately affected. These findings underscore the importance of initiatives to raise awareness of cardiovascular disease in women.

Gender differences in patients with stable angina attending primary care practices.

OBJECTIVE: The primary objective of this study was to assess gender differences in the health status of patients with chronic stable angina using the Seattle Angina Questionnaire (SAQ). Potential contributing clinical factors were also examined. METHODS: Gender disparities in 2005 stable angina patients (712 females) were determined from general practitioner clinical evaluations and patient-completed questionnaire (SAQ). As there were significant age differences between genders, all subsequent analyses were adjusted for age. RESULTS: Compared with men, women with angina had poorer angina-related health outcomes as assessed by the SAQ, including more frequent angina (81±22 vs 85±22, respectively, p<0.001) with greater associated physical limitations (65±27 vs 73±26, respectively, p<0.001) and a poorer quality of life (68±24 vs 71±24, respectively, p=0.0026). CONCLUSION: Women with stable angina have poorer angina-related health outcomes compared with their male counterparts. Multiple factors may contribute to this disparity including differences in clinical factors, underlying biological mechanisms and psychosocial factors.

Simplifying screening for osteoporosis in Australian primary care: the Prospective Screening for Osteoporosis; Australian Primary Care Evaluation of Clinical Tests (PROSPECT) study.

OBJECTIVE: Although bone density by dual-energy x-ray absorptiometry (DXA) is the standard measure for the diagnosis of osteoporosis, as a screening tool, it has significant cost and availability of DXA is not universal. Prospective Screening for Osteoporosis; Australian Primary Care Evaluation of Clinical Tests (PROSPECT) was a national study undertaken to establish an effective prescreening protocol to be used in primary care facilitating targeted radiological investigation for osteoporosis in older women. METHODS: Two hundred sixty-seven primary care physicians recruited 2,466 women 70 years and older who had no previous diagnosis of osteoporosis in a community-based cross-sectional study. The main outcome measures used were lumbar spine and femoral neck T-scores on DXA and presence of a vertebral fracture on thoracolumbar x-ray. Participant characteristics, gap-on-wall occiput test, and rib-to-pelvis distance measurements were provided by each primary care physician. RESULTS: Of the study population, 21.8% (95% CI, 19.9%-23.8%) had osteoporosis of the femoral neck and/or lumbar spine based on DXA, and 24.7% (95% CI, 22.5%-26.9%) had at least one vertebral fracture. Only 7.3% (95% CI, 6.2%-8.3%) had both osteoporosis and radiological vertebral fracture. Univariate and multivariate regression modeling of the demographic and clinical data collected resulted in a three-factor predictive tool for the diagnosis of osteoporosis and/or vertebral fracture that included the following variables: rib-pelvis distance greater than 2 fingerbreadths (yes/no), ever use of estrogen for more than 6 months (yes/no), and body mass index (<25, 25-30, >30 kg/m²). Only screening women classified as moderate to high risk by the tool DXA plus plain x-ray would then result in 14% of women 70 years or older who were not being screened, with 93% of cases being detected. CONCLUSIONS: The Prospective Screening for Osteoporosis; Australian Primary Care Evaluation of Clinical Tests tool will contribute to the diagnosis and management of osteoporosis by facilitating targeted screening and hence reducing the need for unnecessary radiology tests at the primary care level.

Cardiovascular risk perception and evidence--practice gaps in Australian general practice (the AusHEART study).

OBJECTIVE: To examine the perception and management of cardiovascular disease (CVD) risk in Australian primary care. DESIGN, SETTING AND PARTICIPANTS: The Australian Hypertension and Absolute Risk Study (AusHEART) was a nationally representative, cluster-stratified, cross-sectional survey of 322 general practitioners. Each GP was asked to collect data on CVD risk factors and their management in 15-20 consecutive patients aged >or= 55 years who presented between April and June 2008, and to estimate each patient's absolute risk of a cardiovascular event in the next 5 years. MAIN OUTCOME MEASURES: Estimated 5-year risk of a cardiovascular event, proportion of patients receiving appropriate treatment. RESULTS: Among 5293 patients, 29% (1548) had established CVD. A further 22% (1145), when categorised according to the 2009 National Vascular Disease Prevention Alliance guideline, to 42% (2211), when categorised according to National Heart Foundation (NHF) 2004 guideline, had a high (>or= 15%) 5-year risk of a cardiovascular event. Of the 1548 patients with established CVD, 50% were prescribed a combination of a blood pressure (BP)-lowering medication, a statin and an antiplatelet agent, and 9% were prescribed a BP-lowering medication and a statin but not an antiplatelet agent. Among high-risk patients without established CVD, categorised using NHF 2004 adjustments, 34% were prescribed a combination of a BP-lowering medication and a statin. GPs estimated 60% of patients with established CVD as having a risk of less than 15%. The GPs' estimates of risk among patients without established CVD agreed with the centrally calculated estimate (according to the NHF 2004 guideline) in 48% of instances (Kappa = 0.21). CONCLUSIONS: These data confirm substantial undertreatment of patients who are at high risk of a cardiovascular event. We recommend that GPs assess absolute risk for older patients and ensure that high-risk patients receive evidence-based pharmacotherapy.

The prevalence of weekly angina among patients with chronic stable angina in primary care practices: The Coronary Artery Disease in General Practice (CADENCE) Study.

BACKGROUND: Angina, the cardinal symptom of coronary artery disease (CAD), is amenable to a range of therapies, and its routine assessment is considered a performance measure of quality. However, the prevalence of frequent angina among outpatients with CAD is unknown. METHODS: The Coronary Artery Disease in General Practice (CADENCE) Study utilized a cluster-stratified, cross-sectional design to examine angina frequency in patients with stable angina attending Australian primary care practices. The 207 participating primary care practitioners recruited 2031 consecutive patients, irrespective of the purpose of their visit. Angina frequency was quantified with the Seattle Angina Questionnaire (SAQ), and weekly angina was defined as having 1 or more episodes per week over the preceding 4 weeks [hereinafter, "weekly (> or =1) angina"]. RESULTS: Among primary care practice patients with stable angina, 29% (95% confidence interval [CI], 26%-31%) experienced weekly (> or =1) angina, which was associated with greater physical limitations and worse quality of life (24% and 27% lower SAQ scores, respectively; P < .05) compared with those with minimal angina (angina less than once a week over the preceding 4 weeks). The proportion of patients with weekly (> or =1) angina within a clinic ranged from none (14% of clinics) to more than 50% (18% of clinics). Patient characteristics associated with weekly (> or =1) angina included female sex (odds ratio [OR], 1.42; 95% CI, 1.13-1.78), a history of heart failure (OR, 1.59; 95% CI, 1.22-2.08), and peripheral artery disease (OR 1.89; 95% CI, 1.42-2.51; P < .001 for all comparisons). CONCLUSIONS: Almost 1 in 3 patients with stable angina attending primary care practices had angina at least once a week, which was associated with worse quality of life. Moreover, weekly (> or =1) angina varied considerably across clinics, possibly reflecting variability in the identification and management of angina. The potential role of an angina performance measure to improve patients' outcomes, including symptom control, warrants further consideration.

Nonalbuminuric renal impairment in type 2 diabetic patients and in the general population (national evaluation of the frequency of renal impairment cO-existing with NIDDM [NEFRON] 11).

OBJECTIVE Most diabetic patients with impaired renal function have a urinary albumin excretion rate in the normal range. In these patients, the etiology of renal impairment is unclear, and it is also unclear whether this nonalbumunuric renal impairment is unique to diabetes. RESEARCH DESIGN AND METHODS In this study, we examined the frequency and predictors of nonalbumunuric renal impairment (estimated glomerular filtration rate [eGFR] <60 ml/min per 1.73 m(2)) in a nationally representative cohort of 3,893 patients with type 2 diabetes and compared our findings with rates observed in the general population from the Australian Diabetes, Obesity and Lifestyle Study (AusDiab) survey (n = 11,247). RESULTS Of the 23.1% of individuals with type 2 diabetes who had eGFR <60 ml/min per 1.73 m(2) (95% CI 21.8-24.5%), more than half (55%) had a urinary albumin excretion rate that was persistently in the normal range. This rate of renal impairment was predictably higher than that observed in the general population (adjusted odds ratio 1.3, 95% CI 1.1-1.5, P < 0.01) but was solely due to chronic kidney disease associated with albuminuria. In contrast, renal impairment in the absence of albuminuria was less common in those with diabetes than in the general population, independent of sex, ethnicity, and duration of diabetes (0.6, 0.5-0.7, P < 0.001). CONCLUSIONS Nonalbuminuric renal impairment is not more common in those with diabetes. However, its impact may be more significant. New studies are required to address the pathogenesis, prevention, and treatment of nonalbuminuric renal disease.

The management of diabetes in indigenous Australians from primary care.

BACKGROUND: Indigenous Australians have high rates of diabetes and its complications. This study examines ethnic differences in the management of patients with type 2 diabetes in Australian primary care. METHODS: Diabetes management and outcomes in Indigenous patients enrolled in the NEFRON study (n = 144) was systematically compared with that in non-Indigenous patients presenting consecutively to the same practitioner (n = 449), and the NEFRON cohort as a whole (n = 3893). RESULTS: Indigenous Australians with diabetes had high rates of micro- and macrovascular disease. 60% of Indigenous patients had an abnormal albumin to creatinine ratio compared to 33% of non-Indigenous patients (p < 0.01). When compared to non-Indigenous patients, Indigenous patients were more likely to have established macrovascular disease ((adjusted Odds ratio 2.7). This excess in complications was associated with poor glycemic control, with an HbA1c >or= 8.0%, observed in 55% of all Indigenous patients, despite the similar frequency use of oral antidiabetic agents and insulin. Smoking was also more common in Indigenous patients (38%vs 10%, p < 0.01). However, the achievement of LDL and blood pressure targets was the same or better in Indigenous patients. CONCLUSION: Although seeing the same doctors and receiving the same medications, glycaemic and smoking cessation targets remain unfulfilled in Indigenous patients. This cross-sectional study confirms Aboriginal ethnicity as a powerful risk factor for microvascular and macrovascular disease, which practitioners should use to identify candidates for intensive multifactorial intervention.

The use of oral antidiabetic agents in primary care.

BACKGROUND: Guidelines and regulatory documents reflect the potential for chronic kidney disease to impact the efficacy and safety profiles of antidiabetic regimens. We describe the influence of impaired kidney function and its perception by practitioners on the pattern of antidiabetic use in Australian primary care. METHODS: Antidiabetic agent prescribing was documented for 3893 patients with type 2 diabetes from the National Evaluation of the Frequency of Renal impairment cO-existing with Noninsulin dependent diabetes mellitus (NEFRON) study. Patients with and without impaired kidney function, identified by their practitioner or defined by an estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m2, were systematically compared. RESULTS: Most patients received metformin (63%) with sulphonylureas (45%), insulin (13%) and thiazolidinediones (7%) also widely used. Contrary to prescribing guidelines, use of metformin remained frequent (53%) and the proportional usage of sulphonylureas with active metabolites was unchanged in the 23.1% of patients with an eGFR below 60 mL/min/1.73 m2. Even where prescribers identified impaired kidney function in their patients, prescribing of antidiabetic agents was not significantly modified. DISCUSSION: Chronic kidney disease is a common companion to type 2 diabetes in Australia. The move to automated eGFR reporting provides an important opportunity for practitioners to identify impaired kidney function and to improve their management of patients with type 2 diabetes.

The assessment of kidney function by general practitioners in Australian patients with type 2 diabetes (NEFRON-2).

OBJECTIVE: To examine factors influencing the identification of kidney impairment in patients with type 2 diabetes in Australian primary care. DESIGN, SETTING AND PARTICIPANTS: 348 general practitioner investigators were asked to estimate kidney function and its severity in 10-15 consecutively presenting patients with type 2 diabetes (n = 3893). They were then asked, for each patient, whether they routinely estimated kidney function. No instruction was provided on how kidney function should be estimated or categorised. Data were collected between April and September 2005. MAIN OUTCOME MEASURES: Kidney function estimated by the Cockcroft-Gault equation using clinical and laboratory data provided by the GP; estimates of kidney function made by the GP. RESULTS: In 24% of the patients with type 2 diabetes, their GP routinely estimated kidney function. However, few of these patients had impaired kidney function or risk factors for kidney disease. There was a good statistical correlation between the estimates made by GPs and the data-derived estimates (R2 = 0.72). GPs identified patients with data-derived estimates of kidney function < 60 mL/min in over 83% of cases, with a specificity of 90%. Impaired kidney function was reported by GPs in 34.4% of men and 36.4% of women. These figures were discordant with function categorisation using both GP estimates and data-derived values, overlapping in half of the patients. Despite GPs' ability to assess creatinine clearance, "raw" (unstandardised) serum creatinine levels inappropriately influenced the perception of impairment of kidney function. CONCLUSION: GPs can accurately assess kidney function, without reporting of estimated glomerular filtration rate (eGFR). However, even in patients at increased risk of chronic kidney disease, routine estimates are seldom made. Our findings underline the value of the recent initiative recommending automatic reporting of eGFR in Australia.

The burden of chronic kidney disease in Australian patients with type 2 diabetes (the NEFRON study).

OBJECTIVE: To estimate the frequency of chronic kidney disease (CKD) in a clinic-based sample of patients with type 2 diabetes in the setting of Australian primary care. DESIGN, SETTING AND PARTICIPANTS: Expressions of interest were invited from all registered general practitioners in Australia: 500 GP investigators were randomly selected from each stratum (state and urban versus rural location), proportional to the census population, and asked to recruit and provide data for 10-15 consecutively presenting adults with type 2 diabetes between April and September 2005. MAIN OUTCOME MEASURES: Estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m(2) and evidence of kidney damage on urinalysis (eg, microalbuminuria). RESULTS: 348 GP investigators submitted data for 3893 individuals with type 2 diabetes (52% men; median age, 66 years). Almost one in every four patients consulting their GPs had an eGFR < 60 mL/min/1.73 m(2) (23.1%; 95% CI, 21.8%-24.5%). More than one in three had an elevated urinary albumin-creatinine ratio (ACR) (34.6%; 95% CI, 33.3%-35.9%). There was an overlap of 10.4% of patients with both an eGFR < 60 mL/min/1.73 m(2) and an elevated urinary ACR, meaning that almost one in two patients with type 2 diabetes consulting their GPs (47.1%; 95% CI, 45.8%-48.4%) had CKD. CKD was significantly more common in women, in older people, and in individuals with established macrovascular disease. CONCLUSION: CKD is a common complication of type 2 diabetes, found in about half of all patients with type 2 diabetes consulting their GPs. Efforts to increase the recognition of CKD will lead to improved care, and possibly survival, of patients with type 2 diabetes.

The glucose intolerance induced by caffeinated coffee ingestion is less pronounced than that due to alkaloid caffeine in men.

Although acute alkaloid caffeine (CAF) ingestion results in an impaired glucose tolerance, chronic coffee (RCOF) ingestion decreases the risk of developing type 2 diabetes. This study examines the hypothesis that CAF ingestion impairs glucose tolerance to a greater extent than RCOF and that the ingestion of decaffeinated coffee (DECAF) results in a positive effect. Eleven healthy males underwent 4 double-blinded randomized trials. Each trial included the ingestion of either: 1) CAF in capsule form (4.45 mg/kg body weight), 2) RCOF (4.45 mg/kg body weight caffeine), 3) dextrose (placebo, PL) in capsule form, or 4) DECAF (equal in volume to the RCOF trial), followed 1-h later by a 2-h oral glucose tolerance test. Blood samples were collected at baseline (-30), 0 (time of treatment ingestion), 60 (initiation of oral glucose tolerance test), 75, 90, 120, 150, and 180 min. Area under the curve for glucose and insulin were higher (P < or = 0.05) following CAF than both PL and DECAF and, although a similar trend (P = 0.07) was observed following RCOF compared with DECAF, the effect was less pronounced. Interestingly, DECAF resulted in a 50% lower glucose response (P < or = 0.05) than PL, suggesting that the effects of PL and DECAF on glucose tolerance are not the same. These findings suggest that the effects of CAF and RCOF are not identical and may provide a partial explanation as to why acute CAF ingestion impairs glucose tolerance while chronic RCOF ingestion protects against type 2 diabetes.