Detection of sudomotor alterations evaluated by Sudoscan in patients with recently diagnosed type 2 diabetes.

INTRODUCTION: Diabetic peripheral neuropathy (DPN) causes morbidity and affects the quality of life. Before diabetes diagnosis, neuropathic damage may be present. Sudoscan provides accurate measurement of the sudomotor function. This study aimed to assess the abnormalities detected by Sudoscan, offered estimates of DPN prevalence, and investigated the relationship between metabolic and clinical parameters. Additionally, we evaluated the diagnostic accuracy of the Sudoscan compared with monofilament and tuning fork tests for detecting DPN. RESEARCH DESIGN AND METHODS: Cross-sectional descriptive study including patients with type 2 diabetes for <5 years since diagnosis. We investigated the presence of DPN using a 128 Hz tuning fork test, the 10 g monofilament, and the sudomotor dysfunction in feet using Sudoscan. We compared patients with and without alterations in the Sudoscan. A logistic regression model analyzed variables independently associated with sudomotor dysfunction. RESULTS: From 2013 to 2020, 2243 patients were included, 55.1% women, age 51.8 years, and 17.1% with normal weight. Monofilament tests and/or tuning fork examination were abnormal in 29% (95% CI 0.23% to 0.27%) and 619 patients (27.6%, 0.25% to 0.29%) had sudomotor alterations. In logistic regression analysis, age (ß=1.01, 0.005-1.02), diastolic blood pressure (ß=0.98, 0.96-0.99), heart rate (ß=1.01, 1.00-1.02), glucose (ß=1.00, 1.00-1.03), albuminuria (ß=1.001, 1.000-1.001), beta-blockers=1.98, 1.21-3.24) and fibrate use=0.61, 0.43-0.87) were associated with sudomotor dysfunction. The AUC (area under the curve) for Sudoscan was 0.495 (0.469-0.522), with sensitivity and specificity of 24% and 71%, respectively. CONCLUSION: The Sudoscan identified an important proportion of patients with dysfunction, allowing prompt intervention to decrease the risk for complications. TRIAL REGISTRATION NUMBER: NCT02836808.

Clinician prescription of lipid-lowering drugs and achievement of treatment goals in patients with newly diagnosed type 2 diabetes mellitus.

INTRODUCTION: Lipid control is essential in type 2 diabetes mellitus (T2DM). The aim of this study is to investigate factors associated with lipid therapy adherence and achievement of goals in real-life setting among patients with recently diagnosed T2DM. RESEARCH DESIGN AND METHODS: This is a longitudinal analysis in a center of comprehensive care for patients with diabetes. We include patients with T2DM, <5 years of diagnosis, without disabling complications (eg, amputation, myocardial infarct, stroke, proliferative retinopathy, glomerular filtration rate <60 mL/min/m2) and completed 2-year follow-up. The comprehensive diabetes care model includes 9 interventions in 4 initial visits and annual evaluations. Endocrinologists follow the clinic's guideline and adapt therapy to reach risk-based treatment goal. The main outcome measures were the proportion of patients meeting low-density lipoprotein cholesterol (c-LDL) (<100 mg/dL) and triglycerides (<150 mg/dL) and proportion of patients taking statin, fibrate or combination at baseline, 3 months and annual evaluations. RESULTS: We included 288 consecutive patients (54±9 years, 53.8% women), time since T2DM diagnosis 1 (0-5) year. Baseline, 10.8% patients were receiving statin therapy (46.5% moderate-intensity therapy and 4.6% high-intensity therapy), 8.3% fibrates and 4.2% combined treatment. The proportion of patients with combined treatment increased to 41.6% at 3 months, decreased to 20.8% at 1 year and increased to 38.9% at 2 years of evaluation. Patients receiving treatment met LDL and triglycerides goals at 3 months (17% vs 59.7%, relative ratio (RR)=0.89, 95% CI 0.71 to 1.12), at 1 year (17% vs 26.7%, RR=0.62, 95% CI 0.41 to 0.95) and at 2 years (17% vs 29.9%, RR=0.63, 95% CI 0.43 to 0.93). Main reasons for medication suspension: patient considered treatment was not important (37.5%) and other physician suspended treatment (31.3%). CONCLUSION: 88.2% of patients with T2DM required lipid-lowering drugs. Education for patients and physicians is critical to achieve and maintain diabetes goals. TRIAL REGISTRATION NUMBER: NCT02836808.

Leptin partially mediates the association between early-life nutritional supplementation and long-term glycemic status among women in a Guatemalan longitudinal cohort.

BACKGROUND: Early-life exposure to improved nutrition is associated with decreased risk of diabetes but increased risk of obesity. Leptin positively correlates with adiposity and has glucose-lowering effects, thus it may mediate the association of early-life nutrition and long-term glycemic status. OBJECTIVES: We aimed to investigate the role of leptin in the differential association between early-life nutrition and the risks of obesity and diabetes. METHODS: We analyzed data from a Guatemalan cohort who were randomly assigned at the village level to receive nutritional supplements as children. We conducted mediation analysis to examine the role of leptin in the associations of early-life nutrition and adult cardiometabolic outcomes. RESULTS: Among 1112 study participants aged (mean ± SD) 44.1 ± 4.2 y, 60.6% were women. Cardiometabolic conditions were common: 40.2% of women and 19.4% of men were obese, and 53.1% of women and 41.0% of men were hyperglycemic or diabetic. Median (IQR) leptin concentration was 15.2 ng/mL (10.2-17.3 ng/mL) in women and 2.7 ng/mL (1.3-5.3 ng/mL) in men. Leptin was positively correlated with BMI (Spearman's ρ was 0.6 in women, 0.7 in men). Women exposed to improved nutrition in early life had 2.8-ng/mL (95% CI: 0.3, 5.3 ng/mL) higher leptin and tended to have lower fasting glucose (-0.8 mmol/L; -1.8, 0.2 mmol/L, nonsignificant) than unexposed women. There were no significant differences in leptin (-0.7 ng/mL; -2.1, 0.8 ng/mL) or fasting glucose (0.2 mmol/L; -0.5, 0.9 mmol/L) in men exposed to improved nutrition in early life compared with unexposed men. Leptin mediated 34.9% of the pathway between early-life nutrition and fasting glucose in women. The mediation in women was driven by improved pancreatic ß-cell function. We did not observe the mediation effect in men. CONCLUSIONS: Leptin mediated the glucose-lowering effect of early-life nutrition in women but not in men.

Are the U.S. territories lagging behind in diabetes care practices?

AIMS: Although U.S. territories fall within the mandate outlined by Healthy People 2020, they remain neglected in diabetes care research. We compared the prevalence and secular trends of four recommended diabetes care practices in the U.S. territories of Guam, Puerto Rico, and the U.S. Virgin Islands to the 50 United States and D.C. ("U.S. States") in 2001-2015. METHODS: Data were from 390,268 adult participants with self-reported physician diagnosed diabetes in the Behavioral Risk Factor Surveillance System. Diabetes care practices included biannual HbA1c tests, attendance of diabetes education classes, daily self-monitoring of blood glucose, and receipt of annual foot examination. Practices were compared by U.S. territory and between territories and U.S. states. Multivariable models accounted for age, sex, education, and year. RESULTS: Of adults with diagnosed diabetes, 7% to 11% in the U.S. territories engaged in all four recommended diabetes care practices compared with 25% for those, on average, in U.S. states. Relative to the U.S. states, on average, the proportion achieving biannual HbA1c testing was lower in Guam and the U.S. Virgin Islands (45.6% and 44.9% vs. 62.2%), while annual foot examinations were lower in Puerto Rico (45.9% vs 66.1% in the U.S. states). Diabetes education and daily glucose self-monitoring were lower in all three territories. CONCLUSIONS: U.S. territories lag behind U.S. states in diabetes care practices. Policies aimed at improving diabetes care practices are needed in the U.S. territories to achieve Healthy People 2020 goals and attain parity with U.S. states.

Are recommended standards for diabetes care met in Central and South America? A systematic review.

AIMS: We evaluated quality of diabetes care in low- and middle-income countries (LMIC) of Central and South America by documenting the ability to meet the guideline-recommended targets. We also identified barriers to achieving goals of treatment and characteristics of successful programs. METHODS: We searched the National Library of Medicine and Embase databases to systematically compile literature that reported on guideline-recommended processes of care (annual foot, eye, urine examinations, and regular blood glucose testing) and risk factor control (glycemic, blood pressure, and lipid levels) among people with diabetes since 1980. We compared risk factor control across clinic and household populations and benchmarked against the IDF guidelines. RESULTS: The available literature was largely from Mexico, Jamaica, and Brazil with little data from rural regions or smaller countries. Twenty-nine clinic-based and ten population-based studies showed a consistent failure to meet recommended care goals due to multiple underlying social and economic themes. Across all studies, the proportion of those not meeting targets ranged from 13.0 to 92.2% for glycemic control, 4.6 to 92.0% for blood pressure, and 28.2 to 78.3% for lipids. CONCLUSIONS: Few studies report quality of diabetes care in LMICs of the Americas, and heterogeneity across studies limits our understanding. Greater regard for audits, use of standardized reporting methods, and an emphasis on overcoming barriers to care are required.

Overweight and diabetes prevalence among US immigrants.

OBJECTIVES: We estimated the prevalence of overweight and diabetes among US immigrants by region of birth. METHODS: We analyzed data on 34 456 US immigrant adults from the National Health Interview Survey, pooling years 1997 to 2005. We estimated age- and gender-adjusted and multivariable-adjusted overweight and diabetes prevalence by region of birth using logistic regression. RESULTS: Both men (odds ratio [OR] = 3.3; 95% confidence interval [CI] = 1.9, 5.8) and women (OR = 4.2; 95% CI = 2.3, 7.7) from the Indian subcontinent were more likely than were European migrants to have diabetes without corresponding increased risk of being overweight. Men and women from Mexico, Central America, or the Caribbean were more likely to be overweight (men: OR = 1.5; 95% CI = 1.3, 1.7; women: OR = 2.0; 95% CI = 1.7, 2.2) and to have diabetes (men: OR = 2.0; 95% CI = 1.4, 2.9; women: OR = 2.0; 95% CI = 1.4, 2.8) than were European migrants. CONCLUSIONS: Considerable heterogeneity in both prevalence of overweight and diabetes by region of birth highlights the importance of making this distinction among US immigrants to better identify subgroups with higher risks of these conditions.

Five-year changes in adiposity and cardio-metabolic risk factors among Guatemalan young adults.

BACKGROUND: Rapidly transitioning societies are experiencing dramatic increases in obesity and cardio-metabolic risk; however, few prospective studies from developing countries have quantified these increases or described their joint relationships. METHODS: We collected dietary, physical activity, demographic, anthropometric and cardio-metabolic risk factor data from 376 Guatemalan young adults in 1997-98 (aged 20-29 years) and in 2002-04 (aged 25-34 years). RESULTS: In total, 42 % of men and 56 % of women experienced weight gain >5 kg in 5 years. Percent body fat (%BF) and waist circumference (WC) increased by 4.2 % points and 5.5 cm among men, and 3.2 % points and 3.4 cm among women, respectively. Five-year increases in both %BF and WC were associated with lower physical activity, urban residence and shorter height among men but not among women (test for heterogeneity P < 0.05 for residence and physical activity). Changes in %BF and WC and concomitant changes in cardio-metabolic risk factors were similar for men and women. In standardised regression, change in %BF was associated with changes in TAG (beta=0.19; 95 % CI 0.08, 0.30), total:HDL cholesterol (beta=0.22; 95 % CI 0.12, 0.33) and systolic (beta=0.22; 95 % CI 0.12, 0.33) and diastolic (beta=0.18; 95 % CI 0.08, 0.28) blood pressure, but not with glucose; associations were similar for WC. CONCLUSIONS: Over 5 years this relatively young population of Guatemalan adults experienced rapid increases in multiple measures of adiposity, which were associated with adverse changes in lipid and blood pressure levels.

Prevalence of self-reported diabetes and exposure to organochlorine pesticides among Mexican Americans: Hispanic health and nutrition examination survey, 1982-1984.

BACKGROUND: The prevalence of diabetes is higher among Mexican Americans than among non-Hispanic whites. Higher serum levels of organochlorine pesticides in Mexican Americans have been reported. Few studies have explored the association between pesticide exposure and diabetes. OBJECTIVES: We set out to examine the association between self-reported diabetes and serum concentrations of organochlorine pesticides among Mexican Americans residing in the southwestern United States from 1982 to 1984. METHODS: This study was conducted among a sample of 1,303 Mexican Americans 20-74 years of age from the Hispanic Health and Nutrition Examination Survey. Serum concentrations were available for seven pesticides or pesticide metabolites at quantifiable levels in at least 1% of the study population: p,p'-DDT (dichlorodiphenyltrichloroethane), p,p'-DDE (dichlorodiphenyldichloro-ethylene), dieldrin, oxychlordane, beta-hexachlorocyclohexane, hexachlorobenzene, and trans-nonachlor. We used logistic regression to evaluate the association of self-reported diabetes with exposure to organochlorine pesticides, with and without adjustment for total serum lipids. Nonfasting serum glucose values were compared among exposure groups. RESULTS: Self-reported diabetes was significantly associated with serum levels above the detectable limit for trans-nonachlor, oxychlordane, and beta-hexachlorocyclohexane and among those with the highest level of exposure to p,p'-DDT and p,p'-DDE. On adjustment for total serum lipids, the association with p,p'-DDT remained significant. Serum glucose levels were elevated among those exposed to trans-nonachlor and beta-hexachlorocyclohexane. CONCLUSION: This study suggests that higher serum levels of certain organochlorine pesticides may be associated with increased prevalence of diabetes. Additional studies with more extensive clinical assessment are needed to confirm this association.

Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective.

OBJECTIVES: To review the magnitude, characteristics, and public health importance of type 2 diabetes in North American youth. RESULTS: Among 15- to 19-year-old North American Indians, prevalence of type 2 diabetes per 1000 was 50.9 for Pima Indians, 4.5 for all US American Indians, and 2.3 for Canadian Cree and Ojibway Indians in Manitoba. From 1967-1976 to 1987-1996, prevalence increased 6-fold for Pima Indian adolescents. Among African Americans and whites aged 10 to 19 years in Ohio, type 2 diabetes accounted for 33% of all cases of diabetes. Youth with type 2 diabetes were generally 10 to 19 years old, were obese and had a family history of type 2 diabetes, had acanthosis nigricans, belonged to minority populations, and were more likely to be girls than boys. At follow-up, glucose control was often poor, and diabetic complications could occur early. CONCLUSIONS: Type 2 diabetes is an important problem among American Indian and First Nation youth. Other populations have not been well studied, but cases are now occurring in all population groups, especially in ethnic minorities. Type 2 diabetes among youth is an emerging public health problem, for which there is a great potential to improve primary and secondary prevention.