[CROATIAN GUIDELINES FOR THE PHARMACOTHERAPY OF TYPE 2 DIABETES]. / HRVATSKE SMJERNICE ZA FARMAKOLOSKO LIJECENJE SECERNE BOLESTI TIPA 2.

INTRODUCTION: The Croatian Association for Diabetes and Metabolic Disorders of the Croatian Medical Association has issued in 2011 the first national guidelines for the nutrition, education, self-control, and pharmacotherapy of diabetes type 2. According to the increased number of available medicines and new evidence related to the effectiveness and safety of medicines already involved in the therapy there was a need for update of the existing guidelines for the pharmacotherapy of type 2 diabetes in the Republic of Croatia. PARTICIPANTS: as co-authors of the Guidelines there are listed all members of the Croatian Association for Diabetes and Metabolic Diseases, as well as other representatives of professional societies within the Croatian Medical Association, who have contributed with comments and suggestions to the development of the Guidelines. EVIDENCE: These guidelines are evidence-based, according to the GRADE system (eng. Grading of Recommendations, Assessment, Development and Evaluation), which describes the level of evidence and strength of recommendations. CONCLUSIONS: An individual patient approach based on physiological principles in blood glucose control is essential for diabetes' patients management. Glycemic targets and selection of the pharmacological agents should be tailored to the patient, taking into account the age, duration of disease, life expectancy, risk of hypoglyce- mia, comorbidities, developed vascular and other complications as well as other factors. Because of all this, is of national interest to have a practical, rational and applicable guidelines for the pharmacotherapy of type 2 diabetes.

[Prevention of diabetic foot]. / Prevencija dijabetickog stopala.

Diabetic foot (DF) is the most common chronic complication, which depends mostly on the duration and successful treatment of diabetes mellitus. Based on epidemiological studies, it is estimated that 25% of persons with diabetes mellitus (PwDM) will develop the problems with DF during lifetime, while 5% do 15% will be treated for foot or leg amputation. The treatment is prolonged and expensive, while the results are uncertain. The changes in DF are influenced by different factors usually connected with the duration and regulation of diabetes mellitus. The first problems with DF are the result of misbalance between nutritional, defensive and reparatory mechanisms on the one hand and the intensity of damaging factors against DF on the other hand. Diabetes mellitus is a state of chronic hyperglycemia, consisting of changes in carbohydrate, protein and fat metabolism. As a consequence of the long duration of diabetes mellitus, late complications can develop. Foot is in its structure very complex, combined with many large and small bones connected with ligaments, directed by many small and large muscles, interconnected with many small and large blood vessels and nerves. Every of these structures can be changed by nutritional, defensive and reparatory mechanisms with consequential DE Primary prevention of DF includes all measures involved in appropriate maintenance of nutrition, defense and reparatory mechanisms.First, it is necessary to identify the high-risk population for DF, in particular for macrovascular, microvascular and neural complications. The high-risk population of PwDM should be identified during regular examination and appropriate education should be performed. In this group, it is necessary to include more frequent and intensified empowerment for lifestyle changes, appropriate diet, regular exercise (including frequent breaks for short exercise during sedentary work), regular self control of body weight, quit smoking, and appropriate treatment of glycemia, lipid disorders (treatment with fenofibrate reduces the incidence of DF amputations (EBM-Ib/A), hypertension, hyperuricemia, neuropathy, and angiopathy (surgical reconstructive bypass) or endovascular (percutaneous transluminar angioplasty). In the low-risk group of PwDM, no particular results can be achieved, in contrast to the high-risk groups of PwDM where patient and professional education has shown significant achievement (EBM-IV/C). In secondary prevention of DF, it is necessary to perform patient and professional education how to avoid most of external influences for DE Patient education should include all topics from primary prevention, danger of neural analgesia (no cooling or warming the foot), careful selection of shoes, daily observation of foot, early detection all foot changes or small wounds, daily hygiene of foot skin, which has to be clean and moist, regular self measurements of skin temperature between the two feet (EBM-Ib/A), prevention of self treatment of foot deformities, changing wrong habits (walking footless), medical consultation for even small foot changes (EBM-Ib/A) and consultation by multidisciplinary team (EBM-IIb/B). Tertiary DF prevention includes ulcer treatment, prevention of amputation and level of amputation. In spite of the primary and secondary prevention measures, DF ulcers develop very often. Because of different etiologic reasons as well as different principles of treatment which are at the same time prevention of the level of amputation, the approach to PwDF has to be multidisciplinary. A high place in the treatment of DF ulcers, especially neuropathic ulcers, have the off-loading principles (EBM-Ib/A), even instead of surgical treatment (EBM-Ib/A). Necrectomy, taking samples for analysis from the deep of ulcer, together with x-ray diagnostics (in particular NMR), the size of the changes can be detected, together with appropriate antibiotic use and indication for major surgical treatment. The patient has to be instructed to the involved DF with off-loading (EBM-IIb/A). Negative pressure wound therapy can accelerate the closure of complex diabetic foot wounds (EBM- Ib/A). DF local treatment as well as ulcer covering for detritus absorption has not been EBM approved, although covering can diminish secondary infection. Skin or surrogate transplantations looks rationale but very expensive in comparison to off-loading. Randomized clinical trials do not prove usefulness of antibiotic treatment or surgical intervention in uninfected ulcer (EBM-IV/C), but the decision is left to the experienced physician. Evidence of osteomyelitis together with infected DF ulcer changes the prognosis of treatment, increasing the importance of antibiotic or surgical treatment (EBM-IIIB/B). Treatment with hyperbaric oxygen can help in wound healing, but without any influence on revascularization (EBM-Ib/A). At the end, the decision for the level of amputation has to be made. Charcot neuroarthropathy is still not clearly defined, so the randomized controlled trials are rare; thus, there are many new ways of treatment but the basics belongs to off-loading in simple changes through surgical treatment in more complex changes (EBM-IV/C)(rbn1). All available methods for detecting the level of vascularization, angioplasties, and oxymetry have to be used to decide on the minimal level of amputation.

[Cost of diabetes complications treatment: effect of improving glycemic control, blood pressure and lipid status on the occurrence of complications and costs of disease treatment]. / Trosak lijecenja komplikacija secerne bolesti Ucinak poboljsanja kontrole glikemije, krvnog tlaka i lipidnog statusa na pojavu komplikacija i troskove lijecenja bolesti.

Chronic complications of diabetes are the main cause of mortality and disability in people with diabetes, while also leading to growing healthcare system cost burdens. In order to analyze the effects of possible interventions on the health of population and their effectiveness in reducing the cost of the healthcare system, we have made health-economic models of diabetes chronic complications development. The models simulated long-term effect of improving glycemic control, blood pressure and lipid status in patients over a period of 10 years. The simulation results showed that the total savings over the analyzed period could amount to over 2 billion HRK, as effective long term control of risk factors leads to a reduction in the development of complications and death in people with diabetes. Successful treatments of patients provide a variety of savings for each of the chronic complications, and are obtained by simulating the biggest savings in the cost of hospitalization and rehabilitation. The cost-effectiveness analysis leads to the conclusion that the more intensive patient's control and earlier application of a treatment is cost-effective, and change of the healthcare system activities is a necessity.

Metabolic syndrome--community nursing evaluation and intervention: the CroHort study.

This prospective study of 1277 participants investigated patient risk self-assessment, motivation for changes in main determinants of the metabolic syndrome and the impact of community nursing intervention on cardiovascular risk reduction. Observed values of metabolic syndrome determinants indicated an elevated cardiovascular risk. Participants showed greatest motivation for positive changes regarding blood pressure, (3.70 +/- 1.26) then hyperglycemia (3.55 +/- 1.28), hyperlipidemia (3.46 +/- 1.30), overweight and obesity (3.43 +/- 1.28), and physical activity habits (3.29 +/- 1.31). Changes in physical activity and nutritional habits were not related to self-reported motivation regardless of the age and sex (p > 0.05). The most pronounced median improvements were observed in cholesterol (men 4.43%, women 4.89%) and triglycerides (men 3.41%, women 1.49%), with only slight changes in BMI (men 1.08%, women 1.18%) and no change in waist-to-hip ratio and glucose. This study revealed that, although aware and motivated, patients often do not succeed in changing habits. Concomitant changes of the environment and multisectoral prevention approach is necessary.

Cumulative incidence of self-reported diabetes in Croatian adult population in relation to socioeconomic status and lifestyle habits.

The aim of this study was to determine the 5-year cumulative incidence of self-reported diabetes mellitus in relation to various socioeconomic and lifestyle factors in Croatian adult population. The analysis included 2909 participants of the Croatian Health Cohort Study (CroHort) aged 20-79 years (median 55, interquartile range 43-67; 69% women) with no history of diabetes. There were 163 new cases of diabetes (5-year cumulative incidence 5.6%), without significant differences according to sex. Significant predictors of diabetes were age, body mass index, waist and hip circumference in bivariate logistic regression, and being married or living in partnership (OR = 1.57, 95% CI 1.08-2.28; p = 0.018), body mass index (OR =1.11, 95% CI 1.07-1.14; p < 0.001) and age (OR = 1.02, 95% CI 1.01-1.03; p = 0.004) in multivariate model. Our results indicate that approximately 1% of the Croatian adult population develops diabetes each year. Association of living in partnership with higher diabetes incidence requires further investigation.

Lifestyle habits of people with self-reported diabetes: changes during a five-year period.

The aims of our study were to investigate the prevalence of risk factors in persons with previously known diabetes ("old DM"), persons with diabetes developed during the 2003-2008 period ("new DM") and diabetes-free individuals within the CroHort study. Risk factors were defined as physical inactivity, unhealthy nutritional regimen, smoking and excessive alcohol consumption, while diabetes status was self-reported. The most prevalent risk factor in both "old DM" and "new DM" group was physical inactivity (46.7% and 33.7% in 2003; 46.8% and 46.3% in 2008), then smoking (12.1% and 14.6%; 12.7% and 14.4%), unhealthy diet (8.8% and 13.8; 8.2% and 10.0%) and heavy alcohol consumption (11.1% and 6.0%; 7.8% and 13.8%). Diabetes-free individuals had higher rates of smoking and unhealthy diet, and lower rates of alcohol consumption and physical inactivity than both diabetes groups. These results indicate the need for comprehensive actions oriented towards persons with diabetes concerning physical activity.

Gender differences in the control of cardiovascular risk factors in patients with type 2 diabetes -a cross-sectional study.

OBJECTIVE: Trends in diabetes and cardiovascular mortality rates are considerably different between women and men; this can be partially explained by differences in diabetes control. The aim of this cross-sectional study was to assess whether sex differences exist in effective control of cardiovascular risk factors among persons with type 2 diabetes treated at the Vuk Vrhovac University Clinic in 2008. MATERIALS AND METHODS: We performed a cross-sectional analysis including 8,775 patients who attended the clinic in 2008. Levels of HbA1c, systolic and diastolic blood pressure (SBP, DBP), LDL-cholesterol (LDL) and triglycerides (TG) were analyzed. Multiple adjusted odds-ratios were calculated for categories of cardiovascular risk factors considered not being in control (HbA1c ≥ 7%, SBP ≥ 130 mmHg, DBP ≥ 80 mmHg, LDL ≥ 2.5 mmol/L, TG ≥ 1.7 mmol/L). RESULTS: Women had higher levels of HbA1c (7.05 vs. 6.86%; p<0.001), despite the fact that a larger proportion of women were receiving insulin therapy than men (51.3% vs. 44%). Women also had higher mean values of SBP (144.7 vs. 141.9 mmHg; p<0.001) and LDL (2.92 vs. 2.84 mmol/L). There were no differences in DBP (86.1 vs. 86.0 mmHg; p=0.748) and only triglyceride levels were higher in men (2.04 vs. 1.94 mmol/L; p=0.003). In multi-adjusted logistic regression model female sex was associated with a higher odds ratio of having uncontrolled values of HbA1c (OR=1.21; 95%CI 1.11-1.32), SBP (OR=1.21; 95%CI 1.07-1.37) and LDL (OR=1.13; 95%CI 1.04-1.23). CONCLUSION: Women with diabetes have poorer control of main potentially modifiable cardiovascular risk factors than men. This could contribute to disparities in trends in cardiovascular mortality and it demands clinicians' and public health awareness.

[Liraglutide in the treatment of diabetes type 2]. / Liraglutid u lijecenju secerne bolesti tipa 2.

Diabetes type 2 is the most frequent metabolic disorder in Croatia, and also in all developed countries as well as in most of the countries in development. Chronic complications of diabetes are significant contributors to the morbidity in the population, and their management consumes a considerable amount of financial health resources. Previous treatment possibilities showed limited results in reducing the frequency of chronic complications and their consequences. Advancement in medical knowledge provides better understanding of etiology and pathogenesis of diabetes type 2, allowing as well a development of the new categories of drugs. Liraglutide is a representative of a new drug class which shows significant advantages over former medications.

Obesity in type 2 diabetes: prevalence, treatment trends and dilemmas.

This retrospective observational study investigated the prevalence of obesity in persons with type 2 diabetes, trends in obesity resulting from the duration and treatment of diabetes, and treatment-related changes in HbA1c and body mass index (BMI). Data on 1773 type 2 diabetics (802 men and 971 women) were obtained from the CroDiabNET registry. Follow-up included the analysis of patients' age, disease duration, diabetes treatment, BMI and HbA1c values. A significantly higher rate of overweight and obesity was found in persons with type 2 diabetes as compared to the general population. A significant decrease in BMI was observed in the groups treated by diet, and in those treated by oral hypoglycaemic agents (p < 0.05), regardless of their pharmacotherapeutic group, in contrast to a significant increase in BMI observed in the groups treated with insulin (alone or in combination with oral hypoglycaemic agents) (p < 0.05). Persons with type 2 diabetes lost weight only during the first years of the disease, while with diabetes duration and insulin treatment they regained weight. A significant increase in HbA1c was observed in the groups treated with sulfonylureas (p < 0.05), whereas all other groups revealed either a significant decrease (p < 0.05) or no change in HbA1c. Our findings suggest the necessity of an integrated approach to managing type 2 diabetic patients that would simultaneously address both diabetes and obesity. Good glycaemic control is imperative and diabetes treatment should not be postponed. Because of a possible concomitant weight gain, aggressive weight control measures should be applied concurrently in order to achieve maximum treatment benefit.

Impact of a guide dog on glycemia regulation in blind/visually impaired persons due to diabetes mellitus.

The aim was to assess glycemia regulation in a blind diabetic patient after getting a guide dog. Glycosylated hemoglobin (HbA1c) results of a blind patient before and after getting the guide dog were retrospectively collected. The paired t-test results yielded a two-tailed P value of 0.0925, a difference considered not statistically significant; the 95% confidence interval of this difference varied from -0.2494 to 1.889. An improvement of glycemia regulation was observed with the guide dog compared to previous glycemia regulation, however, the difference was not statistically significant. The moderate improvement could probably be attributed to the mobility of the blind person having a guide dog. Standard quality of life tests should be included in the evaluation of diabetic blind persons, especially the impact of a guide dog on glycemic control or other chronic complications of diabetes.

Lipoprotein(a) predicts progression of carotid artery intima-media thickening in patients with type 2 diabetes: A four-year follow-up.

BACKGROUND: The aim of the study was to establish whether increased levels of serum lipoprotein(a) significantly contribute to an increase in intima-media thickness and the number of carotid artery plaques, and consequently to cardiovascular risk in patients with type 2 diabetes mellitus. METHODS: Lipoprotein(a) levels, intima-media thickness and the number of carotid artery plaques were determined at the beginning of the study in 146 patients with type 2 diabetes. Patients were divided into two groups according to serum lipoprotein(a) levels (> or 30 mg/dl had more cardiovascular events, the difference was not statistically significant. CONCLUSIONS: These results indicate that lipoprotein(a) is an independent, genetically determined risk factor closely associated with progression of intima-media thickness in type 2 diabetes.

Diabetes mellitus and hypertension have comparable adverse effects on health-related quality of life.

BACKGROUND: We aimed to assess health-related quality of life (HRQoL) among people with diabetes or hypertension, estimate the effect of cardiovascular comorbidities on HRQoL as well as compare HRQoL in these groups with that of healthy individuals. METHODS: A total of 9,070 respondents aged 18 years and over were assessed for HRQoL. Data were obtained from the Croatian Adult Health Survey. Respondents were divided into five groups according to their medical history: participants with hypertension (RR), hypertension and cardiovascular comorbidities (RR+), diabetes mellitus (DM), diabetes and cardiovascular comorbidities (DM+) and participants free of these conditions (healthy individuals, HI). HRQoL was assessed on 8 dimensions of the SF-36 questionnaire. RESULTS: Participants with diabetes and those with hypertension reported comparably limited (p > 0.05) HRQoL in all dimensions of SF-36, compared with healthy individuals (p < 0.05). If cardiovascular comorbidities were present, both participants with diabetes and participants with hypertension had lower results on all SF-36 scales (p > 0.05) than participants without such comorbidities (p < 0.05). The results remained after adjustment for sociodemographic variables (age, sex, employment, financial status and education). CONCLUSION: Diabetes and hypertension seem to comparably impair HRQoL. Cardiovascular comorbidities further reduce HRQoL in participants with both chronic conditions. Future research of interventions aimed at improving these participants' HRQoL is needed.

[CroDiab web and improvement of diabetes care at the primary health care level]. / CroDiab web I unaprjedenje dijabetoloske skrbi u primarnoj zdravstvenoj zastiti.

BACKGROUND AND AIM: Diabetes is a complex metabolic disorder regarded as one of the most significant public health issues of the 21S century. Keeping a diabetes registry facilitates monitoring of the epidemiological situation, while a structured approach to the registration of diabetic patients (reporting on an optimum information cluster for the follow-up and improvement of diabetes care) contributes to better regulation of patient risk factors. Active patient reporting at the primary health care level has begun in 2006 with setting up the legislative background. The aim of this study was to establish the effect of the CroDiab registry on metabolic parameters in type 2 diabetic patients treated at primary health care level by comparing diabetes indicators between the regularly annually reported type 2 diabetic patients and those that were only intermittently reported to the registry from 2006 until 2008. METHODS: Family physicians submit their reports mainly via CroDiab web, a Croatian web-based system for the collection of data on diabetic patients, which enables analysis of the basic clinical and public health indices. The levels of fasting and postprandial blood glucose, HbA1c, triglycerides, total cholesterol, HDL- and LDL-cholesterol, systolic and diastolic blood pressure, and body mass index were analyzed in 2006 and 2008, and compared between the two study groups. RESULTS: At baseline, differences between the intermittently reported (I) and regularly reported (R) groups were only observed in the systolic (I 142.4+/-16.6, R 136.8+/-16.6 mm Hg; p<0.001) and diastolic (1 83.9+/-8.2, R 82.1+/-10.0 mm Hg; P=0.002) blood pressure, while at the end of the study period differences were also recorded in postprandial blood glucose (I 10.63+3.12, R 10.02+/-3.44 mmol/L; P=0.024), HbA1c (I 7.97+/-1.52, R 7.39+/-1.17%; P<0.001), total cholesterol (I 5.60+/-1.15, R 5.25+/-1.13 mmol/L; p<0.001) and LDL-cholesterol (I 3.28+/-0.93, R 2.98+/-0.92 mmol/L; P<0.001). There were no statistically significant differences in body mass index, fasting glucose, HDL-cholesterol and triglycerides. DISCUSSION AND CONCLUSION: Electronic medical records and structured health care are associated with increased benefits and improvement in metabolic indicators at the primary health care level. Regular reporting and monitoring via CroDiab registry lead to a significant improvement in the majority of metabolic indicators, which is less marked with intermittent reporting. The more pronounced effect observed in the group of patients that were regularly covered by the registry could be attributed to a more comprehensive and regular insight and better patient care associated with continuous monitoring. Further efforts are therefore needed to achieve the widest possible implementation of the CroDiab web system to improve diabetes care at the primary health care level.

Psychoeducation versus treatment as usual in diabetic patients with subthreshold depression: preliminary results of a randomized controlled trial.

BACKGROUND: Research on the effects of treating sub-threshold depression in persons with diabetes is scarce in spite of the findings indicating that this condition is highly prevalent in the diabetic population and may increase the risk of developing a subsequent major depression. This study was aimed at exploring the effects of a psycho-educational intervention on depression- and diabetes-related outcomes in patients with mild to moderate depressive symptoms. METHODS: A randomized controlled study design with a one-year follow-up was used. Fifty patients with mild to moderate depressive symptoms (74% female, aged 57 +/- 9 yrs, diabetes duration of 10 +/- 8 yrs, BMI 31 +/- 6 kg/m2, HbA1C 7.7% +/- 1.4, 53% insulin treated) were randomly assigned to either an intervention or a control group. The intervention group underwent four psycho-educational sessions aimed at enabling self-management of depressive symptoms. The control group was informed about the screening results and depression treatment options while continuing diabetes treatment as usual. Both groups were contacted by phone in 2-3-month intervals, and re-assessed for depression after 6 and 12 months. Changes in depressive symptoms and glycaemic control were considered primary outcomes. Mann-Whitney U test and Friedman ANOVA were used to compare between- and within-group indicators at 6- and 12-month follow-ups. RESULTS: Both the intervention and the control group reported a significant decrease in depressive symptoms as measured by the CES-D scale (Friedman ANOVA chi2 = 10.8 p = .004 and chi2 = 7.3 p = 0.03, respectively). The 6-month and 1-year indicators of glycaemic control as compared to baseline HbA1C values were also improved in both groups (chi2 = 11.6 p = 0.003 and chi2 = 17.1 p = 0.0002, respectively). Between-group differences in depressive symptoms and HbA1C values were not statistically significant either at 6- or at 12-month follow-up (all p > 0.05). CONCLUSION: Psycho-educational treatment appears to be beneficial in diabetic patients with mild to moderate depressive symptoms, but its effects are comparable with the non-specific support given to the subjects in the control group. TRIAL REGISTRATION: Current Controlled Trials ISRCTN58745372.

Lifestyle habits of Croatian diabetic population: observations from the Croatian Adult Health Survey.

The aim of this study was to assess the behavioural risk factors in Croatian diabetic population and to compare them with the lifestyle habits of individuals with no known history of diabetes. The study was a part of the Croatian Adult Health Survey (CAHS), a cross-sectional survey that provided comprehensive health assessment of the Croatian adult population. Risk factors were defined as an unhealthy nutritional regimen, excessive alcohol consumption, smoking and lack of physical activity. Physical inactivity was the most prevalent risk factor observed in a significant number of both diabetic and non-diabetic subjects (44.8% and 29.1%). It was also the only behavioural risk factor that was more prevalent in the diabetic individuals as compared to those without diabetes. Alcohol consumption did not vary significantly between the two groups (5.8% vs. 6.3%), while unhealthy dietary pattern and smoking were less frequent in respondents with diabetes (10.0% vs. 16.5% and 14.3% vs. 23.2%, respectively). Among diabetic patients, a significantly larger proportion of men than women reported smoking (19.2% vs. 10.0%), whereas no such sex-related differences were observed in other behavioural risk factors. Although the most prominent risk factor in diabetic patients was physical inactivity, a significant proportion of respondents with diabetes also reported the presence of other risk factors investigated in this survey. Since the majority of diabetic patients do not reach their treatment goals, there is a substantial need for curative and preventive interventions. Given the importance of physical activity in the treatment and prevention of diabetes and the high proportion of inactive diabetic patients, any future preventive programme in Croatia should address that risk as well.

[Recommendations of Croatian societies on treatment of macrovascular and microvascular complications in patients with metabolic syndrome and diabetes type 2--treatment of residual risk]. / Preporuke Hrvatskih strucnih drustava o lijecenju makrovaskularnih i mikrovaskularnih komplikacija u bolesnika s metabolickim sindromom i secernom bolesti tipa 2--lijecenje preostalog kardiovaskularno [corrected] rizika.

Quite a number of studies have shown that despite achieving targets for total and LDL cholesterol, blood pressure and glycemia according to the guidelines, many patients remain at high residual risk for cardiovascular diseases (CVD), both macrovascular and microvascular. This is particularly true for patients with established CVD, type 2 diabetes, obesity and/or metabolic syndrome who have very often atherogenic dyslipidemia characterized by decreased plasma concentrations of HDL cholesterol and increased triglycerides. To address this issue a working group of experts has been established to produce this document in order to recommend therapeutic interventions for reducing this residual risk. This document has been endorsed by relevant Croatian scientific and professional societies (Croatian atherosclerosis socitey, Croatian hypertension society, Croatian cardiac society, Croatian diabetes society, Croatian endocrinology society, Croatian obesity society, Croatian internal medicine society and Croatian society for clinical pharmacology).

[Incretins in the treatment of diabetes]. / Inkretini u lijecenju secerne bolesti.

Nowadays, diabetes affects about 200 million people worldwide, and represents the sixth-leading cause of death. Approximately 90 to 95% of those affected have type 2 diabetes, caused by two main mechanisms: insulin deficiency or peripheral insulin resistance. Early in the approach, diabetic patients are encouraged to make healthy lifestyle modifications including changes in diet, exercise patterns, and weight control. However, in most of patients, as the disease progresses, pharmacologic treatment becomes necessary. Despite the many pharmacological treatment modalities currently available, glucose control remains unsatisfactory in the type 2 diabetes population as evidenced by average hemoglobin A1c (HbA1c). The incretin mimetics and DPP-IV inhibitors are the new class of medications available for treating patients with diabetes type 2. The glycemic profiles of patients after administrations of incretin mimetics and DPP-IV inhibitors show improvement in postprandial glucose levels and ultimately in HbA1c. Therefore, incretin mimetics and DPP-IV inhibitors may play a clinically significant role in the treatment of patients with type 2 diabetes.

Prevalence of diabetes mellitus in Croatia.

The aim of this study was to obtain an accurate estimate of diabetes prevalence in Croatia and additional estimates of impaired fasting glucose (IFG), undiagnosed diabetes, and insulin resistance. The study was part of the First Croatian Health Project. Field work included a questionnaire, anthropological measurements, and blood sampling. A nationally representative sample of 1653 subjects aged 18-65 years was analyzed. A total of 100 participants with diabetes were detected, among them 42 with previously unknown diabetes. The prevalence was 6.1% (95% CI: 4.59-7.64), with a significant difference by age. IFG prevalence (WHO-criteria) was 11.3%. The ratio of undiagnosed/diagnosed diabetes was 72/100, unevenly distributed by the regions. HOMA-IR was >1 in 40.4% of the subjects. This survey revealed a higher prevalence of diabetes than previously estimated, whereas that of IFG was as expected. A significant difference in the proportion of undiagnosed diabetes among the regions warrants attention.