Five-year changes in biologic risk factors and risk of type 2 diabetes: are attained but not initial risk factor levels of importance?

Independent effects of changes in biologic risk factors on type 2 diabetes incidence remain unclear. The authors examined whether associations between changes in biologic risk factors and diabetes risk are driven by initial or attained risk factor levels. Biologic risk factors were measured at baseline and at each 5-year interval follow-up (rounds 2, 3, and 4) among 4,204 initially healthy men and women, aged 20-59 years, participating in the Dutch Doetinchem Cohort Study (1987-2007). Time-dependent Cox regression analyses were used to analyze associations between changes in waist circumference, blood pressure, and high density lipoprotein cholesterol (HDL cholesterol) and incident diabetes, adjusted for initial or attained levels; 130 diabetes cases occurred during 9 years of follow-up. Five-year increases in waist circumference and blood pressure and decreases in HDL cholesterol were positively associated with risk of diabetes after adjustment for initial levels but no longer after adjustment for attained levels: waist circumference (hazard ratio (HR) = 0.86, 95% confidence interval (CI): 0.69, 1.07), systolic blood pressure (HR = 0.96, 95% CI: 0.84, 1.10), diastolic blood pressure (HR = 0.96, 95% CI: 0.87, 1.06), and HDL cholesterol (HR = 0.91, 95% CI: 0.81, 1.01). In conclusion, the associations between changes in biologic risk factors and risk of diabetes are mainly driven by the attained levels. Hence, not the prior changes, but the attained levels seem to be of importance with regard to diabetes risk.

Weight change and incident diabetes: addressing an unresolved issue.

The impact of weight change on diabetes incidence remains unclear. To clarify the role of weight change as a risk factor for diabetes, the authors assessed the association between weight change and diabetes incidence conditional upon either initial or attained body mass index (BMI). They used 7,837 observations available from repeated measurements of 4,259 participants (men and women aged 20-59 years) in the Dutch population-based Doetinchem Cohort Study (1987-2007) to analyze the association between 5-year weight change and diabetes incidence (n = 124) in the subsequent 5 years. When adjusted for initial BMI, 5-year weight change was a significant risk factor for diabetes (odds ratio = 1.08, 95% confidence interval: 1.04, 1.13 per kilogram of weight change). However, no significant association was found between weight change and diabetes if the association was adjusted for attained BMI (odds ratio = 0.99, 95% confidence interval: 0.94, 1.04 per kilogram of weight change). Results suggest that weight change is associated with diabetes incidence because, conditional upon initial BMI, weight change determines attained BMI. This finding implies that lifestyle interventions can contribute to diabetes prevention because they affect attained BMI. Weight change appears to have no effect on diabetes incidence beyond its effect on attained BMI.

The cost-effectiveness of implementing a new guideline for cardiovascular risk management in primary care in the Netherlands.

BACKGROUND: A new Dutch guideline for cardiovascular disease management substantially extends the number of individuals for whom treatment with statins and/or antihypertensive agents is recommended. We estimated the cost-effectiveness of implementing the new guideline at the national level. METHODS: First, the number of currently untreated individuals who would become eligible for cholesterol-lowering or antihypertensive treatment under the new guideline was estimated using data from a recent population study. Cost-effectiveness of treating this group of patients was then assessed using a mathematical model. RESULTS: Implementing the guideline in the age category 30-69 years would lead to an additional 465,000 individuals requiring treatment. Over a period of 20 years, the cumulative incidence of acute myocardial infarction in the whole population would drop by 3.0%, that of stroke by 3.9%, and all-cause mortality would drop by 0.9%. The lifetime cost-effectiveness ratio was calculated to be 15,000 Euro per quality-adjusted life year gained. In the age categories 70-79 years and 80 years or above, an additional 600,000 and 450,000 persons, respectively, would need to be treated, resulting in corresponding reductions in cumulative incidences of 14 and 18% (acute myocardial infarction), 17 and 22% (stroke), and 1.2 and 0.6% (all-cause mortality) with cost-effectiveness ratios of 20,800 and 32,300 Euro, respectively, per quality-adjusted life year. CONCLUSION: Complete implementation of the new guideline would lead to a considerable increase in the number of individuals requiring treatment. This would be cost-effective up to the age of 70 years.

Lifestyle interventions are cost-effective in people with different levels of diabetes risk: results from a modeling study.

OBJECTIVE: In the current study we explore the long-term health benefits and cost-effectiveness of both a community-based lifestyle program for the general population (community intervention) and an intensive lifestyle intervention for obese adults, implemented in a health care setting (health care intervention). RESEARCH DESIGN AND METHODS: Short-term intervention effects on BMI and physical activity were estimated from the international literature. The National Institute for Public Health and the Environment Chronic Diseases Model was used to project lifetime health effects and effects on health care costs for minimum and maximum estimates of short-term intervention effects. Cost-effectiveness was evaluated from a health care perspective and included intervention costs and related and unrelated medical costs. Effects and costs were discounted at 1.5 and 4.0% annually. RESULTS: One new case of diabetes per 20 years was prevented for every 7-30 participants in the health care intervention and for every 300-1,500 adults in the community intervention. Intervention costs needed to prevent one new case of diabetes (per 20 years) were lower for the community intervention (2,000-9,000 euros) than for the health care intervention (5,000-21,000 euros). The cost-effectiveness ratios were 3,100-3,900 euros per quality-adjusted life-year (QALY) for the community intervention and 3,900-5,500 euros per QALY for the health care intervention. CONCLUSIONS: Health care interventions for high-risk groups and community-based lifestyle interventions targeted to the general population (low risk) are both cost-effective ways of curbing the growing burden of diabetes.

Do parents who smoke underutilize health care services for their children? A cross sectional study within the longitudinal PIAMA study.

BACKGROUND: A higher prevalence of respiratory symptoms and an associated increase in health care utilization among children with parents who smoke is to be expected. From previous studies however, it appears that parents who smoke may underutilize health services for their children, especially with respect to respiratory care. This study explores the validity and generalizability of the previous assumption. METHODS: Data were obtained from a Dutch birth-cohort study; the Prevention and Incidence of Asthma and Mite Allergy (PIAMA) project. Information regarding parental smoking, the child's respiratory symptoms and health care use and potential confounders were obtained by postal questionnaires. Multivariate logistic models were used to relate parental smoking to the child's respiratory symptoms and health care use. RESULTS: The study comprised 3,564, 4-year old children. In the crude analysis, respiratory symptoms were more frequent among children with a parent who smoked, while health care utilization for respiratory symptoms was not significantly different between children with or without a parent who smoked. In the multivariate analyses, maternal smoking had a larger impact on the child's respiratory symptoms and health care use as compared to paternal smoking. Maternal smoking was positively associated with mild respiratory symptoms of the child, adjusted odds ratio [AOR] 1.50 (1.19-1.91), but not with severe respiratory symptoms AOR 1.03 (0.75-1.40). Among children with mild respiratory symptoms, children with a mother who smoked were less likely to be taken to the general practitioner (GP) for respiratory symptoms, than children with mothers who did not smoke, AOR 0.58 (0.33-1.01). This finding was less pronounced among children with severe respiratory symptoms AOR 0.86 (0.49-1.52). Neither GP visits for non-respiratory symptoms nor specialized care for respiratory disease were significantly associated with parental smoking. CONCLUSION: Mothers who smoke appear to underutilize health care for their children with mild respiratory symptoms. Health care workers should be informed about this phenomenon. Inquiring after the respiratory health of the children during regular visits to healthy baby clinics may help to track potential underutilization of care.

Radiographic hip disorders and associated complications in severe cerebral palsy.

We performed a cross-sectional study of 160 adult patients with severe cerebral palsy to study the relationship between radiographic hip disorders (migration and deformity of the femoral head), on the one hand, and complications such as handling problems, seating problems, decubitus ulcers, fractures and contractures, on the other hand. Both migration and deformity were positively related to the need for a special seat in the wheelchair and adduction contractures of the hip. We conclude that migration and deformity of the femoral head, if possible, should be prevented in patients with severe cerebral palsy.

Determinants of hip pain in adult patients with severe cerebral palsy.

The purpose of our investigation was to study the relationship between radiographic results of the femoral head and pain in people with severe cerebral palsy. We conducted a cross-sectional study on hip radiography results and pain in 160 patients with severe cerebral palsy. Eighteen percent of our patients had hip pain in hip-loading situations. Migration and deformity were closely related. There was a significant association with hip pain (odds ratio, 2.79; 95% confidence interval 1.01-7.70). There is a high prevalence of hip pain after unsuccessful femoral bone surgery. Migration and deformity of the femoral head are strongly interrelated, and are associated with pain.

Cost-effectiveness of lifestyle modification in diabetic patients.

OBJECTIVE To explore the potential long-term health and economic consequences of lifestyle interventions for diabetic patients. RESEARCH DESIGN AND METHODS A literature search was performed to identify interventions for diabetic patients in which lifestyle issues were addressed. We selected recent (2003-2008), randomized controlled trials with a minimum follow-up of 12 months. The long-term outcomes for these interventions, if implemented in the Dutch diabetic population, were simulated with a computer-based model. Costs and effects were discounted at, respectively, 4 and 1.5% annually. A lifelong time horizon was applied. Probabilistic sensitivity analyses were performed, taking account of variability in intervention costs and (long-term) treatment effects. RESULTS Seven trials with 147-5,145 participants met our predefined criteria. All interventions improved cardiovascular risk factors at > or =1 year follow-up and were projected to reduce cardiovascular morbidity over lifetime. The interventions resulted in an average gain of 0.01-0.14 quality-adjusted life-years (QALYs) per participant. Health benefits were generally achieved at reasonable costs (< or =euro50,000/QALY). A self-management education program (X-PERT) and physical activity counseling achieved the best results with > or =0.10 QALYs gained and > or =99% probability to be very cost-effective (< or =euro20,000/QALY). CONCLUSIONS Implementation of lifestyle interventions would probably yield important health benefits at reasonable costs. However, essential evidence for long-term maintenance of health benefits was limited. Future research should be focused on long-term effectiveness and multiple treatment strategies should be compared to determine incremental costs and benefits of one over the other.

[Diabetes mellitus in the Netherlands: estimate of the current disease burden and prognosis for 2025]. / Diabetes mellitus in Nederland: schatting van de huidige ziektelast en prognose voor 2025.

OBJECTIVE: To estimate the number of people with diagnosed diabetes mellitus in the Netherlands in 2007 using a new method; to describe trends in the past; to predict the situation in 2025. DESIGN: Model calculations. METHODS: Based on five general practice records (Nijmegen Continuous Morbidity Registration [CMR], Netherlands Information Network of General Practice [LINH], Limburg Family Practice Registration Network [RNH-Limburg], Registration Network University Family Practices, Leiden and its environs [RNUH-LEO], and the transition project) the prevalence and incidence of diagnosed diabetes in the Netherlands in 2007 was estimated. Trends in the prevalence of diagnosed diabetes were estimated from the five records over the period 2000-2007. The prevalence of diagnosed diabetes in 2025 was estimated using the Dutch Chronic Diseases Model, which takes into account demographic developments and a further increase in obesity in the Netherlands in the future. RESULTS: In 2007, 740,000 persons (95% CI: 665,000-824,000) with diabetes were undergoing care. The incidence of new diabetes during 2007 was 71,000 (95% CI: 57,000-90,000). The prevalence of diagnosed diabetes increased by almost 80% in 2000-2007. The model projection resulted in an estimate of 1.3 million people with diagnosed diabetes in 2025, i.e. 8% of the Dutch population. There is a high level of uncertainty about these estimates. CONCLUSION: The increase in the number of diabetes patients in 2025 has consequences for care and will require measures to be taken in coming years in the areas of prevalence and care organisation.

Lipid-lowering treatment for all could substantially reduce the burden of macrovascular complications of diabetes patients in the Netherlands.

BACKGROUND: We aimed to quantify the potential health benefits of increased use of lipid-lowering treatment (LLT), according to current guidelines, for the Dutch diabetes population. DESIGN: Simulation study. METHODS: We compared the long-term health outcomes for a scenario in which all diabetes patients received LLT to those in a 'current practice' scenario, in which 28% received LLT. The model reflected the Dutch diabetes population 40-80 years of age, in 2003. Sensitivity analyses were performed, using more conservative assumptions. RESULTS: Over the lifetime, LLT for all diabetes patients reduced the expected cumulative incidences of coronary heart disease (CHD) and stroke by, respectively, 6 and 9%. Average life expectancy of Dutch diabetes patients would increase by 0.33 years, ranging from 0.14 years for patients aged 70-79 years, to 0.84 years for patients aged 40-49 years at the start of the simulation. Life-long treatment for patients aged 50-59 contributed most to the life years gained (55,000 out of 146,000). With reduced effectiveness of LLT and fewer patients starting LLT, the cumulative incidences of both CHD and stroke would decrease by approximately 2%. The number needed to treat to prevent one incident case of cardiovascular disease over lifetime was 20 for CHD and 44 for stroke. CONCLUSION: This simulation study shows that increased use of LLT can substantially reduce the expected future burden of CHD and stroke in the Dutch diabetes population.