[Show abstract][Hide abstract] ABSTRACT: We sought to identify factors associated with participant retention in a 2-year, physician-lead, multidisciplinary, clinical weight management program that employs meal replacements to produce weight loss and intensive behavioral interventions and financial incentives for weight loss maintenance. We studied 270 participants enrolled in 2010 and 2011. Sociodemographic factors, health insurance, distance traveled, body mass index, comorbidities, health-related quality-of-life, and depression were explored as potential predictors of retention.
Mean age was 49 ± 8 years and BMI was 41 ± 5 kg/m(2). Retention was excellent at 3 months (90%) and 6 months (83%). Attrition was greatest after participants were transitioned to regular foodstuffs and fell to 67% at 12 months and 51% at 2 years. Weight decreased by 15 ± 12 kg and BMI decreased by 5.1 ± 4.0 kg/m(2) in 2-year completers. Older age, lower baseline BMI, and financial incentives for program participation were independently associated with retention. Fewer depressive symptoms at baseline were associated with retention.
This multidisciplinary, clinical, weight management program demonstrated high retention and excellent outcomes. Older age at baseline, less extreme obesity, and financial incentives were associated with program retention.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to develop and validate a computer simulation model for coronary heart disease (CHD) in type 2 diabetes mellitus (T2DM) that reflects current medical and surgical treatments.
We modified the structure of the CHD submodel in the Michigan Model for Diabetes to allow for revascularization procedures before and after first myocardial infarction, for repeat myocardial infarctions and repeat revascularization procedures, and for congestive heart failure. Transition probabilities that reflect the direct effects of medical and surgical therapies on outcomes were derived from the literature and calibrated to recently published population-based epidemiologic studies and randomized controlled clinical trials. Monte Carlo techniques were used to implement a discrete-state and discrete-time multistate microsimulation model. Performance of the model was assessed using internal and external validation. Simple regression analysis (simulated outcome=b0+b1×published outcome) was used to evaluate the validation results.
For the 21 outcomes in the six studies used for internal validation, R(2) was 0.99, and the slope of the regression line was 0.98. For the 16 outcomes in the five studies used for external validation, R(2) was 0.81, and the slope was 0.84.
Our new computer simulation model predicted the progression of CHD in patients with T2DM and will be incorporated into the Michigan Model for Diabetes to assess the cost-effectiveness of alternative strategies to prevent and treat T2DM.
[Show abstract][Hide abstract] ABSTRACT: To determine if individualized education before Ramadan results in a safer fast for people with type 2 diabetes.
Patients with type 2 diabetes who received care from participating clinics in Egypt, Iran, Jordan and Saudi Arabia and intended to fast during Ramadan 2014 were prospectively studied. Twelve clinics participated. Individualized education addressed meal planning, physical activity, blood glucose monitoring and acute metabolic complications and when deemed necessary, provided an individualized diabetes treatment plan.
774 people met study criteria, 515 received individualized education and 259 received usual care. Those who received individualized education were more likely to modify their diabetes treatment plan during Ramadan (97% vs 88%, p<0.0001), to perform self-monitoring of blood glucose at least twice daily during Ramadan (70% vs 51%, p<0.0001), and to have improved knowledge about hypoglycemic signs and symptoms (p=0.0007). Those who received individualized education also reduced their body mass index (-1.1±2.4 kg/m(2) vs -0.2±1.7 kg/m(2), p<0.0001) and glycated haemoglobin (-0.7±1.1% vs -0.1±1.3%, p<0.0001) during Ramadan compared those who received usual care. There were more mild (77% vs 67%, p=0.0031) and moderate (38% vs 19%, p<0.0001) hypoglycemic events reported by participants who received individualized education than those who received usual care, but fewer reported severe hypoglycemic events during Ramadan (23% vs 34%, p=0.0017).
This individualized education and diabetes treatment program helped patients with type 2 diabetes lose weight, improve glycemic control and achieve a safer fast during Ramadan.
[Show abstract][Hide abstract] ABSTRACT: Context: Gestational diabetes (GDM) confers a high risk of type 2 diabetes. In the Diabetes Prevention Program (DPP), intensive lifestyle (ILS) and metformin prevented or delayed diabetes in women with a history of GDM. Objective: The objective of the study was to evaluate the impact of ILS and metformin intervention over 10 years in women with and without a history of GDM in the DPP/Diabetes Prevention Program Outcomes Study. Design: This was a randomized controlled clinical trial with an observational follow-up. Setting: The study was conducted at 27 clinical centers. Participants: Three hundred fifty women with a history of GDM and 1416 women with previous live births but no history of GDM participated in the study. The participants had an elevated body mass index and fasting glucose and impaired glucose tolerance at study entry. Interventions: Interventions included placebo, ILS, or metformin. Outcomes Measure: Outcomes measure was diabetes mellitus. Results: Over 10 years, women with a history of GDM assigned to placebo had a 48% higher risk of developing diabetes compared with women without a history of GDM. In women with a history of GDM, ILS and metformin reduced progression to diabetes compared with placebo by 35% and 40%, respectively. Among women without a history of GDM, ILS reduced the progression to diabetes by 30%, and metformin did not reduce the progression to diabetes. Conclusions: Women with a history of GDM are at an increased risk of developing diabetes. In women with a history of GDM in the DPP/Diabetes Prevention Program Outcomes Study, both lifestyle and metformin were highly effective in reducing progression to diabetes during a 10-year follow-up period. Among women without a history of GDM, lifestyle but not metformin reduced progression to diabetes.
[Show abstract][Hide abstract] ABSTRACT: Type 1 diabetes has been associated with an elevated relative risk (RR) of mortality compared to the general population. To review published studies on the RR of mortality of Type 1 diabetes patients compared to the general population, we conducted a meta-analysis and examined the temporal changes in the RR of mortality over time.
Systematic review of studies reporting RR of mortality for Type 1 diabetes compared to the general population. We conducted meta-analyses using a DerSimonian and Laird random effects model to obtain the average effect and the distribution of RR estimates. Sub-group meta-analyses and multivariate meta-regression analysis was performed to examine heterogeneity. Summary RR with 95% CIs was calculated using a random-effects model.
26 studies with a total of 88 subpopulations were included in the meta-analysis and overall RR of mortality was 3.82 (95% CI 3.41, 3.4.29) compared to the general population. Observations using data prior to 1971 had a much larger estimated RR (5.80 (95% CI 4.20, 8.01)) when compared to: data between; 1971 and 1980 (5.06 (95% CI 3.44, 7.45)); 1981-90 (3.59 (95% CI 3.15, 4.09)); and those after 1990 (3.11 (95% CI 2.47, 3.91)); suggesting mortality of Type 1 diabetes patients when compared to the general population have been improving over time. Similarly, females (4.54 (95% CI 3.79-5.45)) had a larger RR estimate when compared to males (3.25 (95% CI 2.82-3.73) and the meta-regression found evidence for temporal trends and sex (p<0.01) accounting for heterogeneity between studies.
Type 1 diabetes patients' mortality has declined at a faster rate than the general population. However, the largest relative improvements have occurred prior to 1990. Emphasis on intensive blood glucose control alongside blood pressure control and statin therapy may translate into further reductions in mortality in coming years.
PLoS ONE 11/2014; 9(11):e113635. DOI:10.1371/journal.pone.0113635 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective
To describe patient and provider characteristics associated with outpatient revisit frequency and to examine the associations between the revisit frequency and the processes and intermediate outcomes of diabetes care.
Research Design and Methods
We analyzed data from Translating Research Into Action for Diabetes (TRIAD), a prospective, multicenter, observational study of diabetes care in managed care.
Our analysis included 6,040 eligible adult participants with type 2 diabetes (42.6% ≥ 65 years of age, 54.1% female) whose primary care providers were the main provider of the participants’ diabetes care. The median (interquartile range) revisit frequency was 4.0 (3.7, 6.0) visits per year. Being female, having lower education, lower income, more complex diabetes treatment, cardiovascular disease, higher Charlson comorbidity index, and impaired mobility were associated with higher revisit frequency. The proportion of participants who had annual assessments of HbA1c and LDL-cholesterol, foot examinations, advised or documented aspirin use, and influenza immunizations were higher for those with higher revisit frequency. The proportion of participants who met HbA1c (< 9.5%) and LDL-cholesterol (< 130 mg/dL) treatment goals was higher for those with a higher revisit frequency. The predicted probabilities of achieving more aggressive goals, HbA1c < 8.5%, LDL-cholesterol < 100 mg/dL, and blood pressure < 130/85 or even < 140/90 mmHg were not associated with higher revisit frequency.
Revisit frequency was highly variable and was associated with both sociodemographic characteristics and disease severity. A higher revisit frequency was associated with better processes of diabetes care, but the association with intermediate outcomes was less clear.
Journal of Diabetes and its Complications 11/2014; 28(6). DOI:10.1016/j.jdiacomp.2014.06.006 · 1.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE Glycated hemoglobin (HbA(1c)), a standard measure of chronic glycemia for managing diabetes, has been proposed to diagnose diabetes and identify people at risk. The Diabetes Prevention Program (DPP) was a 3.2-year randomized clinical trial of preventing type 2 diabetes with a 10-year follow-up study, the DPP Outcomes Study (DPPOS). We evaluated baseline HbA(1c) as a predictor of diabetes and determined the effects of treatments on diabetes defined by an HbA(1c) >= 6.5% (48 mmol/mol). RESEARCH DESIGN AND METHODS We randomized 3,234 nondiabetic adults at high risk of diabetes to placebo, metformin, or intensive lifestyle intervention and followed them for the development of diabetes as diagnosed by fasting plasma glucose (FPG) and 2-h postload glucose (2hPG) concentrations (1997 American Diabetes Association [ADA] criteria). HbA(1c) was measured but not used for study eligibility or outcomes. We now evaluate treatment effects in the 2,765 participants who did not have diabetes at baseline according to FPG, 2hPG, or HbA(1c) (2010 ADA criteria). RESULTS Baseline HbA(1c) predicted incident diabetes in all treatment groups. Diabetes incidence defined by HbA(1c) >= 6.5% was reduced by 44% by metformin and 49% by lifestyle during the DPP and by 38% bymetformin and 29% by lifestyle throughout follow-up. Unlike the primary DPP and DPPOS findings based on glucose criteria, metformin and lifestyle were similarly effective in preventing diabetes defined by HbA(1c). CONCLUSIONS HbA(1c) predicted incident diabetes. In contrast to the superiority of the lifestyle intervention on glucose-defined diabetes, metformin and lifestyle interventions had similar effects in preventing HbA(1c)-defined diabetes. The long-term implications for other health outcomes remain to be determined.
Diabetes Care 10/2014; 38(1). DOI:10.2337/dc14-0886 · 8.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose: Previous studies have revealed lower prostate specific antigen concentrations in men with type 2 diabetes, paralleling the reported lower prevalence of prostate cancer in diabetic men. Data are lacking on prostate specific antigen in men with type 1 diabetes whose insulin and obesity profiles differ from those with type 2 diabetes mellitus. In this study we examined the relationship between long-term glycemic control and prostate specific antigen in men with type 1 diabetes mellitus. Materials and Methods: Total prostate specific antigen was measured at one time in 639 men in the EDIC, the observational followup of participants in the DCCT. The relationship between DCCT/EDIC weighted mean hemoglobin A1c and log prostate specific antigen was assessed using linear regression modeling after adjusting for age, body mass index, total testosterone, statin and thiazide medication use, diabetes duration, and DCCT randomization arm and cohort. Results: Median subject age was 52 years, body mass index was 28.4 kg/m(2) and DCCT/EDIC time-weighted hemoglobin A1c was 7.9%. Median prostate specific antigen was 0.64 ng/ml (IQR 0.43, 1.05). Prostate specific antigen increased significantly with age (p < 0.0001) and with lower time-weighted hemoglobin A1c (p < 0.0001). Each 10% increase in hemoglobin A1c was accompanied by an 11% reduction in prostate specific antigen (p = 0.0001). Conclusions: Prostate specific antigen decreases as hemoglobin A1c increases in men with type 1 diabetes mellitus. This relationship is independent of age, body mass index, androgen levels, medication use and measures of diabetes severity, which suggests that factors related to glycemia may directly affect prostate specific antigen levels.
The Journal of Urology 09/2014; 187(4):e33. DOI:10.1016/j.juro.2012.02.124 · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective
To evaluate the performance of three alternative methods to identify diabetes in patients visiting Emergency Departments (EDs), and to describe the characteristics of patients with diabetes who are not identified when the alternative methods are used.
Research Design and Methods
We used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2009 and 2010. We assessed the sensitivity and specificity of using providers’ diagnoses and diabetes medications (both excluding and including biguanides) to identify diabetes compared to using the checkbox for diabetes as the gold standard. We examined the characteristics of patients whose diabetes was missed using multivariate Poisson regression models.
The checkbox identified 5,567 ED visits by adult patients with diabetes. Compared to the checkbox, the sensitivity was 12.5% for providers’ diagnoses alone, 20.5% for providers’ diagnoses and diabetes medications excluding biguanides, and 21.5% for providers’ diagnoses and diabetes medications including biguanides. The specificity of all three of the alternative methods was > 99%. Older patients were more likely to have diabetes not identified. Patients with self-payment, those who had glucose measured or received IV fluids in the ED, and those with more diagnosis codes and medications, were more likely to have diabetes identified.
NHAMCS’s providers’ diagnosis codes and medication lists do not identify the majority of patients with diabetes visiting EDs. The newly introduced checkbox is helpful in measuring ED resource utilization by patients with diabetes.
Journal of diabetes and its complications 09/2014; 28(5). DOI:10.1016/j.jdiacomp.2014.02.005 · 1.93 Impact Factor