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Multifactorial control and treatment intensity of type-2 diabetes in primary care settings in Catalonia


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Many studies on diabetes have demonstrated that an intensive control of glycaemia and the main associated risk factors (hypertension, dislipidaemia, obesity and smoking) reduce cardiovascular morbi-mortality. Different scientific societies have proposed a multifactorial approach to type 2 diabetes.The objective of this study was to identify the degree of control of glycosylated haemoglobin (HbA1c) and of cardiovascular risk factors in type 2 diabetic patients, using the GedapS 2004 guidelines, and to analyse the type and intensity of drug treatment. This cross-sectional, multicentre, epidemiological study was conducted in a primary care setting in Vallès Occidental South, Catalonia. Data were collected of 393 patients aged 18 and above who were diagnosed with diabetes mellitus type 2. Biodemographic and clinical data, cardiovascular risk factors, associated cardiovascular disease, and treatment were assessed. Descriptive and multivariable analysis with logistic regression was realized. A total of 392 patients with a mean age of 66.8 years (SD = 10.6) (45.4% male patients) were analyzed. The duration of diabetes was 8.4 years (SD = 7.6). The degree of multifactorial control of risk factors was only 2.6%, although in more than 50% individual cardiovascular risk factor was controlled, except for LDL cholesterol (40.6%) and systolic blood pressure (29.6%). Furthermore, only 13.0% of subjects had an optimal BMI, 27.5% an optimal waist circumference. Treatment for diabetes was prescribed in 82.7% of patients, for hypertension 70.7%, for dyslipidaemia 47.2% and 40.1% were taking antiplatelets. Over 50% of type 2 diabetic patients presented optimal control of the majority of individual cardiovascular risk factors, although the degree of multifactorial control of diabetes was insufficient (2.6%) and should be improved. Drug treatment can be intensified using a larger number of combinations, particularly in patients with target organ damage and associated clinical cardiovascular disease.
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Multifactorial control and treatment intensity of
type-2 diabetes in primary care settings in
Lucas Mengual
, Pilar Roura
, Marta Serra
, Montserrat Montasell
, Gemma Prieto
, Sandra Bonet
Background: Many studies on diabetes have demonstrated that an intensive control of glycaemia and the main
associated risk factors (hypertension, dislipidaemia, obesity and smoking) reduce cardiovascular morbi-mortality.
Different scientific societies have proposed a multifactorial approach to type 2 diabetes.
The objective of this study was to identify the degree of control of glycosylated haemoglobin (HbA1c) and of car-
diovascular risk factors in type 2 diabetic patients, using the GedapS 2004 guidelines, and to analyse the type and
intensity of drug treatment.
Methods: This cross-sectional, multicentre, epidemiological study was conducted in a primary care setting in Vallès
Occidental South, Catalonia. Data were collected of 393 patients aged 18 and above who were diagnosed with
diabetes mellitus type 2. Biodemographic and clinical data, cardiovascular risk factors, associated cardiovascular
disease, and treatment were assessed. Descriptive and multivariable analysis with logistic regression was realized.
Results: A total of 392 patients with a mean age of 66.8 years (SD = 10.6) (45.4% male patients) were analyzed.
The duration of diabetes was 8.4 years (SD = 7.6). The degree of multifactorial control of risk factors was only 2.6%,
although in more than 50% individual cardiovascular risk factor was controlled, except for LDL cholesterol (40.6%)
and systolic blood pressure (29.6%). Furthermore, only 13.0% of subjects had an optimal BMI, 27.5% an optimal
waist circumference. Treatment for diabetes was prescribed in 82.7% of patients, for hypertension 70.7%, for
dyslipidaemia 47.2% and 40.1% were taking antiplatelets.
Conclusion: Over 50% of type 2 diabetic patients presented optimal control of the majority of individual
cardiovascular risk factors, although the degree of multifactorial control of diabetes was insufficient (2.6%) and
should be improved. Drug treatment can be intensified using a larger number of combinations, particularly in
patients with target organ damage and associated clinical cardiovascular disease.
Diabetes mellitus (DM) is a chronic disease with a pre-
valence of 4.5% - 18.5% in Spain [1]. According to the
World Health Organisation (WHO), the prevalence of
diabetes in Spain was expected to increase by as much
as 40% between 2000 and 2025 [2]. DM is the seventh
leading cause of death in Spain [3].
Several studies [4-7] in diabetic patients have shown
that close control of glycaemia and the main cardiovas-
cular risk factors, such as arterial hypertension (AHT),
dyslipidaemia, obesity and smoking, reduces cardiovas-
cular morbimortality.
Furthermore, the United Kingdom Prospective Dia-
betes Study (UKPDS) has shown that for every 1%
reduction in glycosylated haemoglobin (HbA1c) there is
a decrease in any DM-related complication and in mor-
tality [8]. However, recent studies [9-11] recommend
that HbA1c levels of 7% should be achieved and main-
tained in adult patients, without dropping below 6.5%.
Based on current evidences, different scientific socie-
ties have proposed using an approach using multifactor-
ial control of risk factors in patients with type-2
diabetes (DM2)[12-14].
* Correspondence:
Contributed equally
Adknoma Health Research, Barcelona, Spain
Mengual et al.Cardiovascular Diabetology 2010, 9:14
© 2010 Mengual et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
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reproduction in any medium, provided the original work is properly cited.
Despite these recommendations [14,15], multifactorial
control of risk factors in diabetes is still insufficient
[16-18]. Thus, for example, Mostaza et al [19], reported
that optimal control of all risk factors was found in just
7% of diabetic patients. The current consensus is that
diabetic patients should be seen at a primary care centre
for the purpose of prevention and control [20], and this
is also ratified by the WHO document [21]. In this con-
text, our study was aimed to identify the degree of con-
trol of HbA1c and multifactorial control of risk factors
in type 2 diabetic patients, using the GedapS 2004
guidelines [22].
Study design and population
The study had a cross-sectional, multicentre, epidemio-
logical design. It focused on primary care in normal
clinical practice provided in the Vallès Occidental South
region in the north of the province of Barcelona. The
region had a population of 429,816 persons. Forty physi-
cians were selected using simple randomisation from a
total of 186 physicians belonging to 16 primary care
teams in 8 towns in the zone. The physicians who
agreed to participate in the study were given a specific
training session to explain the study objectives, proce-
dures, and, in particular, how to collect data and record
it in the Case Report Form (CRF). The study was
approved by the Institutional Review Board of the Jordi
Gol Institute for Research in Primary Care (Institut dIn-
vestigació en Atenció Primària Jordi Gol; IDIAP Jordi
The patients were recruited according the following
selection criteria:
Inclusion criteria
patients aged 18 and above diagnosed of DM2 at least 6
months prior to study inclusion and who had given
informed consent to participate in the study.
Exclusion criteria
patients with type 1 diabetes mellitus (DM1), patients
with DM2 in a terminal phase and those with a severely
deteriorated quality of life or who would have had diffi-
culty in attending the centre during the study period,
and patients who, in the investigatorsopinion,pre-
sented any condition which could hinder their participa-
tion (communication problems, cognitive or sensorial
disorder, language barrier and severe psychiatric
The sample size was calculated in terms of the pri-
mary objective (to determine the degree of control of
HbA1c in patients with type-2 diabetes attended at pri-
mary care in Vallès Occidental South, using the GedapS
2004 guidelines). A previous study (TranSTAR study)
[17], found that HbA1c was controlled in 18.8% of
patients. Using the binomial distribution, 390 patients
with type-2 diabetes would provide an accuracy of 4%
for estimating the proportion of diabetic patients with
good HbA1c control, with a 95% confidence interval,
assuming that 10% of patients would not be valid for
the analysis.
Data collection
Between July 2007 and January 2008, each physician
included the first diabetic patient attending his/her pri-
mary care practice who met the inclusion criteria, up to
a total of 10 patients per physician in the course of 10
The following study variables were recorded in an
electronic CRF, applying internal consistency rules to
ensure data quality control: biodemographic data (age,
sex, weight, height, waist circumference, year of diag-
nose with DM2), physical exercise (hours/week), cardio-
vascular risk factors, associated cardiovascular disease,
smoking habit, clinical data (blood pressure, heart rate,
blood tests, kidney function, proteinuria, glycaemic and
lipid profile) and treatments (antidiabetics, antihyperten-
sives, antidyslipidaemics, antiplatelets, anticoagulants).
Measurement and diagnostic criteria
Normal values
We used the normal values recommended in the Eur-
opean Guidelines [23] for blood pressure (BP), obesity,
sedentary lifestyle, smoking and alcohol.
Blood pressure (BP)
It was measured as recommended by the ESH-ESC
guidelines [24]. BP was recorded twice per visit and the
mean value calculated.
Waist circumference
It was measured in centimetres with a tape measure at
the midpoint between the lower part of the last rib and
the top of the iliac crest.
Left ventricular hypertrophy
It was assessed following ESH-ESC guidelines [24]:
Sokolow criteria (SV1+RV5-6>38 mm), Cornell criteria
(RaVL+SV3>28 in men and 20 in women) or by
Body Mass Index (BMI)
The BMI is used to classify a persons weight status. It is
calculated using the formula: weight (kg)/height (m
It was diagnosed following the criteria set out in the
clinical guidelines [25], which consider to be indicative
of hypercholesterolaemia a total cholesterol level of
200 mg/dL in primary prevention, or an LDL-cholesterol
level of 100 mg/dL in secondary prevention.
Cardiovascular Risk
It was calculated using Framingham Risk Tables [26]
which estimate the 10-year risk of suffering a coronary
event, angina or fatal or non-fatal myocardial infarction.
Mengual et al.Cardiovascular Diabetology 2010, 9:14
Page 2 of 7
Low cardiovascular risk was considered as less than 5%,
slight risk as 5-9%, moderate risk as 10-19%, high risk
as 20-39% and very high risk as over 39%.
Studys primary objective was to determine the degree of
control of HbA1c and multifactorial control of risk fac-
tors in type 2 diabetic patients, using the GedapS 2004
guidelines [22]. This guideline consider good control as
fulfilment of the following conditions: HbA1c lower
than 7%, total cholesterol lower than 200 mg/dL, LDL
cholesterol lower than 100 mg/dL, HDL cholesterol
higher than 40 mg/dL, triglycerides (TG) lower than
150 mg/dL, systolic blood pressure (SBP) lower
than 130 mmHg, diastolic blood pressure (DBP) lower
than 80 mmHg and not smoking. When all these condi-
tions are fulfilled simultaneously, it can be considered
that a patient has good multifactorial control. This
guideline also recommends a body mass index (BMI)
between 18.5 and 24.9 kg/m
and a waist circumference
of less than 102 cm for men and 88 cm for women.
Statistical methodology
betic patients. Evaluable patients were all those who met
the selection criteria and had a recorded value of the
principal study variable (HbA1c). The qualitative vari-
ables were described using absolute and relative fre-
quencies, whereas the quantitative variables were
described using their mean, standard deviation, median,
minimum and maximum, including the total number of
valid values. Parametric tests (StudentstorANOVA)
or non-parametric tests (Mann-Whitney or Kruskal-
Wallis) were used to compare quantitative variables for
patient subgroups, depending on the characteristics of
the variable being studied. The chi-squared test was
used for qualitative variables. Logistic regression was
performed to assess the association between good DM2
control (HbA1c) and the independent variables found to
be of interest in the bivariate analysis. All statistical ana-
lyses were performed with a two-tailed confidence level
of 95%. The SAS statistical package was used (version
Clinical and analytical characteristics
A total of 393 patients with DM2 were recruited,
although one was subsequently excluded as the principal
study variable was not specified, to give a final total of
392 patients. The mean age was 66.8 years (SD = 10.6).
54.6% were women.
The mean duration of DM2 was 8.4 years (SD = 7.6).
44.8% of patients were obese (BMI 30). The mean
BMI was 29.3 kg/m
in men and 30.6 kg/m
in women
(p < 0.01). Waist circumference was higher than recom-
mended (102 cm in men and 88 cm in women) in
51.4% of the men and 83.1% of the women; this differ-
ence was statistically significant (p < 0.05). A total of
11.1% of the patients were active smokers, 81.3% of
whom were male (44.2% 60 years of age).
As regards physical activity, more than half the sample
(59.0%) undertook regular physical exercise (walking as
a minimum) for about one hour an average of 5 days
per week.
When we analysed the degree of control of cardiovas-
cular risk factors, individually, the majority had good
control of over 50%. It should be noted that 54.8% of
that had poor control included SBP < 130 mmHg
(29.6%), LDL cholesterol < 100 mg/dL (40.6%), BMI <
25 (13.1%) and waist circumference < 102 cm in men
and 88 cm in women (27.5%) (Figure 1). The most rele-
vant clinical characteristics are listed in Additional file
1. Good BP control (SBP < 130 and DBP < 80) was
found in 24.7% of the sample. All cardiovascular risk
factors were well controlled in just 2.6% of the diabetic
patients in this study, using the criteria set out in
GedapS 2004.
Cardiovascular Risk: Cardiovascular risk factors and
associated complications
Cardiovascular risk (CVR), as determined using the Fra-
mingham Risk Tables, showed that 23.2% of patients
presented a low risk, 37.5% a slight risk, 30.1% a moder-
ate risk, 8.4% a high risk and 0.8% a very high risk.
The most prevalent cardiovascular risk factors were
AHT (73.0%), dyslipidaemia (58.2%) and obesity (44.8%).
Microvascular complications were present in 26.0% of
patients, the most common being nephropathy (17.8%;
(13.5% with microalbuminuria and 3.7% with protei-
nuria)) and retinopathy (12.1%).
Macrovascular complications were present in 24.5% of
the sample, with ischaemic cardiopathy (12.5%) and per-
ipheral arteriopathy (11.0%) being the most prevalent. In
all, 44.9% of the sample had some type of target organ
damage and/or clinical cardiovascular disease.
Factors associated with control of HbA1c
In the bivariate analysis, factors associated with a good
control of HbA1c (<7%) to a statistically significant
degree (p < 0.05) were: shorter history of DM2; female
patients; lower SBP level; lower triglycerides (TG) level;
lower albumin level in urine; higher LDL cholesterol;
less intensive treatment for DM2, dyslipidaemia and
antiplatelets; and lower CVR (Additional file 2).
The logistic regression analysis showed that the prob-
ability of good HbA1c control (<7%) was 4.09-fold
higher in patients taking one or two antidiabetic drugs
Mengual et al.Cardiovascular Diabetology 2010, 9:14
Page 3 of 7
compared with those taking more than two antidiabetic
drugs. Furthermore, this probability was 2.62-fold higher
in patients with no retinopathy than in those with
Drug treatment description
82.7% of patients in this study took antidiabetic drugs.
52.8% of them were on monotherapy (59.2% on metfor-
min) and 47.2% took a combination therapy. 14.9% of
patients had insulin treatment either alone or in combina-
tion with oral drugs. Likewise, 70.7% of patients took anti-
hypertensives (93.4% of patients diagnosed with AHT),
either in monotherapy (42.2%) or combination therapy
(57.8%). 47.2% were being treated for dyslipidaemia (75.9%
of patients diagnosed with dyslipidaemia), 40.1% were tak-
ing antiplatelet drugs and 5.6% anticoagulants (Additional
3). As regards the cardiovascular risk, 16.7% of patients
considered to be at high or very high risk (20) were not
taking any treatment for DM2, 22.2% were not on antihy-
pertensives, 52.8% were not receiving treatment for dysli-
pidaemia and 55.6% were not on antiplatelets.
With regard to treatment intensity and the presence of
target organ damage and/or clinical cardiovascular dis-
ease, there was significantly higher treatment intensity
for hypertension and anti-platelets. There were no dif-
ferences in treatment intensity for diabetes and dyslipi-
daemia (Additional file 4).
Of the patients with HbA1c 7%, 31.2% were being
treated with one oral drug and 64.6% were on combina-
tion therapy, 39.4% of whom were taking two oral
drugs, 2.9% taking three, 18.2% one oral drug plus insu-
lin and 4.2% insulin combinations. Finally, 20.7% of
patients presented kidney disease, 72.8% of whom were
taking angiotensin converting enzyme inhibitors (ACEI)
or angiotensin II receptor blockers (ARB).
The primary objective of the DM2VALLES study was to
identify the degree control of HbA1c, the degree of indi-
vidual and multifactorial control of risk factors in type 2
diabetic patients attended at primary care centres.
According to other studies [19,27] we only found good
simultaneous control of all risk factors in 2.6% of the
study population, although there was good control of
individual factors such as HbA1c, total cholesterol, HDL
cholesterol, TG, DBP and smoking habit. The hardest
parameters to control were SBP and LDL cholesterol, as
also reported previously [27,28].
Figure 1 Degree of cardiovascular risk factor control according to GedapS 2004 in the DM2VALLES study population. Adequate control:
Hb1Ac < 7%; Cholesterol < 200 mg/dl; LDL < 100 mg/dl; HDL > 40 mg/dl; TG < 150 mg/dl; SBP/DBP < 130/80 mmHg; BMI: 18.5-249 kg/m2;
Waist circumference < 102 cm in men and < 88 cm in women.
Mengual et al.Cardiovascular Diabetology 2010, 9:14
Page 4 of 7
The degree control of HbA1c was found to be related
to the duration of diabetes. This control worsened with
length of illness due to the progressive deterioration of
the beta cells, as reported by other authors [4,5,18]. The
high percentage of patients with good HbA1c control
found in our study contrasts the values obtained in
other studies, despite their similar duration of diabetes
(8.4 years) [18]. This may be explained by the health
policy that has been implemented in this area for several
years on intervention and control in diabetes.
One important finding which should be highlighted is
the high number of patients with a BMI of 30 kg/m2
(44.8%), a figure which is similar to those found in pre-
vious studies [18,29,30] and which also contributes to
the poor multifactorial control of our patients. Indeed,
weight loss can result in as much as 0.5 reductions in
the HbA1c percentage [12] since a reduction in body fat
is associated with reduced insulin resistance and there-
fore better glycaemic control.
The benefits of regular physical exercise in the general
population, and in diabetic patients in particular, are
well known. Indeed, exercise is a key component in the
treatment of diabetes, together with diet, as it also helps
to improve cardiovascular risk factors [12,13]. Our study
showed positive results in this area, because over half
the study population exercised on a regular basis.
The number of smokers in our sample was lower than
in other studies, although the prevalence of smoking in
diabetic male subjects under the age of 60 was higher
than in the general population in Catalonia [16]. Con-
trolling this risk factor should be prioritized in diabetics
in light of the relationship between smoking and micro-
and macrovascular complications and mortality [13,22].
The prevalence of nephropathy, retinopathy, ischaemic
cardiopathy, stroke and peripheral arteriopathy observed
in our study was similar to that observed in other stu-
dies carried out recently in Spain [18,29].
Although patients with DM2 are characterised by their
high level of cardiovascular risk, our results based on
the Framingham Risk Tables showed that, in contrast to
previous studies [28,29,31], the majority of the sample
(60.7%) had a low or slight risk (<10%). These findings
are a result of the good individual control of the major-
ity of the cardiovascular risk factors presented by the
patients in our study.
patients were taking antidiabetics, with good control of
HbA1c levels in more than 50% of the sample. However,
we found a low use (15.6%) of insulin in monotherapy
or combination therapy. The number of patients receiv-
ing insulin treatment varies considerably from one study
to another. Thus, the percentage is as low as 9.6% in
some cases, and in others it is almost twice higher
(approximately 30%) [18,27,28].
An adequate control of LDL cholesterol level
(<100 mg/dL) was observed in 40.6% of patients, which
is notably higher than the low values reported in other
studies also conducted in primary care settings [27,28].
Despite the findings of studies such as ATP III [32] and
CARDS [33] which recommend pharmacological treat-
ment, only 47.2% of our patients were on treatment for
dyslipidaemia. The use of a more intensive treatment
than hypolipidaemic drugs in diabetic patients should
therefore be considered [13].
Although 70.7% of the sample was on antihypertensive
treatment, only 24.7% presented good blood pressure
control (<130/80 mmHg). In our study, 57.8% of
patients were taking combinations of antihypertensive
drugs. The review by Bakris et al.[34] showed that com-
bination therapy with two or more drugs is required for
good BP control in diabetic patients, which suggests
that the patients in our study were being inappropriately
treated in this respect and their treatment should be
intensified by either increasing the dose or using combi-
nations of drugs. A quarter of diabetic patients with kid-
ney disease were not being treated with either ACEIs or
ARB despite the fact this practice is recommended in
the literature because these drugs have been shown to
slow advancing kidney damage [35].
Antiplatelet treatment was being used in 40.1% of all
patients, a similar value to that reported in other studies
[16,27] and it was being used by 44.4% of patients in the
high cardiovascular risk group. Indication for this treat-
ment in primary prevention is currently controversial [36].
In the group of patients with high cardiovascular risk
(20), where intensified treatment is particularly indi-
cated, a high percentage were either receiving no drug
treatment (16.7% for DM2, 22.2% for AHT, 52.8% for
dyslipidaemia, 55.6% for antiplatelet agents) or only
monotherapy (38.9% for DM2 and 36.1% for AHT).
Treatment should also be intensified in patients with
target organ damage and/or clinical cardiovascular dis-
ease, because many patients in these groups are not on
treatment, or they are on monotherapy.
With regard to the limitations of our study, it should
first be noted that the study population was recruited
from a metropolitan area of Barcelona, which limits its
validity to urban areas. Second, the study sample was cho-
sen from a population seeking primary care. This means
that we were unable to analyse the characteristics of dia-
betic patients who do not attend such primary care setting,
although it the centres participating in this study have all
been operating for more than 10 years and they cover
more than 90% of the diabetic population in the region.
The results of this study suggest that there is still room for
improvement in the clinical and therapeutic management
Mengual et al.Cardiovascular Diabetology 2010, 9:14
Page 5 of 7
of patients with type-2 diabetes attended at primary care
centres in our area. The purpose of this would be to
achieve good multifactorial control of all risk factors,
because previous studies [4,5] have shown that this strat-
egy is beneficial in slowing down or preventing the appear-
ance of chronic complications of type-2 diabetes. The
elevated level of obesity that we observed in our study sug-
gests that we should strengthen populational strategies
aimed at improving the healthy lifestyle of the population.
Additional file 1: Clinical and analytical characteristics in the
DM2VALLES study population. SD: Standard deviation, BMI: Body mass
index; SBP: Systolic blood pressure; DBP: Diastolic blood pressure.
Additional file 2: Factors associated with glycosylated haemoglobin
control in the DM2VALLES study population.
Chi-squared test;
Mann-Whitney U test; BMI: Body mass index; HbA1c: Glycosylated
haemoglobin; SBP: Systolic blood pressure; DBP: Diastolic blood pressure;
CVR: Cardiovascular risk; DM2: Diabetes mellitus type 2.
Additional file 3: Treatment for the cardiovascular risk factors in the
DM2VALLES study population. ASA: Acetylsalicylic acid; ARB:
Angiotensin-II receptor blockers; ACEI: Angiotensin converting enzyme
Additional file 4: Treatment intensity and the presence of target
organ damage and/or clinical cardiovascular disease in the
DM2VALLES study population.
Chi-squared test; DM: Diabetes
Mellitus; AHT: Arterial hypertension; TOD + CCD: target organ damage
and/or clinical cardiovascular disease.
We would like to thank Jordi Gol i Gurina Institution and Laboratories
Boehringer Ingelheim for supporting this study and the following
researchers for collecting the data: Jordana Baron, Ana; Traveria Solas,
Miquel; Mampell, Manel; Vidal Farell, Montserrat; San Jose Mataro, Joaquim;
Yuste Marco, M
del Carmen; Bonet Simó, Josep Maria; Gasulla Pascual,
Griselda; Magem, Joan; Bel, Carme; Rubio Villar, Montserrat; Garcia Lopez, M
Carmen; Gallego Laredo, Francico Javier; Cruz Cubells, Lourdes; Martinez
Artes, Xavier; Hernández Alapáñez, Elisabeth; Ferreres Pi, Concepcion; Ortega
González, Raquel; Acosta Sosa, Iliana; Quiñones Ruiz, Sagrario; Soler Carbó,
Montserrat; López Lifante, Victor Miguel; Herranz Fernandez, Marta; Mazarico,
Tomas; Tomás Lachos, Montserrat; Farre Trepat, Neus; Pablos Herrero, Eva;
Cánovas Garrido, M
Carmen; Vilà Moneny, Jordi; Rebagliato i Nadal, Oriol;
Catarineu Almansa, Berta; Salido Cano, Antonio; Ayala Mitjavila, Rita.
Author details
Health Care Centre Badia del Vallès, Badia del Vallès, Barcelona, Spain.
Health Care Centre Ca nOriac, Sabadell, Barcelona, Spain.
Health Care
Centre Rosa dels Vents, Barberà del Vallès, Barcelona, Spain.
Unitat de
Suport a la Recerca, Ámbito Centro, Barcelona, Spain.
Adknoma Health
Research, Barcelona, Spain.
All authors participated in the design and the coordination of the study,
reviewed the statistical analysis and participated in writing the manuscript.
They all read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 21 September 2009 Accepted: 29 March 2010
Published: 29 March 2010
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Cite this article as: Mengual et al.: Multifactorial control and treatment
intensity of type-2 diabetes in primary care settings in Catalonia.
Cardiovascular Diabetology 2010 9:14.
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Mengual et al.Cardiovascular Diabetology 2010, 9:14
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... Furthermore, long-term hyperglycemia will result in obesity, glucose and lipid metabolism disorders. And current studies have found that the incidence of type II diabetes increased rapidly in the last decades (Mengual et al., 2010;Cani, 2012). Besides the genetic factors, the rapidly changes of environmental factors are the major causes of it (Willett, 2002). ...
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Abstract Fast food is becoming increasing popular as a social phenomenon, and it usually contains high fat contents. Matcha is one versatile tea, and its application in food brings lots of new consumers. Herein, a high-fat diet containing matcha was prepared, and in this study we investigated the effects of such a diet on lipid metabolism and intestinal flora of normal and diabetic mice. Results showed that diabetes had significant weight loss, hyperphagia, hyperlipidemia and intestinal flora disturbance, with particularly significantly increased Alistipes, Prevotella, Helicobacter, Acetatifactor and Bacteroides, and decreased Alloprevotella, Lactobacillus, Allobaculum and Akkermansia. In diabetes, matcha decreased serum triglyceride and LDL-C, increased HDL-C, reversed those bacteria trends besides Alistipes, Prevotella and Akkermansia. In normal mice, matcha decreased serum LDL-C, increased Parabacteroides, Bacteroidales_unclassified, Erysipelotrichaceae_unclassified and Barnesiella, Lachnospiraceae_unclassified, and decreased Helicobacter and Clostridium XlVa. Most importantly, matcha increased Porphyromonadaceae_unclassified, Lactobacillus, Alloprevotella, Prevotella and Allobaculum; and decreased Bacteroides and Enterobacteriaceae_unclassified in diabetes, however these changed bacteria in normal mice showed an opposite trend from diabetes. Intestinal flora balance is vital important to host, matcha helps to improve the balance of lipid metabolism and intestinal flora according to different character of host, and is a valuable addition to develop functional food.
... As a multifactorial disease, diabetes requires more than one treatment of multiple risk factors [17]. The intestinal microbiota is a complicated microbial ecosystem, and keeping the intestinal flora in balance plays an important role in staying healthy [18]. ...
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Glucagon-like peptide-1 (GLP-1) reduces postprandial hyperglycaemia, but its short half-life inhibits clinical application. The aim of the current study was to evaluate the treatment efforts of an engineered strain, Lactobacillus plantarum-pMG36e-GLP-1 (L. plantarum-pMG36e-GLP-1), that continuously expresses GLP-1 in spontaneous type 2 diabetes mellitus (T2DM) monkeys. After 7 weeks of oral supplementation with L. plantarum-pMG36e-GLP-1, the fasting blood glucose (FPG) of monkeys was significantly (p < 0.05) reduced to a normal level and only a small amount of weight was lost. The results of metagenomic sequencing showed that L. plantarum-pMG36e-GLP-1 caused a substantial (p < 0.05) reduction in the intestinal pathogen Prevotella and marked enhancement of butyrate-producing Alistipes genera. According to the functional analysis using Kyoto Encyclopaedia of Genes and Genomes (KEGG) pathways, 19 metabolism-related pathways were significantly enriched in T2DM monkeys after treatment with L. plantarum-pMG36e-GLP-1. LC-MS faecal metabolomics analysis found 41 significant differential metabolites (11 higher and 30 lower) in monkeys after treatment pathways linked to the metabolism of cofactors and vitamins were the most relevant. The present study suggests that L. plantarum-pMG36e-GLP-1 had an impact on the gut microbial composition and faecal metabolomic profile in spontaneous T2DM monkeys and may be a novel candidate for diabetes treatment.
... A study from the USA showed that 26.0% achieved all targets (HbA1c J o u r n a l P r e -p r o o f < 7.0%, systolic BP < 140 mmHg and LDL < 2.6 mmol/l and non-smoking status) (45). In a study from primary care in Spain, Mengual et al. showed that the optimal glycaemic control was achieved in 54.8%, LDL control in 40.6%, and systolic BP control in 29.6% of patients (46). Mostaza et al. studied 8817 patients with T2DM with a history of coronary artery disease and found that 49.7%, 29%, 38.2%, achieved the desired HbA1c, LDL and systolic BP, respectively (47). ...
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Background Diabetic microvascular complications are a major cause of morbidity and are related to glycaemic control and cardiovascular risk factors. Aims We sought to determine the association of microvascular complications in relation to control of glycemia, blood pressure and lipids in T2DM patients attending secondary care in Qatar. Methods This is a cross-sectional study undertaken in patients with T2DM attending Qatar's National Diabetes Centres. Patients underwent assessment of glycemia, blood pressure and lipids and prevalence of diabetic peripheral neuropathy (DPN), retinopathy and microalbuminuria. Results We included 1114 subjects aged 52.1 ± 11.3 years with a duration of diabetes 10.0 ± 7.6 years and had a prevalence of 25.8% for DPN, 34.3% for painful DPN, 36.8% for microalbuminuria and 25.1% for retinopathy. Patients who achieved an HbA1c ≤ 7.0% compared to >7% had a significantly lower prevalence of DPN (P < 0.01), painful DPN (P < 0.01), retinopathy (P < 0.01) and microalbuminuria (P < 0.007). Patients who achieved a systolic BP ≤ 140 mmHg compared to >140 mmHg had a significantly lower prevalence of DPN (P < 0.001), painful DPN (P < 0.001), retinopathy (P < 0.001) and microalbuminuria (P < 0.001). Patients who achieved an LDL ≤2.6 mmol/l compared to >2.6 mmol/l had a significantly higher prevalence of DPN (P < 0.03), but no difference in other outcomes. There was no difference in microvascular complications between those who achieved a HDL-C ≥ 1.02 mmol/l, and among those who achieved triglycerides ≤1.7 mmol/l. Conclusions Optimal control of glycemia and blood pressure, but not lipids is associated with a lower prevalence of diabetic microvascular complications.
... Diabetes mellitus (DM) is a multifactorial disorder caused by genetic, epigenetic, environmental and lifestyle related factors resulting in the development of pathophysiological manifestation such as beta cell dysfunction, relative deficiency of insulin, insulin resistance, hyperglycaemia, hypercholesterolemia, metabolic endotoxemia, systemic inflammation, intestinal permeability, defective incretin secretion, ectopic fat storage and oxidative stress. 1,2 Abnormal glucose metabolism is causally related to a greater risk of several chronic disorders, including obesity, dyslipidaemia, and cardiovascular disease. Deadliest part of diabetes is its various complications which affects many organ systems and responsible for majority of morbidity and mortality associated with disease. ...
BACKGROUND Diabetes mellitus (DM) is a metabolic disorder, characterized by hyperglycaemia, insulin deficiency and insulin resistance. Along with diet, exercise, and oral antidiabetic drugs (OADs), probiotic intervention in novel food formulations enriched with specific bacterial strains could also be effective. In patients with type 2 DM and obesity, there is alteration in composition of the gut microbiota resulting in moderation of intestinal permeability and increasing endotoxin secretion. The utility of probiotic therapy in the management of type 2 DM has not been fully explored. Probiotics also regulate gut microflora and plasma lipids. The study was designed with a purpose of assessing the role of probiotics in glucose and lipid metabolism and its effectiveness in controlling blood sugar and lipid profile in type 2 DM. METHODS The single-blind randomized controlled study was conducted from February 2019 to January 2020 in the Department of Medicine, SCB Medical College and Hospital, Cuttack, in patients of type 2 DM. A total of 80 patients were included in the study with 40 as cases and another 40 as controls. Statistical analysis was performed using SPSS version 20. The mean ± standard deviation, median and ranges were calculated using chi square test and independent t-test. The level of significance was considered as P < 0.05. RESULTS The FBS and HbA1C levels were decreased by 16 mg / dl and 0.5 % respectively after consuming probiotics (P < 0.001). The total cholesterol, triglyceride, low density lipoprotein was decreased and high density lipoprotein level was increased after taking probiotics which was significant (P < 0.001). Probiotics help in cholesterol reduction through different mechanisms. CONCLUSIONS Probiotics have a definite role in improving glycaemic status and lipid levels in type 2 DM. KEYWORDS Glycosylated Haemoglobin, Type 2 DM, Probiotics, Intestinal Permeability
... The rapid increase in the prevalence of diabetes is the most severe and challenging health problem of the 21st century worldwide (van den Oever et al. 2010). Type-2 diabetes mellitus (T2DM) is a multifactorial disorder and various factors, such as genetic, epigenetic, environmental and lifestyle, are associated with it (Mengual et al. 2010, Cani 2012. Patients with poorly controlled diabetes experience various macro-and microvascular complications that have irreversible impact on the body. ...
This study aimed to determine the effect of Bacillus Coagulans symbiotic supplementation on metabolic factors and inflammation in patients with type-2 diabetes. In this clinical trial, 50 patients with type-2 diabetes were randomly assigned to the symbiotic (containing Bacillus Coagulans + Lactobacillus rhamnosus + Lactobacillus acidophilus and fructooligosaccharide) or placebo groups to receive one sachet daily for 12 weeks. Glycaemic Index, lipid profile, and hs-CRP were measured at the beginning and end of the study. Analysis of covariance demonstrated that fasting blood glucose (FBG), insulin, homeostatic Model Assessment for Insulin Resistance (HOMA-IR), β-cell function (HOMA-β) (p <.05) and hs-CRP (p <.05) significantly declined in the treatment group compared with the placebo group. So, the current study indicated that Bacillus Coagulans symbiotic supplementation could improve metabolic factors and inflammation in patients with type-2 diabetes.
Background and objective: The prevalence of type 2 diabetes (T2D) is high, it is increasing and its degree of control seems to be improvable with important social and health consequences. The objective of this study is to determine the regional differences in the degree of glycaemic control of T2D in Spain and its associated factors. Material and methods: Cross-sectional, multicentre, observational study in patients with T2D between 18 and 85 years of age selected by consecutive sampling between 2014 and 2018. The population was divided into four regions: north, centre, Mediterranean and south-east. The main variable was the value of glycated haemoglobin (HbA1c). Sociodemographic and clinical variables, presence or absence of other risk factors and treatment were recorded. Results: A total of 1587 patients with T2D were analysed, with a mean age of 65.93 years (standard deviation [SD] 10.14); 54.5% were men; the mean duration of T2D was 8.63 years (SD 6.64) and the mean HbA1c value was 7.05%. Of the total, 59.8% had an HbA1c value ≤ 7% (north 59.5%, centre 59.5%, Mediterranean 60.6% and south-east 59.8%; P=.99). The factors for poor control were: in the north, duration of T2D and being sedentary; in the centre, duration of T2D and having a low income; in the Mediterranean, duration of T2D; and in the south-east, duration of T2D and having a low level of education or income. Overall, 76.2% of the subjects had hypertension, 75.1% dyslipidaemia, and 51.7% obesity, with significant differences between regions only being observed in the case of dyslipidaemia (P<.001). Conclusions: No differences were observed in the degree of diabetes control in the different regions, with the percentage of patients needing intensification in their control being high in all of them. The factors associated with poor control were the duration of the disease, a low level of education or income, and a sedentary lifestyle.
Resumen Antecedentes y objetivo La prevalencia de diabetes tipo 2 (DM2) es elevada, está aumentando y su grado de control parece mejorable, con importantes consecuencias sociosanitarias. El objetivo de este estudio es conocer las diferencias regionales en el grado de control glucémico de la DM2 en España y sus factores asociados. Materiales y métodos Estudio transversal, multicéntrico, observacional en pacientes con DM2 entre 18 y 85 años seleccionados por muestreo consecutivo entre 2014 y 2018. Se dividió la población en cuatro regiones: Norte, Centro, Mediterráneo y Sureste. La variable principal fue el valor de la hemoglobina glucosilada (HbA1c). Se registraron variables sociodemográficas, clínicas, presencia o no de otros factores de riesgo y tratamiento. Resultados Fueron analizados 1.587 pacientes con DM2, con una edad de 65,93 (desviación estándar [DE] 10,14) años, el 54,5% eran hombres, la antigüedad media de la DM2 era de 8,63 (DE 6,64) años y la HbA1c media era del 7,05%. El 59,8% tenían una HbA1c ≤ 7% (Norte 59,5%, Centro 59,5%, Mediterráneo 60,6% y Sureste 59,8%; p = 0,99). Los factores de mal control fueron en el Norte la antigüedad de la DM2 y ser sedentario; en el Centro, la antigüedad de la DM2 y tener un bajo nivel de renta; en el Mediterráneo, la antigüedad de la DM2, y en el Sureste, la antigüedad de la DM2 y tener un bajo nivel de estudios o renta. El 76,2% de los sujetos presentaban hipertensión; el 75,1%, dislipemia, y el 51,7%, obesidad, observándose solo diferencias significativas entre regiones en el caso de la dislipemia (p < 0,001). Conclusiones No se observaron diferencias en el grado de control de la diabetes en las diferentes regiones, siendo el porcentaje de pacientes con necesidad de intensificación en su control elevado en todas ellas. Los factores asociados al mal control fueron la antigüedad de la enfermedad, un bajo nivel de estudios y de renta, y el sedentarismo.
A huge plethora of dynamic microbial communities present in and on the human body have a significant impact both on local (as for the gut microbiota on energy metabolism and obesity) and on distant scales (as the association of the periodontal disease with coronary heart disease). This microbiota contributes significantly to the host biology including digestion, metabolism, extraction of nutrients, synthesis of vitamins, and prevention against pathogenic colonization and also the modulation of the immune system in the host body. The composition and diversity of these microbiota have a strong association with gastrointestinal tract disorders as well as many metabolic disorders including type 2 diabetes mellitus (T2DM), cardiovascular diseases (CVDs), obesity, hypercholesterolemia, hypocholesterolemia, etc. which present an increasing public health concern and can hamper host’s quality of life. Probiotics are living organisms that exert their beneficial effect on host health, whereas prebiotics are nondigestible food ingredients that benefit the host by selectively stimulating the growth or activity of one or a limited number of microbes in the host. The present state of knowledge indicates that careful manipulation of the gut microbiota could be a promising approach for the prevention and management of metabolic diseases. Manipulation of gut microbiota through the administration of prebiotics and probiotics may assist in weight loss, reducing plasma blood glucose levels and also serum lipid levels, decreasing CVD and T2DM. We analyze currently available data to ascertain further benefits and limitations of probiotics and prebiotics in the treatment of metabolic diseases. The focus of this review is to examine the role of the microbiome in most morbid human metabolic diseases and to highlight the current challenges and discussion areas of their prevention and management with applications of prebiotics and probiotics as functional foods.
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Background Improved blood-glucose control decreases the progression of diabetic microvascular disease, but the effect on macrovascular complications is unknown. There is concern that sulphonylureas may increase cardiovascular mortality in patients with type 2 diabetes and that high insulin concentrations may enhance atheroma formation. We compared the effects of intensive blood-glucose control with either sulphonylurea or insulin and conventional treatment on the risk of microvascular and macrovascular complications in patients with type 2 diabetes in a randomised controlled trial. Methods 3867 newly diagnosed patients with type 2 diabetes, median age 54 years (IQR 48-60 years), who after 3 months' diet treatment had a mean of two fasting plasma glucose (FPG) concentrations of 6.1-15.0 mmol/L were randomly assigned intensive policy with a sulphonylurea (chlorpropamide, glibenclamide, or. glipizide) or with insulin, or conventional policy with diet. The aim in the intensive group was FPG less than 6 mmol/L. in the conventional group, the aim was the best achievable FPG with diet atone; drugs were added only if there were hyperglycaemic symptoms or FPG greater than 15 mmol/L. Three aggregate endpoints were used to assess differences between conventional and intensive treatment: any diabetes-related endpoint (sudden death, death from hyperglycaemia or hypoglycaemia, fatal or non-fatal myocardial infarction, angina, heart failure, stroke, renal failure, amputation [of at least one digit], vitreous haemorrhage, retinopathy requiring photocoagulation, blindness in one eye,or cataract extraction); diabetes-related death (death from myocardial infarction, stroke, peripheral vascular disease, renal disease, hyperglycaemia or hypoglycaemia, and sudden death); all-cause mortality. Single clinical endpoints and surrogate subclinical endpoints were also assessed. All analyses were by intention to treat and frequency of hypoglycaemia was also analysed by actual therapy. Findings Over 10 years, haemoglobin A(1c) (HbA(1c)) was 7.0% (6.2-8.2) in the intensive group compared with 7.9% (6.9-8.8) in the conventional group-an 11% reduction. There was no difference in HbA(1c) among agents in the intensive group. Compared with the conventional group, the risk in the intensive group was 12% lower (95% CI 1-21, p=0.029) for any diabetes-related endpoint; 10% lower (-11 to 27, p=0.34) for any diabetes-related death; and 6% lower (-10 to 20, p=0.44) for all-cause mortality. Most of the risk reduction in the any diabetes-related aggregate endpoint was due to a 25% risk reduction (7-40, p=0.0099) in microvascular endpoints, including the need for retinal photocoagulation. There was no difference for any of the three aggregate endpoints the three intensive agents (chlorpropamide, glibenclamide, or insulin). Patients in the intensive group had more hypoglycaemic episodes than those in the conventional group on both types of analysis (both p<0.0001). The rates of major hypoglycaemic episodes per year were 0.7% with conventional treatment, 1.0% with chlorpropamide, 1.4% with glibenclamide, and 1.8% with insulin. Weight gain was significantly higher in the intensive group (mean 2.9 kg) than in the conventional group (p<0.001), and patients assigned insulin had a greater gain in weight (4.0 kg) than those assigned chlorpropamide (2.6 kg) or glibenclamide (1.7 kg). Interpretation Intensive blood-glucose control by either sulphonylureas or insulin substantially decreases the risk of microvascular complications, but not macrovascular disease, in patients with type 2 diabetes. None of the individual drugs had an adverse effect on cardiovascular outcomes. All intensive treatment increased the risk of hypoglycaemia.
Basis: Diabetes mellitus type 2 has a very aggressive atherosclerosis profile, which means that the control of the cardiovascular risk factors should be very demanding. There are doubts concerning the attainment of such suitable objectives in primary care because of the difficulties for reproducing the conditions of clinical trials. Methods: Observational, descriptive, cross-sectional, and multicenter study. It was designed in order to establish the level of control of principal risk factors (tobacco, hypertension, hyperglycemia, dyslipemia, obesity), and the use of aspirin, in type 2 diabetics cared in Primary Care centers in Ciudad Real province. 405 patients were evaluated by 33 physicians from 18 Primary Care centers. Results: HbA1c values < 7% were obtained in 51.51%, 45.9% of patients showed obesity, average glycemia was 163.61 +/- 51.47. Blood pressure < 130/85 was detected in 18.50% of patients, 62.22% of patients took some hypotensive drug and 51.20% antihypertensives. LDL-c < 100 mg/dl was detected in 10.21% but only 30.61% was on hypolipemic drugs. HDL-c was not determined in 26% of patients, and was 45 mg/dl in 66.44%. Aspirin was prescribed in 31.35%; 9.63% of patients were smoker. No patient reached all necessary prevention objectives. Conclusions: The control of the different risk factors in type 2 diabetics in Primary Care does not guarantee appropriate cardiovascular prevention. The behavior concerning to smoking was good in this study, and the levels of HDL-c and triglycerides were acceptable. Pharmacological treatment should have been most frequent and intense.
For several years the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) decided not to produce their own guidelines on the diagnosis and treatment of hypertension but to endorse the guidelines on hypertension issued by the World Health Organization (WHO) and International Society of Hypertension (ISH)1,2 with some adaptation to reflect the situation in Europe. However, in 2003 the decision was taken to publish ESH/ESC specific guidelines3 based on the fact that, because the WHO/ISH Guidelines address countries widely varying in the extent of their health care and availability of economic resource, they contain diagnostic and therapeutic recommendations that may be not totally appropriate for European countries. In Europe care provisions may often allow a more in-depth diagnostic assessment of cardiovascular risk and organ damage of hypertensive individuals as well as a wider choice of antihypertensive treatment. The 2003 ESH/ESC Guidelines3 were well received by the clinical world and have been the most widely quoted paper in the medical literature in the last two years.4 However, since 2003 considerable additional evidence on important issues related to diagnostic and treatment approaches to hypertension has become available and therefore updating of the previous guidelines has been found advisable. In preparing the new guidelines the Committee established by the ESH and ESC has agreed to adhere to the principles informing the 2003 Guidelines, namely 1) to try to offer the best available and most balanced recommendation to all health care providers involved in the management of hypertension, 2) to address this aim again by an extensive and critical review of the data accompanied by a series of boxes where specific recommendations are given, as well as by a concise set of practice recommendations to be published soon thereafter as already done in 2003; …