Study findings support reciprocal peer support as a method of improving diabetes management.

Many patients with diabetes would benefit from assistance in self-managing their condition between clinic visits, say Michele Heisler (University of Michigan Medical School, Ann Arbor, Michigan, USA) and colleagues.

Nurse-led assistance has been shown to be effective, but providing this sort of care can be difficult in a real-life setting, especially when resources are low.

In this study, Heisler and team assessed the efficacy of reciprocal peer support (RPS), where patients are paired with another age-matched patient and given peer communication skills training, versus nurse care management (NCM) for improvement of diabetes self-management.

The researchers recruited 244 men with diabetes and glycated hemoglobin (HbA1c) levels during the preceding 6 months greater than 7.5%.

The primary outcome was 6-month change in HbA1c. In total, 113 and 103 men were randomly assigned to and completed the 6-month RPS or NCM interventions, respectively.

Mean HbA1c decreased by 0.29% in the RPS group, but increased by 0.29% in the NCM group, amounting to a significant 0.58% between-group difference.

When the researchers looked at men with an initial HbA1c greater than 8%, those in the RPS group had a reduction in HbA1c of 0.88% versus 0.07% for those in the NCM group.

The RPS patients were encouraged to talk to their paired partner at least once a week on the telephone and were given the option to attend occasional group sessions at 1, 3, and 6 months. Those in the NCM group attended an initial 1.5-hour diabetes education session and were then assigned to a Nurse Care Manager and encouraged to contact them if they needed help with their diabetes management.

Writing in the Annals of Internal Medicine, the authors write that “periodic nurse-facilitated, patient driven group sessions supplemented with one-on-one peer-support telephone calls between age-matched partners improved glycemic control and other key outcomes more than providing NCM services alone among diabetic men.”

They say: “Because many chronically ill patients need more support for self-care than most health care systems can provide, models that increase the quality and intensity of assistance through peer support, such as ours, deserve further exploration.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

Free abstract

Researchers report that treatment with metformin appears to reduce mortality rates in patients with heart failure (HF) and diabetes.

David Aguilar (Baylor College of Medicine, Houston, Texas, USA) and colleagues explain that although diabetes and HF commonly co-exist, optimal treatment for such patients has not been studied in detail.

To investigate the possible benefits of metformin for these patients, Aguilar and team studied mortality rates over 2 years of follow-up in 6185 patients with HF and diabetes, of whom 1561 were treated with metformin and 4624 were not.

All the patients were taking a combination of other drugs including: insulin, sulfonylureas, thiazolidinediones, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, spironolactone, beta blockers, and statins.

As reported in the journal Circulation: Heart Failure, 246 (15.8%) patients taking metformin and 1177 (25.5%) of those who were not taking the medication died during follow-up, a statistically significant between-group difference.

The researchers carried out a propensity-score (probability of being treated given the covariates) matched analysis. This showed that death occurred within 2 years in 232 (16.1%) and 285 (19.8%) patients in the metformin and no metformin groups, respectively, corresponding to a significant 24% reduction in the relative risk for death with metformin.

Of note, the investigators found no significant differences in hospitalization for HF or total hospitalization rates between the two groups.

“Given the current burden and expected growth in the number of patients with diabetes and HF, it is critically important that future studies assess the optimal treatment strategy for glycemic control in this population,” say Aguilar and co-authors.

“Addressing these issues will require carefully designed prospective observational studies to confirm safety and randomized controlled clinical trials to assess efficacy,” they conclude.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

Free abstract

Elderly Type 2 diabetes patients have limited joint mobility (LJM) compared with their nondiabetic peers, show study findings.

LJM has previously been observed in young Type 1, but not older Type 2, diabetic patients, explain Michele Abate (University G d’Annunzio Chieti-Pescara, Chieti Scalo, Italy) and colleagues.

In the current study, the team investigated the frequency of LJM in 30 elderly, well-controlled Type 2 diabetics, aged 73.9 years on average. For comparison purposes, 30 age- and gender-matched nondiabetics were also included, as were 10 young nondiabetics aged 26.3 years on average.

The team evaluated the range of motion (ROM) of the ankle, knee, elbow, shoulder, and hip joints using a double-armed goniometer. They also measured abnormalities of the supraspinatus, patellar, and Achilles tendons using a standardized ultrasound technique.

As might be expected, elderly individuals (diabetic and nondiabetic) had a significantly lower mobility in all joints except the knee and elbow flexion compared with the younger controls.

In addition, elderly diabetic patients had a significantly greater degree of LJM than their nondiabetic counterparts, particularly for ankle dorso- and plantar flexion (ROM=8.0 and 25.0° vs 11.9 and 32.9°, respectively), hip flexion and adduction (ROM=103.1 and 29.0° vs 116.0 and 32.1°, respectively) and shoulder abduction and flexion (ROM=138.0 and 137.0° vs 158.0 and 149.0°, respectively).

Abate and co-workers also observed a greater number of tendon abnormalities on ultrasound in diabetic than nondiabetic elderly participants.

The authors write that non-enzymatic glycosylation of collagen with advance glycation endpoints (AGEs) formation, and the subsequent increase of intermolecular collagen cross-links, is likely to be the main pathogenetic mechanism for LJM in diabetes patients.

Writing in the Archives of Gerontology and Geriatrics, the authors conclude: “Beside physiotherapy and proper control of hyperglycemia, pharmacological interventions, which may influence AGE formation or removal, and prevent or reverse joint stiffness, are desirable.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

Free abstract

Type 2 diabetes patients with prostate cancer who undergo radical prostatectomy are more likely to have advanced grade disease at final pathology than nondiabetics, say researchers.

Furthermore, positive diabetes mellitus status can predict a subsequent finding of high-grade prostate cancer - Gleason score 8 or higher - earlier than treatment, at initial prostate biopsy, says the Italian research team.

“Our findings should be considered when counseling diabetic patients,” suggest Firas Abdollah and colleagues from Vita-Salute University in Milan.

“In view of these patients’ predisposition to develop a high-grade tumor, regular prostate-specific antigen (PSA) screening may be advised in order to detect prostate cancer at early stages,” they add in the journal Prostate Cancer and Prostatic Diseases.

The prevalence of Type 2 diabetes mellitus in a cohort of 2060 patients who underwent prostatectomy between 2001 and 2009 was 7.1%. The researchers tested the hypothesis that these diabetic patients would have a higher incidence of high-grade tumors than their non-diabetic counterparts.

Indeed, after adjustment for potential confounding factors including clinical stage, PSA level, body mass index, and year of treatment, Abdollah and team observed that Type 2 diabetic patients had a 2.7-fold increased risk for having high-grade prostate cancer at initial biopsy.

This trend was mirrored in the final pathology findings at prostatectomy: after adjustment for the same factors, diabetic patients were 2.4 times more likely to have high-grade disease compared with non-diabetic patients.

These risk differences are highlighted by the finding of significantly more disease with a Gleason score of 8 or higher among men with Type 2 diabetes at biopsy (16.3% vs 7.6%) and after prostatectomy (21.1% vs 11.7%) compared with non-diabetic men.

Abdollah et al recommend that their results be verified in a prospective manner before being applied to clinical practice, but they do maintain that theirs is the first analysis of Type 2 diabetes mellitus status and prostatectomy findings in a non-Northern American cohort.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

Free abstract

Researchers demonstrate that improved cardiorespiratory fitness, achieved though aerobic and resistance exercise training, is associated with significant reductions in glycated hemoglobin (HbA1c) in individuals with Type 2 diabetes.

Writing in the journal Diabetologia, Glen Kenny (University of Ottawa, Ontario, Canada) and colleagues report results from a study of 251 patients with Type 2 diabetes who were randomly assigned to participate in aerobic, resistance, or aerobic and resistance exercise for 6 months.

They found that aerobic and resistance training alone led to significant 0.51% and 0.38% reductions in HbA1c, respectively, over the study period.

Combined exercise training led to greater reductions in HbA1c at 6 months than those achieved by the aerobic and resistance training groups, with respective additional reductions of 0.46% and 0.59%.

To assess fitness, the researchers measured peak oxygen consumption (VO₂ peak), workload, treadmill time, and ventilator threshold measurements from maximal treadmill exercise testing both at study enrollment and at 6 months.

The team found that for the aerobic group the beneficial changes in HbA1c were linked to improvements in VO₂ peak and workload, whereas improvements in strength on the seated rowing machine and in mid-thigh muscle cross-sectional area were associated with improved HbA1c in the resistance group.

For the combined group, improvements in VO₂ peak, workload, and ventilatory threshold were most significantly linked with HbA1c decreases. Of note, in this group increases in muscle cross-sectional area were not significantly linked with improved HbA1c.

“Both aerobic and resistance exercise training alone cause clinically important improvements in physical fitness and glycemic control,” summarize the authors.

“However, the association between changes in physical fitness and glycemic control may be more pronounced with combined exercise training due to improvements in aerobic fitness and in muscular strength,” they suggest.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

Free abstract

Investigators have found that being a member of an ethnic minority, having low socioeconomic status, being overweight, and having a family history of diabetes are all associated with childhood-onset Type 2 diabetes.

Type 2 diabetes is predominantly a condition affecting middle aged and older people, but in recent years has become significantly more common in younger age groups.

Kenneth Copeland (University of Oklahoma College of Medicine, Oklahoma City, USA) and colleagues report baseline characteristics from the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) cohort, which represents the largest and best-characterized sample of American youth (aged 10-17 years) with Type 2 diabetes.

In total, 704 participants (64.9% female) were recruited who had a mean age of 14.0 years and disease duration of 7.8 months.

As Type 2 diabetes is a degenerative condition with a significant long-term health impact, it is important to assess factors that may increase the risk for development at an early age.

Copeland and team found that the mean body mass index Z-score was high, at 2.15 (generally indicative of being above the 95th percentile). Family history of diabetes was common, at 89.4%, and 72.6% were non-Hispanic Black or Hispanic (31.5% and 41.1%, respectively).

In addition, 26.3% had blood pressure in the 90th percentile or higher, 13.0% had microalbuminuria, 79.8% had low high-density lipoprotein cholesterol, and 10.2% had high triglycerides.

Regarding socioeconomic factors, 38.8% were living with both biological parents, 41.5% had a household income below US$25,000 (€17,967), and 26.3% had parents or guardians with low educational attainment (lower than high school degree).

“The baseline characteristics of the TODAY cohort can be interpreted as representative of youth with Type 2 diabetes throughout the US in general,” write the authors in the Journal of Clinical Endocrinology and Metabolism.

Following baseline measurements, the participants were randomly assigned to treatment with metformin, metformin plus rosiglitazone, or metformin plus lifestyle intervention and will be followed up for 2-6 years.

“Final outcome data will yield insights applicable to the treatment of youth with Type 2 diabetes,” add the researchers.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

Free abstract

Results from a study in rats suggest that fathers who are overweight and eat a high-fat diet could increase the risk for diabetes in their daughters.

“We’ve known for a while that overweight mums are more likely to have chubby babies, and that a woman’s weight before and during pregnancy can play a role in future disease in her children, partly due to the critical role the intrauterine environment plays in development,” said study leader Margaret Morris from the University of New South Wales in Sydney, Australia.

“But until now, the impact of the father’s environment - in terms of his diet - on his offspring had not been investigated.”

Writing in the journal Nature, the team reports results from a study of male rats fed a high-fat diet (n=9), which resulted in high body weight (22% increase vs normal males), adiposity, and impaired glucose tolerance, that were mated with normal weight female rats. The researchers also mated a group of normal-weight male rats fed a normal diet (n=8) with normal-weight females for comparison purposes.

Compared with controls, female offspring of the male rats fed a high-fat diet had early onset impaired insulin secretion and glucose tolerance that worsened over time, but were of normal weight and adiposity.

Further analysis, showed that these females had disrupted expression of 642 pancreatic islet genes, suggesting epigenetic modification as a primary cause, say the authors.

“This is the first report of non-genetic, intergenerational transmission of metabolic consequences of a high-fat diet from father to offspring,” commented Morris.

“A family history of diabetes is one of the strongest risk factors for the disease; however until now, the extent of any influence of non-genetic paternal factors has been unclear.”

“It adds another level to our understanding of the causes of the growing epidemics in obesity and diabetes,” she said. “While here we studied female offspring, we need to examine whether the effect is also found in males.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

Free abstract

Results from a randomized, placebo controlled study confirm that linagliptin is an effective add-on to metformin for improving glycemic control in patients with Type 2 diabetes.

The novel dipeptidyl peptidase-4 inhibitor linagliptin has previously been shown to be an effective add-on to metformin for treatment of Type 2 diabetics in a small, 12-week study.

For the purposes of this study, Marja-Riitta Taskinen (Helsinki University Central Hospital, Finland) and colleagues recruited 701 participants with Type 2 diabetes and a glycated hemoglobin (HbA1c) level of 7.0-10.0% who were being treated with metformin and a maximum of one other antihyperglycemic drug (discontinued at baseline). The patients were enrolled from 82 centers in 10 countries across the world.

The participants were randomly assigned to take metformin 1500 mg/day or more for a run-in period of 6 weeks and then begin treatment with linagliptin 5 mg/day (n=524) or placebo (n=177) for 24 weeks.

The team found that linagliptin treatment was associated with significant reductions in HbA1c, fasting plasma glucose, and 2-hour post prandial glucose of 0.49%, 0.59 mmol/l, and 2.7 mmol/l, respectively, at 24 weeks compared with baseline. In contrast, placebo treatment was associated with increases of 0.15%, 0.58 mmol/l, and 1.0 mmol/l in these respective values.

Linagliptin was well-tolerated overall and most side effects were mild to moderate, occurring at a similar rate in the placebo and linagliptin groups. Severe adverse events were experienced by 2% and 1% of the linagliptin and placebo groups, respectively.

Rates of hypoglycemia were low and only occurred in 3 linagliptin- and 5 placebo-treated patients. Body weight did not change significantly over the 24 weeks in either the placebo or linagliptin groups.

“This study demonstrates that, for patients inadequately controlled on metformin alone, the addition of linagliptin 5 mg once daily over 24 weeks brings a significant and clinically meaningful improvement in glycemic control, evident in measures of pre and postprandial plasma glucose as well as HbA1c,” conclude the authors.

The results of this study are published in the journal Diabetes, Obesity and Metabolism.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

Free abstract

MedWire Links
Linagliptin effective and well tolerated in combination with metformin

Low levels of serum potassium are significantly predictive for incident Type 2 diabetes, show results from the ARIC Study cohort.

The Atherosclerosis Risk in Communities (ARIC) Study is an ongoing prospective cohort study that began in 1986. To date, participants have been followed-up for 9 years in-person and 17 years over the telephone.

For the purposes of this study, Frederick Brancati (Johns Hopkins University, Baltimore, Maryland, USA) and colleagues assessed links between baseline serum potassium levels and incident Type 2 diabetes in 12,209 ARIC Study participants.

During the 9 years of in-person follow-up, 1475 individuals developed incident Type 2 diabetes.

When compared with participants with a normal-high potassium concentration (5.0-5.5 mEq/l), those with levels below 4.0, 4.0-4.4, and 4.5-4.9 mEq/l had significant 64%, 64%, and 39% increases in relative risk for incident Type 2 diabetes, respectively.

The team note that this increased risk persisted for an additional 8 years of telephone follow-up, based on self-reported diabetes diagnosis, with baseline potassium levels lower than 5.0 mEq/l linked to a 20-30% increase in relative risk for Type 2 diabetes.

The authors say that their findings cannot be used to prove causality, but say that they “deserve further investigation.”

They suggest that “clinical trials should be developed to assess if increasing serum potassium, through medications, pharmacologic supplementation, or increased dietary intake - all relatively simple interventions - could indeed reduce the risk of incident diabetes mellitus.”

The results of this study are published in the Archives of Internal Medicine.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

Free abstract

Giving primary healthcare physicians access to an electronic feedback system with information on all their patients with Type 2 diabetes leads to significantly improved quality of care, say researchers.

Trine Guldberg (Aarhus University, Denmark) and colleagues enrolled 86 Danish general practices (158 primary healthcare physicians) and 2458 patients with Type 2 diabetes aged 40-70 years in a randomized controlled trial of electronic feedback.

Half the practices were randomly assigned to receive electronic feedback, in the form of a CD-ROM distributed three times during the 15 month follow-up period, and half were not.

The CD’s provided to the physicians in the electronic feedback group allowed them to see lists of patients attending their practice with Type 2 diabetes and sort the data according to relevant variables such as glycated hemoglobin (HbA1c) and cholesterol levels, giving an overview of the health of the patients and their level of control over their condition.

Writing in the journal Diabetic Medicine, the team reports that provision of electronic feedback seemed to significantly improve the quality of patient care compared with no feedback.

For example, patients being treated at practices in the electronic feedback group redeemed more prescriptions for oral antidiabetic drugs (32.8% vs 12.0%), insulin (33.8% vs 12.4%), lipid-lowering medication (38.3% vs 18.6%), and blood pressure lowering medication (27.6% vs 16.3%) than those treated at practices that were given no feedback.

However, the authors note that no significant differences in mean HbA1c or total serum cholesterol were observed between the two patient groups.

“Our findings indicate that electronic feedback to general practitioners about their diabetes care improves prescription patterns, which seems to be the most accessible process measure to influence via electronic feedback,” write Guldberg et al.

“Whether the revealed effects are due to an increased attention to guideline measures by way of the system, or whether the system itself had features that specifically turned attention to prescription of Type 2 diabetes-related medicines is unclear,” they add.

“However, this will be explored further in a mixed-method study based on the results of this quantitative evaluation of the study and the results of the qualitative evaluation which has also been performed.”

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010

Free abstract