The relation between parameters from homeostasis model assessment and glycemic control in type 2 diabetes.

OBJECTIVE: To determine the association of insulin sensitivity and pancreatic beta-cell function parameters assessed by the homeostasis model assessment (HOMA) and glycemic control, and their potential utilization in the clinical care of patients with type 2 diabetes mellitus. MATERIAL AND METHOD: The HOMA indices were assessed in 204 (62 males, 142 females) type 2 diabetic outpatients aged 60.7 +/- 10.9 years. All patients were non-insulin treated for their diabetes. The correlation between variables including logarithmically transformed HOMA-%S and HOMA-%B, body mass index (BMI) and duration of diabetes to glycemic control were assessed The value of the disposition index (HOMA-%SxHOMA-%B) that best discriminated patients with good glycemic control (HbA1C < 7%) from those without (HbA1C > or = 7%) was determined. RESULTS: Both log (HOMA-%S) and log (HOMA-%B) were inversely related to HbA1C with comparable degrees of association (beta = -0.62, p < 0.001 and beta = -0.61, p < 0.001, respectively). The log-transformed disposition index of at least 3.57 had a sensitivity of 74.2% and a specificity of 67.6% in classifying patients as having HbA1C < 7%. The result suggested that in order to achieve acceptable glycemic control, oral hypoglycemic agents should be adjusted to maximize the likelihood of the log-transformed disposition index reaching 3.57. CONCLUSIONS: Glycemic control in diabetic patients partially depends on both insulin sensitivity and pancreatic beta-cell function. Assessing both parameters with the HOMA model is likely to result in a more rational approach for achieving better glycemic control in type 2 diabetic patients.

Thailand diabetes registry project: current status of dyslipidemia in Thai diabetic patients.

OBJECTIVE: To determine the prevalence of dyslipidemia in adult Thai type 2 diabetes who attended diabetes clinics in university and tertiary-care hospitals. MATERIAL AND METHOD: A cross-sectional, multi-center, hospital-based diabetes registry was conducted in 11 diabetic clinics in tertiary medical centers in Bangkok and major provinces between April and December 2003. A group of 9419 diabetic patients were registered. Individual Demographic data including education and socioeconomic status were collected. The results of the physical examination for complications, history screening and laboratory results were recorded. The prevalence of the various complications of diabetes was analyzed and the percentage achievement of metabolic control calculated. RESULTS: Of the 9419 diabetic patients registered 8769 had complete demographic and plasma lipid data. Mean age was 59.5 +/- 13.3 years. The percentage of male patients was 33.9%. In the present study, there were 8464 type 2 diabetes and 383 type I diabetes. History of coronary artery disease and cerebrovascular disease were present in 8.1 and 4.2 percent ofthepatients, respectively. More than 80% of the patients had dyslipidemia. The patients with CVD had higher proportion of achieving the LDL target (< 100 mg/dl, 43 vs. 34%). More than half of the patients (55%) were taking lipid lowering medications, but one-third (30%) did not despite havingfulfilled indications. The patients covered by government supported health plan were less likely to received lipid-lowering medication than the patients covered by private health plans (OR 0.65, 95% CI 0.57-0.75). The two most commonly used lipid-lowering agents were HMG CoA reductase inhibitors (76%) and fibrates (19%), both agents were used in combination in 5% ofthe patients. Only 40.1% ofthe patients on lipid-lowering medications reached the target LDL goal (<100 mg/dl). CONCLUSION: Elevated LDL cholesterol was the most common lipid abnormality in the present study. Although 55% of the patients were taking lipid lowering agents, another 42% of the patients needed the medication. More than half of the patients treated needed more intensive lipid lowering in order to achieve the LDL goal. If the authors wish to follow the current (2005) American Diabetes Association recommendations, we would have to treat up to 97% of diabetic patients with lipid lowering

Thailand diabetes registry project: type of diabetes, glycemic control and prevalence of microvascular complications in children and adolescents with diabetes.

OBJECTIVE: To determine the etiology, glycemic control and prevalence of microvascular complications in Thai diabetic patients who were diagnosed at the age of less than 18 years and who attended diabetes clinics in university or tertiary care hospitals. MATERIAL AND METHOD: A cross-sectional, multi-center, hospital-based diabetes registry was carried out from diabetes clinics of 11 tertiary centers. Demographic data including laboratory results and microvascular complications were recorded. RESULTS: Two-hundred-and-fifty out of the 9419 (2.66%) diabetic patients were diagnosed before the age of 18 years, 78% had Type 1 diabetes (T1DM), 18.4% had Type2 diabetes (T2DM) and 3.6% had other types of diabetes. Mean +/- SD HbAlc of T1DM was 9.3 +/- 2.5, T2DM was 9.7 +/- 2.6 and other types of diabetes were 8.6 +/- 4%. The majority of patients had poor glycemic control according to ADA and WHO guidelines. The percentage of patients who had diabetes for more than 5 years but had not been screened for nephropathy and retinopathy were 57.7% and 16% in T1DM and were 46.4% and 14.2% in T2DM respectively. A significant correlation between microvacular complications (nephropathy and retinopathy) and duration of disease was found in T1DM (p < 0.001). CONCLUSION: The majority of Thai children and adolescents with diabetes had TIDM and unsatisfactory glycemic control. Screening for microvascular complications was under international standard. The national strategic plan for management of this disease especially in this age group should be urgently implemented.

Thailand diabetes registry project: prevalence of vascular complications in long-standing type 2 diabetes.

OBJECTIVE: To explore the nature of diabetic complications in type 2 diabetic patients who had had diabetes for longer than 15 years (long-DM), compared to those with duration of less than 15 years (short-DM). MATERIAL AND METHOD: Patients studied were adult type 2 diabetic patients registered to the Diabetes Registry Project, a nationwide cross-sectional study of diabetes mellitus in Thailand. Information collected included demographic data, age at diagnosis of diabetes, blood pressure, body mass index, fasting plasma glucose, HbA(1c), serum creatinine, and major diabetic vascular complications, including diabetic retinopathy (DR), albuminuria or renal insufficiency (diabetic nephropathy; DN), myocardial infarction (MI), stroke, peripheral arterial disease (PAD), foot ulcer and amputation. RESULTS: There were 9284 patients, consisting of 2244 (24.17%) subjects with long-DM (mean +/- SD, mean duration of DM21.3 +/- 5.8 years), and 7040 subjects with short-DM (mean duration 7.0 +/- 3.9 years). The long-DM group was older than the short-DM group (65.5 +/- 10.3 vs. 58.2 +/- 12.6 year-old, p less than 0.0001), and had higher HbA(1c) (8.5 vs. 8.0%, p = 0.009). The prevalence of diabetic complications in the long-DM group was higher than that in the short-DM group (DN 49.4% vs. 33.9%, DR 54.3% vs. 22.8%; MI 9.4% vs. 3.5%, PAD 17.3% vs. 5.5%, foot ulcer 13.4% vs. 5.3%, stroke 9.4% vs. 7.0% and amputation 5.5% vs 2.0%; allp values less than 0.01). The duration of DM significantly affected the risk of diabetic complications after adjustment for age, hypertension, and levels of glycemic control. CONCLUSION: Diabetic duration was independently associated with increased risk of having diabetes-related complications without threshold. Monitoring of complications in patients having long-standing diabetes is warranted in order to provide appropriate management.

Thailand diabetes registry project: prevalence, characteristics and treatment of patients with diabetic nephropathy.

OBJECTIVES: To identify the prevalence and characteristics of patients with Diabetic Nephropathy (DN) and to evaluate adequacy of glycemic and blood pressure control of these patients in the authors' registry. MATERIAL AND METHOD: A cross-sectional, multicenter, hospital-based diabetic registry was carried out in diabetes clinics of 11 tertiary centers in Thailand. DN was defined as the presence of at least two out of three of these symptoms; positive microalbuminuria, positive dipstick proteinuria or creatinine levels equal to or greater than 2 mg/dl. One center that did not perform urine microalbumin measurement was excludedfrom the analysis. Overt nephropathy was defined as the presence of gross proteinuria or renal insufficiency. RESULTS: The study included 4875 patients (females 63.8%) with a mean (SD) duration ofdiabetes of 12.8 (8.2) years. The prevalence of DN was 42.9% (microalbuminuria 19.7% and overt nephropathy 23.2%). There were 373 (7.7%) patients with renal insufficiency and 24 (0.47%) with end-stage renal disease. By multivariate analysis, factors associated with DN were age, duration of diabetes, male sex, smoking, blood pressure, HbA1c, dyslipidemia and presence of diabetic retinopathy. Prevalence of ischemic heart disease and cerebrovascular disease in patients with DN was 11.5% and 6.6% respectively. Mean (SD) HbA1c in patients with nephropathy was 8.2 (2.6)%. Only 25% of subject had HbA1c of less than 7%, 46% had blood pressure ofmore than 140/90 mmHg and 84% received at least one antihypertensive drug. However, the target blood pressure of less than 130/80 mmHg could be achieved in only 18% of these patients. The mean (SD) number of antihypertensive drugs was 1.7 (1.1). Nearly 60% of patients received either ACE inhibitors or ARBs. CONCLUSION: DN was very common. The overall picture of DN in the present survey suggests the seriousness of the problem and prompts more aggressive intervention.

Thailand diabetes registry project: prevalence and risk factors associated with lower extremity amputation in Thai diabetics.

OBJECTIVE: To determine the prevalence and risk factors associated with lower extremity amputation (LEA) in Thai diabetics. MATERIAL AND METHOD: A cross-sectional, multicenter hospital-based diabetes registry was carried out from April to December 2003. Baseline characteristics and risk factors were analysed from 9419 diabetic patients. peripheral vascular disease (PVD) was defined as absent or diminished dorsalis pedis (DP) and posterior tibialis (PT) pulses to palpation in the same limb. LEA was defined as surgical removal of part of a lower extremity. RESULTS: The prevalence of LEA was 1.5% (142). Mean diabetes duration was 10 years (SD = 7.6). Out of 556 patients with a history of foot ulcer 123 (22.1%) underwent amputation. PVD was present in 370 patients. Most ofLEAs were toe amputations (64.1%). Multiple logistic regression analysis of risk factors (adjusted OR, [95% confidence interval], p value) revealed a high risk of LEA in patients with a history of ulcer (59.2, [32.8-106.8], p < 0.001), peripheral vascular disease (5.3, [3.1-9.2], p < 0.001), diabetic retinopathy (2.2, [1.3-3.8], p = 0.004), and insulin injection (1.9, [1.1-3.2], p < 0.023). CONCLUSION: Patients at risk for LEA were those with a history of foot ulcer, absence of peripheral pulse, diabetic retinopathy and insulin injection. Preventive strategies should be considered in these groups of patients. Data should be interpreted with caution as the number of patients with amputation was few and information on neuropathy was not available.

Thailand diabetes registry project: prevalence and risk factors of stroke in thai diabetic patients.

OBJECTIVE: To determine the prevalence of stroke and its risk factors in Thai diabetic patients who attended the diabetes clinics of university and tertiary-care hospitals. MATERIAL AND METHOD: A cross-sectional, multi-center hospital-based diabetes registry was carried out at diabetes clinics of 11 university and tertiary-care hospitals. Demographic data, clinical characteristics, common drugs used and laboratory parameters were analyzed for prevalence and risk factors associated with stroke. RESULTS: The prevalence of stroke in the patients studied was 3.5%. Most of the patients were type 2 diabetes and had ischemic stroke. One of the risk factors associated with stroke was age greater than 60 years, and the risk appeared to be highest if the patients' age was greater than 70 years (adjust OR = 3.29, p = 0.012). Other risk factors included male sex, systolic blood pressure of > or =140 mmHg, use of oral hypoglycemic agents, lipid lowering agents and aspirin. There was no association between stroke and duration of diabetes, occupation, educational level, BMI, smoking, alcohol drinking, diastolic blood pressure, use of antihypertensive drugs or insulin, glycemic control, lipid profiles and kidney function. CONCLUSION: Ischemic stroke was common among Thai patients with diabetes especially in the elderly. The present result emphasizes the relationship between level of systolic blood pressure and the occurrence of stroke. Optimal blood pressure control should be underscored in caring for diabetic patients.

Thailand diabetes registry (TDR) project: clinical status and long term vascular complications in diabetic patients.

OBJECTIVE: The primary objectives of the Thailand Diabetes Registry project were to identify the characteristics of Thai diabetic patients in tertiary care medical centers and to determine the extent of long term diabetic complications. The secondary objective aimed at building up and strengthening clinical research network among Thai experts in diabetes mellitus and collection of baseline data for future follow-up study. MATERIAL AND METHOD: A cross-sectional, multi-center, hospital-based diabetes registry was carried out from diabetes clinics of 11 tertiary centers. Demographic data, clinical status of diabetes and its complications were collected and analyzed for the prevalence of complications and risk factors. RESULTS: Nine-thousand-four-hundred-and-nineteen patients were registered for the project and 94.6% were type 2 diabetes. Mean +/- SD of age was 59.4 +/- 13.5 and duration of diabetes was and 10 +/- 7.6 years. Only 38.2% of the subjects achieved glycemic control of FPG under 130 mg/dl in only 30.7% had an HbA lc of less than 7%. The overall prevalence of dyslipidemia found in this population was 73.3%, hypertension was 63.3% and obesity (BMI >25 kg/m2) was 52.6%. Diabetic nephropathy was the most common complication accounting for 43.9% followed by retinopathy 30.7%, IHD 8.1% and cerebrovascular disease 4.4%. CONCLUSION: The prevalence of dyslipidemia and hypertension were high in this population, which may be associated with the high prevalence of diabetic complications. The unsatisfactory control of metabolic status may be due to aging and long duration of diabetic patients in this registry.

Thailand diabetes registry project: glycemic control in Thai type 2 diabetes and its relation to hypoglycemic agent usage.

OBJECTIVE: To determine the pattern of hyperglycemic agent usage in Thai type 2 diabetics (T2 DM) who attended the diabetes clinic in university and tertiary-care hospitals. The achievement oftarget glycemic control by various modalities of treatment was also analyzed. MATERIAL AND METHOD: A cross-sectional, hospital-based diabetes registry of 8913 type 2 diabetic patients in 11 tertiary care hospitals and medical schools was carried out from April to December 2003. Demographic data, usage of hypoglycemic agents and level of glycemic control were collected to determine the pattern ofuse, associated factors, and achievement of glycemic control. RESULTS: Overall, 2342 (26.3%) of T2 DM achieved HbA1C less than 7%. The percentage of patients treated with metformin was 70.8%, sulfonylureas (SU) was 68.7% and insulin was 25.3%. Only 7.0% of patients received alpha-Glucosidase Inhibitor (AGI), 5.7% received ThaiZoliDinediones (TZD), 1.1% received repaglinide, and 3.2% was on diet control alone. Target glycemic control was achieved in 57.6%, 37.1%, 52%, 16.7%, 62.5%, 52% and 16.9% of patients who were on diet control only, monotherapy with SQU, metformin, TZD, AGI, repaglinide and insulin,respectively. Sulfonylureas were the most commonly used drug for monotherapy. Metformin with sulfonylurea was the most common combination therapy and was used in 39.5% of patients. More than 60% of the patients treated with metformin monotherapy had body mass index (BMI) of more than 25 kg/m2, as compare to less than half of patient treated with other monotherapy agent. Mean +/- SD duration of diabetes in thepatients treated with metformin alone was 5.9 +/- 5.5 years, less than that in the SU-treated patients (8.3 +/- 7.1 years) and also in the insulin-treated patients (14.8 +/- 9.0 years). TDZ were commonly prescribed in combination with sulfonylureas and metformin in subjects with relatively longer duration of diabetes. CONCLUSION: Better treatment strategies for glucose control ofdiabetic patients on medical treatments should be encouraged to improve glycemic control and reduce long term complications.

Thailand diabetes registry project: prevalence of diabetic retinopathy and associated factors in type 1 diabetes mellitus.

OBJECTIVE: To determine the prevalence and factors associated with Diabetic Retinopathy (DR) of type 1 diabetes mellitus in Thailand. MATERIAL AND METHOD: A cross-sectional, multicenter hospital-based study was carried out from April to December 2003. Diabetic patients in diabetic clinics of 11 tertiary centers were registered. Retinopathy was evaluated by the ophthalmologists. RESULTS: Seven thousand one hundred and ni neteen diabetic patients received retinal examination. The number of patients with type 1 diabetes was 347. The prevalence of DR in type 1 diabetes was 21.6% (75). This consisted of Non-Proliferative DR (NPDR) 10.9% (38) and Proliferative DR (PDR) 10.7%. Patients with DR were significantly older, predominantly female, longer duration ofdiabetes, had higher BMI, systolic Blood Pressure (BP), diastolic BP serum creatinine, and TriGlycerides (TG) levels than those without DR. Both groups ofpatients were not different in term ofplasma glucose and glycosylated hemoglobin levels. Although the patients with DR had a higher percentage of overt proteinuria than those without DR, there was no difference in percentage of patients with positive microalbuminuria in both groups. This may be explained by limitation of data (only 16% had results of microalbuminuria and 19% had results of proteinuria). After adjusted for duration of diabetes, serum creatinine and smoking status, factors (adjusted odds ratio [95% confidence interval]) associated with DR were duration of diabetes 5-9.9 years (4.0 [1.49-10.91]), 10-14.9 years (6.86 [2.45-19.20]), 15-19.9 years (21.13 [7.22-61.78]), > or =20 years (22.15 [7.32-66.99]) when compared with duration of diabetes less than 5 years, serum creatinine >2 mg/dl (6.0 [2.09-17.22]) when compared with creatinine less than 2 mg/dl. From the presented model, age, gender, systolic BP >140 mmHg, diastolic BP >90 mmHg, serum TG and smoking status were not factors associated with DR. CONCLUSION: Diabetic retinopathy affects about one fifth of type 1 diabetic patients in our study. The authors found the factors associated with DR in type 1 DM were duration of diabetes and serum creatinine. Regular screening for DR and more aggressive management of metabolic factors should be done to reduce the prevalence ofDR.

Microalbuminuria prevalence study (MAPS) in hypertensive patients with type 2 diabetes in Thailand.

BACKGROUND: Microalbuminuria represents the earliest clinical evidence of diabetic nephropathy, and is a marker of increased cardiovascular (CV) morbidity and mortality. OBJECTIVES: This analysis of Thai data from the Microalbuminuria Prevalence Study (MAPS) assessed the prevalence of macroalbuminuria and microalbuminuria in hypertensive patients with type 2 diabetes. DESIGN: Cross-sectional clinic-based epidemiological study. MATERIAL AND METHOD: A total of 100 patients were enrolled, of which 97 patients constituted the per-protocol population (patients with bacteriuria and haematuria were excluded). Patients attended one study visit with no follow-up. RESULTS: Overall, the prevalence of diabetic kidney disease was high, with macroalbuminuria contributing 13.4% [9.9-16.9; 95% confidence interval (CI)] and microalbuminuria contributing 43.3% [38.3-48.3; 95%CI]. CONCLUSION: Annual screening for microalbuminuria is recommended for all patients with type 2 diabetes, as early treatment is critical for reducing CV risks. Clinical studies have shown that renin-angiotensin system inhibitors can slow the progression of diabetic nephropathy.

Improvement of fat redistribution, insulin resistance and hepatic fatty infiltration in HIV-associated lipodystrophy syndrome by pioglitazone: a case report.

HIV-associated lipodystrophy syndrome is a syndrome occurring in HIV-infected patients who were treated with highly-active antiretroviral therapy (HAART), especially regimen containing protease inhibitors. The syndrome consists of fat redistribution, with loss of subcutaneous fat and increase in visceral fat, and metabolic disturbances, including glucose intolerance or overt diabetes and dyslipidemia. No standard treatment has been established for this syndrome. Pioglitazone is an oral antidiabetic agent that acts primarily on adipose tissue to reduce insulin resistance. The authors report a 50-year old HIV-infected woman who developed HIV-associated lipodystrophy syndrome after 3 months of HAART. She had significant weight loss with obvious loss of subcutaneous fat, together with development of hypertension, diabetes and dyslipidemia. After treatment with 30 milligrams of pioglitazone daily, her body weight increased within the first month of treatment. Subcutaneous fat loss was restored. Improvement in glycemic and lipid control was also noted. CT scan of the abdomen revealed that fatty infiltration in the liver was markedly decreased. Visceral fat as assessed by CT scan had also decreased. Pioglitazone appeared to have beneficial effects in this patient.