[Bariatric surgery: who, when and where?; an overview for the referring physician]. / Bariatrische chirurgie: hoe, wanneer, wat en bij wie?

- Bariatric surgery is performed in patients with a body mass index (BMI) > 40kg/m2, or BMI > 35 kg/m2 with obesity-related comorbidities. The Roux-en-Y gastric bypass and sleeve gastrectomy are the most frequently used procedures.- On average, patients have lost 25-27% of their original weight 10 years after surgery.- Obesity-related comorbidities improve dramatically in many patients following surgery. The effect is most noticeable in patients with diabetes mellitus type 2 and obstructive sleep apnoea syndrome. - The prevalence of 30-day complications is < 5%. Mortality is < 0.2% in centres with a lot of experience. - Commonly occurring long-term complications of bariatric surgery include deficiencies, particularly of iron and vitamin B12, along with gallstone disease and sagging skin. - Specific complications can arise following Roux-en-Y gastric bypass, such as internal herniation and hypoglycaemia, and these are often not recognised.

Vitamin B12 deficiency and the lack of its consequences in type 2 diabetes patients using metformin.

OBJECTIVES: To study vitamin B12 concentrations in patients with type 2 diabetes with and without metformin use and to identify risk factors and consequences of low vitamin B12 concentrations. RESEARCH DESIGN AND METHODS: This study had a cross-sectional design. During eight weeks all patients with type 2 diabetes visiting the diabetic outpatient clinic of the Isala Clinics in Zwolle were approached for participation. Participation included measurement of haemoglobin, mean corpuscular volume and vitamin B12 levels. Data on neuropathy were retrospectively searched for in the patient records. Vitamin B12 deficiency was defined as serum B12 concentrations <150 pmol/l. RESULTS: In the total cohort (n=298), the overall prevalence of vitamin B12 concentrations <150 pml/l was 9.7% (95% CI 6.6-13.7%). In type 2 diabetes patients not taking metformin (n=134), the prevalence was 4.4% (95% CI 1.6-9.4%) compared with 14.1% in metformin users (n=164) (95% CI 9.2-20.4%; p=0.006). Each 100 mg step in metformin dose increased (OR=1.081, p=0.014), whereas PPI use lowered (OR=0.322, p=0.037) the odds of having a vitamin B12 deficiency in logistic regression. Nevertheless, metformin use did not predict the chance on having anaemia or neuropathy. CONCLUSION: Among patients with type 2 diabetes using metformin, the prevalence of vitamin B12 deficiency is higher than compared with patients not using metformin. However, metformin use did not predict the chance of having anaemia or neuropathy.

What do professionals recommend regarding the frequency of self-monitoring of blood glucose?

BACKGROUND: Patients' adherence to guidelines regarding self-monitoring of blood glucose (SMBG) is limited. However, there are no previous reports about the recommendations that are given in clinical practice concerning SMBG. The aim of this study was to investigate what healthcare providers recommend to insulin-treated patients with diabetes regarding frequency and timing of SMBG. METHODS: In this cross-sectional descriptive study, primary care assistants, diabetes specialised nurses and doctors in the Netherlands were invited via e-mail to complete an internet survey. RESULTS: A total of 980 (14%) professionals returned the questionnaire. Insulin pump users and patients with type 1 diabetes (T1DM) on 4 injections a day were advised to perform SMBG daily by 96% and 63% of the professionals, respectively. The majority of the professionals advised these patients to perform 3-4 measurements per day. There was less agreement on the timing (pre- and÷or postprandial). Patients with type 2 diabetes (T2DM) on four injections were advised to perform SMBG less frequently. There was a wide variation in recommendations that were given to patients with T2DM on less intensive insulin regimens. CONCLUSION: This study investigated SMBG from a professional's perspective. A considerable and relevant variation in the recommendations about the number and timing of SMBG was observed. The most striking differences were found in patients with T2DM on less intensive insulin regimes, also with respect to the frequency of SMBG. Well-designed studies are necessary in order to give a more evidence-based advice on the basic frequency and timing of SMBG.

Time for considering other blood pressure target values in elderly patients with type 2 diabetes?

Although blood pressure control has undoubtedly proven its benefits in reducing the high cardiovascular risk in patients with type 2 diabetes mellitus (T2DM), it still remains unclear whether intensive antihypertensive treatment in old age (> 75 years) is beneficial. Many of the current guidelines recommend a systolic blood pressure (SBP) < 140 mmHg or lower, unless patients are at high risk for possible adverse events such as postural hypotension (1,2). This perspective aims to get a discussion started on the appropriate target SBP value for patients with T2DM aged older than 75 years.We would like to propose the less stringent value of< 160 mmHg in this specific population.

Glycaemic control and the risk of mortality in elderly type 2 diabetic patients (ZODIAC-20).

AIMS: Studies on macrovascular consequences of glucose control in elderly patients (>75 years) with type 2 diabetes mellitus (T2DM) are lacking. The present study aimed to investigate the relationship between HbA(1c) and mortality in this specific population. METHODS: Between 1998 and 1999, 374 primary care patients with T2DM aged older than 75 years participated in the Zwolle Outpatient Diabetes project Integrating Available Care study, a prospective observational study. Early 2009, data on mortality were collected. Updated means for annually measured HbA(1c) values were calculated after a follow-up time of 10 years. Updated mean HbA(1c) was used as a time-dependent covariate in a Cox proportional hazard model. Main outcome measures were all-cause and cardiovascular disease (CVD) mortality. Analyses were performed in strata according to diabetes duration (<5, 5-11 and ≥11 years). RESULTS: In the group with a diabetes duration <5 years, an increase of 1% in the updated mean HbA(1c) level was associated with an increase in all-cause and CVD mortality risk of 51% (95% CI 17-95%) and 72% (95% CI 19-148%), respectively. Glycaemic control was not related to mortality for patients with a diabetes duration ≥5 years. CONCLUSION: Poor glycaemic control is related to increased all-cause and CVD mortality in patients >75 years with T2DM of short duration (<5 years). DISCUSSION: Because of the observational study design, our results should be interpreted with caution. Nevertheless, they are suggestive that improving glycaemic control may be beneficial in elderly patients with T2DM, especially in those with recently diagnosed T2DM. Randomised-controlled trials are necessary to investigate whether this holds true.

Self-monitoring of blood glucose in tablet-treated type 2 diabetic patients (ZODIAC).

BACKGROUND: Whether self-monitoring of blood glucose (SMBG) improves glycaemic control in patients with type 2 diabetes mellitus (T2DM) not using insulin is questionable. Our aim was to investigate the effects of SMBG in patients with T2DM who were in persistent moderate glycaemic control whilst not using insulin. METHODS: Patients were eligible when between 18 and 70 years of age, with an HbA1c between 7 and 8.5%, using one or two oral blood glucose lowering agents. Forty-one of the anticipated 52 patients were randomly assigned to receive either SMBG added to usual care, or to continue with usual care for one year. A fasting glucose value and three postprandial glucose values were measured twice weekly (including a Saturday or a Sunday). The primary efficacy parameter was HbA1c. Furthermore, health-related quality of life and treatment satisfaction were assessed using the Short-form 36 Health Survey Questionnaire (SF-36), the Type 2 Diabetes Symptom Checklist (DSC-r), the Diabetes Treatment Satisfaction Questionnaire (DTSQ) and the WHO -Wellbeing Index (WHO-5). RESULTS: Change in HbA1c between groups was -0.05% (95% CI: -0.51, 0.41; p=0.507). Also, there were no significant changes between groups on the DTSQ , DSC type 2, WHO-5 or SF -36, except for the SF -36 dimension 'health change' which was lower in the SBMG group (mean difference: -12 (95% CI: -20.9, -3.1). CONCLUSION: On top of the absence of a clinical benefit, tablet-treated T2DM patients experienced some worsening of their health perception. We therefore argue that the use of SMBG in this patient group is questionable, and its unlimited use and promotion should be reconsidered.

[New blood glucose-lowering drugs in type 2 diabetes: a review of the literature]. / Nieuwe bloedglucoseverlagende middelen bij type 2 diabetes: een literatuuroverzicht.

OBJECTIVE: To describe the efficacy and safety of the glucagon-like peptide 1 (GLP-1) analogues exenatide and liraglutide, and the dipeptidyl peptidase-4 (DPP-4) inhibitors vildagliptin and sitagliptin, registered in the Netherlands for treatment of type 2 diabetes mellitus (DM2). DESIGN: Literature study. METHOD: The Medline database was searched up to and including August 2009 for systematic reviews and randomised trials with a minimum duration of 12 weeks in patients with DM2. Two authors independently selected the studies based on the title, abstract and, if necessary, the full text. RESULTS: In addition to 1 systematic review on GLP-1 analogues and 1 review on DPP-4 inhibitors, 10 studies on DPP-4 inhibitors and 16 studies on GLP-1 analogues were included. According to these studies, the DPP-4 inhibitors sitagliptin and vildagliptin gave a mean HbA1c reduction of 0.7% and 0.6% respectively. GLP-1 analogues led to a mean HbA1c reduction of 1%, which is comparable to insulin therapy. Sitagliptin was associated with a slight increase in the number of upper respiratory tract infections. In a large number of patients, GLP-1 analogues were associated with gastrointestinal complaints. DPP-4 inhibitors were associated with a small weight gain, compared with weight loss in patients treated with GLP-1 analogues. Data on microvascular and macrovascular complications, as well as data on mortality, are not yet available in either group. CONCLUSION: GLP-1 analogues regulate blood glucose levels as effectively as the current glucose-lowering agents; DPP-4 inhibitors are less effective. GLP-1 analogues lead to a clear weight reduction while DPP-4 inhibitors cause slight weight gain. Data on efficacy and safety in the longer term are not yet available.

[Increase in the number of people with diabetes mellitus: need for a master plan]. / Toename van het aantal mensen met diabetes mellitus: noodzaak van een deltaplan.

The predicted increase in the number of people in the Netherlands known to have diabetes mellitus to 1.3 million people in 2025 is rather staggering. Subjects with type 2 diabetes mellitus account for most of the increase. An important part of this rise is due to changing living conditions, including obesity and being overweight, sedentary behaviour, and an unhealthy lifestyle. In order to alleviate this expected rise, much energy will have to be put into preventive measures, with much effort in the initial phases and results only to be expected after a prolonged period. These efforts will be necessary not only within the health care system, but in the population as a whole, with focus on changing attitudes and lifestyles.

Diabetes specialist nurse as main care provider for patients with type 2 diabetes.

BACKGROUND: The objective of this study was to determine whether the management of type 2 diabetes (DM2) can be transferred from an internist to a nurse specialised in diabetes (NSD). METHODS: Ninety-three patients with DM2 referred by their general practitioner were randomised; 84 patients completed the study. The intervention group received care from an NSD who treated glycaemia, blood pressure and lipid profile by protocol. The control group received care from an internist. The primary endpoint was the main decrease in HbA1c. Secondary endpoints included blood pressure, lipid profile, healthcare costs, QOL , and patient satisfaction. RESULTS: HbA1c, total cholesterol, LDL cholesterol and cholesterol/HDL ratio decreased significantly in both study populations after a follow-up time of 12 months. Cholesterol/HDL ratio decreased by 0.4 and 0.9 in the NSD and control group respectively (p=0.034 for the difference between groups). The decreases (95% confidence interval) in systolic blood pressure were 8.6 mmHg (2.6, 14.7) in the NSD group and 4.0 mmHg (-0.9, 8.9) in the control group, without a significant difference between groups. After one year, 33.3% of the patients in the NSD group achieved an HbA1c level. <7% compared with 2.2%at baseline (p=0.002). Healthcare costs were less and patient satisfaction with the NSD s was significantly better(p<0.001), while maintaining the same QOL . CONCLUSION: NSD s using treatment protocols are able to provide effective care for patients with DM 2, comparable with the care provided by an internist, with respect to clinical parameters, and superior with respect to healthcare costs and patient satisfaction.

Intensification of therapy and no increase in body mass index with longer disease duration in type 2 diabetes mellitus (ZODIAC-5).

BACKGROUND: Decreased insulin sensitivity and beta-cell failure are the two key components in the pathogenesis of type 2 diabetes mellitus (T2DM). Secondary treatment failure is often attributed to the development of obesity-related insulin resistance in combination with continued loss of beta-cell function. OBJECTIVE: Assess metabolic control, body mass index (BMI) and treatment in relationship to diabetes duration to study these mechanisms. METHODS: Cross-sectional study of 7875 patients with T2DM in primary care in The Netherlands. Clinical data and laboratory results were obtained for the 2005 annual visit. Patients were grouped according to diabetes duration in 2-year intervals. Each step in the traditional treatment sequence was considered as a sign of progression of beta-cell failure. RESULTS: Complete data regarding duration and treatment were available for 6850 patients (87%). After the initial years following diagnosis, treatment with diet alone decreases and oral hypoglycaemic agents (OHA) are prescribed to an increasing percentage of patients. Treatment with OHA diminishes after approximately 10 years following diagnosis and treatment with insulin increases until approximately two-thirds of patients with diabetes duration of more than 20 years are being treated with insulin. BMI does not increase with longer disease duration. CONCLUSION: The concept of beta-cell failure as the primary determinant of the chronic progression of T2DM is supported by these results, whereas a deterioration of obesity-related insulin sensitivity as indicator is not supported.

[Measuring the blood pressure in both arms is of little use; longitudinal study into blood pressure differences between both arms and its reproducibility in patients with diabetes mellitus type 2]. / Weinig nut van bloeddrukmeting aan beide armen; longitudinale studie naar interarmbloeddrukverschillen en de reproduceerbaarheid daarvan bij patiënten met diabetes mellitus type 2.

OBJECTIVE: To determine the prevalence of inter-arm blood pressure differences > 10 mmHg in patients with diabetes mellitus type 2 (DM2) and to determine whether these differences are consistent over time. DESIGN: Descriptive. METHOD: In an evaluation study of 169 DM2 patients from 5 general practices in 2003 and 2004, different methods of oscillatory measurement were used to investigate inter-arm blood pressure differences > 10 mmHg systolic or diastolic. These methods were: one measurement in each arm non-simultaneously (method A), one measurement simultaneously (B) and the mean of two simultaneous measurements (C). RESULTS: With method A an inter-arm blood pressure difference was found in 33% of patients. This percentage diminished to 9 with method C. In 44% (n = 7) of the patients in whom method C detected a relevant blood pressure difference, this difference was not found with method A. In 79% of patients the inter-arm blood pressure difference was not reproduced after one year. CONCLUSION: In daily practice, one non-simultaneous blood pressure measurement in each arm (method A) was of little value for identification of patients with inter-arm blood pressure differences. The reproducibility was poor one year later. Bilateral blood pressure measurement is therefore of little value.

[Cinnamon: not suitable for the treatment of diabetes mellitus]. / Kaneel: niet geschikt als behandeling voor diabetes mellitus.

OBJECTIVE: To identify published studies evaluating the effects of cinnamon on glycaemic control. DESIGN: Literature search. METHOD: The Medline database was searched using all possible combinations of the words and medical subject headings (MeSH) 'cinnamon', 'diabetes mellitus', 'HbA1C' and 'glucose'. All human or animal studies in which cinnamon was administered as intervention were included. RESULTS: Several animal studies and 5 randomized placebo-controlled trials in humans were found. Most of the animal studies described beneficial effects of cinnamon on glycaemic control. One placebo-controlled trial in patients with type 2 diabetes found that cinnamon intake was associated with favourable effects on fasting plasma glucose. None of the studies reported an improvement in HbA1C. A study in patients with type 1 diabetes found that cinnamon had no effect. CONCLUSION: Based on the currently available evidence, cinnamon should not be recommended for the improvement ofglycaemic control.

Pitfalls in blood pressure measurement in daily practice.

BACKGROUND: Accurate blood pressure (BP) readings and correctly interpreting the obtained values are of great importance. However, there is considerable variation in the different BP measuring methods suggested in guidelines and used in hypertension trials. OBJECTIVE: To compare the different methods used to measure BP; measuring once, the method used for a large study such as the UKPDS, and the methods recommended by various BP guidelines. METHODS: In 223 patients with type 2 diabetes from five family practices BP was measured according to a protocol to obtain the following data: A = first reading, B = mean of two initial readings, C = at least four readings and the mean of the last three readings with less than 15% coefficient of variation difference, D = mean of the first two consecutive readings with a maximum of 5 mm Hg difference. Mean outcomes measure is the mean difference between different BP measuring methods in mm Hg. RESULTS: Significant differences in systolic/diastolic BP were found between A and B [mean difference (MD) systolic BP 1.6 mm Hg, P < 0.001], B and C (MD 5.7/2.8 mm Hg, P < 0.001), B and D (MD 6.2/2.8 mm Hg, P < 0.001), A and C (MD 7.3/3.3 mm Hg), and A and D (MD 7.9/3.0 mm Hg, P < 0.001). CONCLUSION: Different methods to assess BP during one visit in the same patient lead to significantly different BP readings and can lead to overestimation of the mean BP. These differences are clinically relevant and show a gap between different methods in trials, guidelines and daily practice.

Cross-sectional relationship between glycaemic control, hyperglycaemic symptoms and quality of life in type 2 diabetes (ZODIAC-2).

BACKGROUND: To describe the relationship between glycaemic control, hyperglycaemic symptoms and quality of life (HRQOL) in type 2 diabetic patients. METHODS: In a shared-care diabetes project HRQOL was assessed. A total of 1664 patients with type 2 diabetes were identified in 32 primary healthcare practices. Of these patients, 1149 were included. HRQOL was measured using a generic questionnaire (Rand-36), completed by 1006 of the 1149 participants. RESULTS: The number of hyperglycaemic symptoms was higher in women (1.88) compared with men (1.64), without differences in mean haemoglobin A1c (HbA1c) (7.5%)-Univariate analyses showed negative relationships between all dimensions of the Rand-36 and hyperglycaemic symptoms (p<0.001), but between only one dimension and HbA1c (p=0.005). Multivariate analyses showed no association between any of the dimensions of the Rand-36 and HbA1c, but the relationship between hyperglycaemic symptoms persisted in all dimensions (p<0.001). Notwithstanding these results, the presence of hyperglycaemic symptoms was related to higher HbA1c. CONCLUSION: In type 2 diabetic patients, as assessed by a generic questionnaire, there is an evident relationship between hyperglycaemic symptoms and HRQOL and not between HbA1c and HRQOL. Subjective hyperglycaemic symptoms are, independent of HbA1c, important for HRQOL in type 2 diabetic patients, and should therefore not be neglected in the management of diabetes.

[Diagnosis of diabetes mellitus: limited use for portable blood-glucose measuring devices]. / Diagnostiek van diabetes mellitus: beperkte plaats voor draagbare glucosemeters.

In the Netherlands, guidelines for the diagnosis of diabetes mellitus are confusing and differ from the international guidelines. Capillary blood-glucose testing using a blood-glucose device is allowed used as a diagnostic tool, although this test is imprecise. The Dutch laboratories measure blood-glucose concentrations by a more precise accurate method, but sometimes measure glucose levels in capillary whole blood and sometimes in venous plasma. These results are not comparable, because the results of capillary measurements are lower than the plasma measurements. In daily practice, health-care professionals are using different methods and are often not aware of the differences in glucose values that may result. They do not realise that glucose devices and laboratory glucose measurements may differ and that capillary- and plasma-glucose values are not interchangeable. Uniformity within the Dutch laboratories with regard to the glucose measurements is urgently needed, as is revision of the Dutch guidelines concerning the diagnosis of diabetes mellitus. This should be based solely on venous plasma-glucose values determined in a laboratory. Portable blood-glucose devices should not be used as a diagnostic tool for diabetes mellitus. These should only be used for blood-glucose control monitoring during treatment or as a screening tool.

[Use of stairs in a hospital increased by a sign near the stairs or the elevator]. / Trapgebruik in een ziekenhuis bevorderd met een bordje bij de trap of de lift.

OBJECTIVE: To investigate whether signs encouraging taking the stairs or discouraging taking the elevator lead to an increasing number of patients taking the stairs instead of the elevator in a hospital. DESIGN: Interventional study. METHOD: During a period of 6 weeks in the period October-December 2004, an investigator recorded how many patients took the stairs and how many took the elevator on the first floor of a hospital close to a diabetes outpatient clinic. A baseline measurement was done over a period of 2 weeks and 4 weeks were used for evaluating the effect of 2 different interventions, each lasting 2 weeks. During the first intervention, a sign was hung up near the elevator, which read: 'Exercise is healthy, take the stairs'. During the second intervention the sign read: 'Use of this elevator is exclusively for personnel and persons with restricted mobility'. Staff members and disabled patients were excluded from the study. RESULTS: A total of 2674 movements were counted. Use of the stairs increased statistically significantly during both interventions: from 54.6% to 63.4% during the first intervention and to 70.4% during the second intervention. CONCLUSION: Signs in a diabetes outpatient clinic that either encouraged the use of the stairs or discouraged the use of the elevator increased the patients' use of the stairs.

[Chromium and insulin resistance]. / Chroom en insulineresistentie.

Since as early as the 50s of the last century, it has been known that chromium is essential for normal glucose metabolism. Too little chromium in the diet may lead to insulin resistance. However, there is still no standard against which chromium deficiency can be established. Nevertheless, chromium supplements are becoming increasingly popular. Various systematic reviews have been unable to demonstrate any effects of chromium on glycaemic regulation (possibly due partly to the low dosages used), but there is a slight reduction in body weight averaging 1 kg. In a double-blind randomised placebo-controlled trial in a Chinese population with type-2 diabetes mellitus, supplementation with 1000 micrograms of chromium led to a fall in the glycosylated haemoglobin level (HbA1c) by 2%. Toxic effects of chromium are seldom seen; recently, however, the safety of one of the dosage forms of chromium, chromium picolinate, has been questioned. One should be aware that individual patients with type-2 diabetes mellitus may have an increased risk of hypoglycaemic episodes when taking chromium supplements as self-medication.