Impact of Age, Frailty, and Dementia on Prescribing for Type 2 Diabetes at Hospital Discharge 2012-2016.

BACKGROUND: The risks of intensive blood glucose lowering may outweigh the benefits in vulnerable older people. OBJECTIVES: Our primary aim was to determine whether age, frailty, or dementia predict discharge treatment types for patients with type 2 diabetes (T2D) and related complications. Secondly, we aimed to determine the association between prior hypoglycemia and discharge treatment types. DESIGN, SETTING AND PARTICIPANTS: We conducted a cohort study involving 3,067 patients aged 65-99 years with T2D and related complications, discharged from Melbourne's Eastern Health Hospital Network between 2012 and 2016. MEASUREMENTS: Multinomial logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CI) for the association between age, frailty, dementia and hypoglycemia, and being prescribed insulin-only, non-insulin glucose-lowering drugs (GLDs) or combined insulin and non-insulin GLDs compared to no GLD. International Classification of Diseases-10 codes were used to identify dementia status and prior hypoglycemia; frailty was quantified using the Hospital Frailty Risk Score. RESULTS: Insulin-only, non-insulin GLDs, combined insulin and non-insulin GLDs, and no GLDs were prescribed to 19%, 39%, 20%, and 23% of patients, respectively. Patients >80 years were less likely than patients aged 65-80 to be prescribed any of the GLD therapies, (eg. non-insulin GLDs [OR 0.67; 95%CI 0.55-0.82]), compared to no GLD. Similarly, high vs. low frailty scores were associated with not being prescribed any of the three GLD therapies, (eg. non-insulin GLDs [OR 0.63; 95%CI 0.45-0.87]). However, dementia was not associated with discharge prescribing of GLD therapies. Patients with a hypoglycemia-related admission were more likely than those not hospitalized with hypoglycemia to receive insulin-only (OR 4.28; 95%CI 2.89-6.31). CONCLUSIONS: Clinicians consider age and frailty when tailoring diabetes treatment regimens for patients discharged from hospital with T2D and related complications. There is scope to optimize prescribing for patients with dementia and for those admitted with hypoglycemia.

Pharmacological treatment initiation for type 2 diabetes in Australia: are the guidelines being followed?

AIM: To determine the patterns and predictors of pharmacological treatment initiation for type 2 diabetes and whether treatment initiation is consistent with Australian clinical practice guidelines that recommend metformin monotherapy. METHODS: Individuals aged 40-99 years initiating a non-insulin type 2 diabetes medication between July 2013 and February 2018 were identified from a 10% random national sample of pharmacy dispensing data. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the predictors of initiating sulfonylurea monotherapy, non-guideline monotherapy and combination therapy compared with metformin monotherapy. Predictors included age, sex, initiation year and comorbidities determined using the Rx-Risk comorbidity index. RESULTS: Of the 47 860 initiators, [47% women, mean age 60.7 (sd 12.1) years], 85.8%, 4.6%, 1.9% and 7.7% received metformin monotherapy, sulfonylurea monotherapy, non-guideline monotherapy and combination therapy, respectively. Increasing age was associated with increasing odds of initiating sulfonylurea monotherapy and non-guideline monotherapy. Combination therapy initiation was less likely in women (OR 0.74, 95% CI 0.69-0.79) and people with more comorbidities (e.g. OR 0.36, 95% CI 0.29-0.44 for seven or more comorbidities vs. no comorbidities) but more likely in congestive heart failure (OR 1.42, 95% CI 1.22-1.65), cerebrovascular disease (OR 1.50, 95% CI 1.32-1.69) and dyslipidaemia (OR 1.29, 95% CI 1.19-1.40). CONCLUSION: Treatment initiation in Australia is largely consistent with clinical practice guidelines, with 86% of individuals initiating metformin monotherapy. Initiation on combination therapy was more common in men and in those with fewer comorbidities.

Cardiovascular disease management in people with diabetes outside North America and Western Europe in 2006 and 2015.

AIM: Optimal treatment of cardiovascular disease is essential to decrease mortality among people with diabetes, but information is limited on how actual treatment relates to guidelines. We analysed changes in therapeutic approaches to anti-hypertensive and lipid-lowering medications in people with Type 2 diabetes from 2006 and 2015. METHODS: Summary data from clinical services in seven countries outside North America and Western Europe were collected for 39 684 people. Each site summarized individual-level data from outpatient medical records for 2006 and 2015. Data included: demographic information, blood pressure (BP), total cholesterol levels and percentage of people taking statins, anti-hypertensive medication (angiotensin-converting enzyme inhibitors, calcium channel blockers, angiotensin II receptor blockers, thiazide diuretics) and antiplatelet drugs. RESULTS: From 2006 to 2015, mean cholesterol levels decreased in six of eight sites (range: -0.5 to -0.2), whereas the proportion with BP levels > 140/90 mmHg increased in seven of eight sites. Decreases in cholesterol paralleled increases in statin use (range: 3.1 to 47.0 percentage points). Overall, utilization of anti-hypertensive medication did not change. However, there was an increase in the use of angiotensin II receptor blockers and a decrease in angiotensin-converting enzyme inhibitors. The percentage of individuals receiving calcium channel blockers and aspirin remained unchanged. CONCLUSIONS: Our findings indicate that control of cholesterol levels improved and coincided with increased use of statins. The percentage of people with BP > 140/90 mmHg was higher in 2015 than in 2006. Hypertension treatment shifted from using angiotensin-converting enzyme inhibitors to angiotensin II receptor blockers. Despite the potentially greater tolerability of angiotensin II receptor blockers, there was no associated improvement in BP levels.

Meeting American Diabetes Association diabetes management targets: trends in Mauritius.

AIMS: To examine the proportion of people with diabetes in the multi-ethnic country of Mauritius meeting American Diabetes Association targets in 2009 and 2015. METHODS: Data from independent population-based samples of 858 and 656 adults with diagnosed diabetes in 2009 and 2015, respectively, were analysed with regard to recommended American Diabetes Association targets for HbA1c , blood pressure and LDL cholesterol. RESULTS: In 2015 compared with 2009, the proportion of people achieving American Diabetes Association targets for glycaemic control in Mauritius was higher in women (P≤0.01) and in those with only a primary education level (P=0.07), but not in men or people with a higher level of education. Achievement of blood pressure <140/90 mmHg was higher in 2015 compared with 2009 (60% vs 42%) in people of South Asian ethnicity (P<0.001), but not in those of African ethnicity (P=0.16). The percentages of people with LDL cholesterol <2.59 mmol/l were 42.1% and 50.4%, in 2009 and 2015, respectively (P=0.27). Better control of HbA1c and blood pressure was observed in groups in which that control was poorest in 2009. The use of glucose-, blood pressure- and LDL cholesterol-lowering medication was higher in 2015 than in 2009. CONCLUSIONS: In certain subgroups, namely women, those with poorer education and those of South Asian ethnicity, whose target achievement was the poorest in 2009, control of glycaemia and blood pressure was better in 2015 as compared with 2009. While these findings are encouraging, further work is required to improve outcomes.

Incidence of chronic kidney disease among people with diabetes: a systematic review of observational studies.

AIMS: The aim was to systematically review published articles that reported the incidence of chronic kidney disease among people with diabetes. METHODS: A systematic literature search was performed using MEDLINE, Embase and CINAHL databases. The titles and abstracts of all publications identified by the search were reviewed and 10 047 studies were retrieved. RESULTS: A total of 71 studies from 30 different countries with sample sizes ranging from 505 to 211 132 met the inclusion criteria. The annual incidence of microalbuminuria and albuminuria ranged from 1.3% to 3.8% for Type 1 diabetes. For Type 2 diabetes and studies combining both diabetes types, the range was from 3.8% to 12.7%, with four of six studies reporting annual rates between 7.4% and 8.6%. In studies reporting the incidence of eGFR < 60 ml/min/1.73 m2 using the Modification of Diet on Renal Disease (MDRD) equation, apart from one study which reported an annual incidence of 8.9%, the annual incidence ranged from 1.9% to 4.3%. The annual incidence of end-stage renal disease ranged from 0.04% to 1.8%. CONCLUSIONS: The annual incidence of microalbuminuria and albuminuria is ~ 2-3% in Type 1 diabetes, and ~ 8% in Type 2 diabetes or mixed diabetes type. The incidence of developing eGFR < 60 ml/min/1.73 m2 is ~ 2-4% per year. Despite the wide variation in methods and study design, within a particular category of kidney disease, there was only modest variation in incidence rates. These findings may be useful in clinical settings to help understand the risk of developing kidney disease among those with diabetes.

Trends in diabetes and obesity in Samoa over 35 years, 1978-2013.

AIMS: Population surveys of Type 2 diabetes mellitus and obesity conducted in Samoa over three decades have used varying methodologies and definitions. This study standardizes measures, and trends of Type 2 diabetes mellitus and obesity for 1978-2013 are projected to 2020 for adults aged 25-64 years. METHODS: Unit records from eight surveys (n = 12 516) were adjusted to the previous census for Division of residence, sex and age to improve national representativeness. Type 2 diabetes mellitus is defined as a fasting plasma glucose ≥ 7.0 mmol/l and/or on medication. Obesity is defined as BMI ≥ 30 kg/m2 . Random effects meta-regression was employed to assess time trends following logit transformation. Poisson regression from strata was used to assess the effects of mean BMI changes on Type 2 diabetes mellitus period trends. RESULTS: Over 1978-2013, Type 2 diabetes mellitus prevalence increased from 1.2% to 19.6% in men (2.3% per 5 years), and from 2.2% to 19.5% in women (2.2% per 5 years). Obesity prevalence increased from 27.7% to 53.1% in men (3.6% per 5 years) and from 44.4% to 76.7% (4.5% per 5 years) in women. Type 2 diabetes mellitus and obesity prevalences increased in all age groups. From period trends, Type 2 diabetes mellitus prevalence in 2020 is projected to be 26% in men and women. Projected obesity prevalence is projected to be 59% in men and 81% in women. Type 2 diabetes mellitus period trends attributable to BMI increase are estimated as 31% (men) and 16% (women), after adjusting for age. CONCLUSION: This is the first study to produce trends of Type 2 diabetes mellitus and obesity in Samoa based on standardized data from population surveys. Type 2 diabetes mellitus is equally prevalent in both sexes, and obesity is widespread. Type 2 diabetes mellitus prevalence in Samoa is likely to continue to increase in the near future.

Residential distance from major urban areas, diabetes and cardiovascular mortality in Australia.

BACKGROUND: Living outside major urban centres is associated with increased mortality in the general population but whether having diabetes further impacts on the effects of living outside major urban centres is not known. This study explores the impact of residential location and diabetes on all-cause, ischemic heart disease (IHD) and stroke mortality in Australia. METHODS: We included 1,101,053 individuals (all ages) with diabetes on the national diabetes register, between 2000 and 2010. Vital statistics were collected by linkage to the death registry. The Accessibility/Remoteness Index of Australia (ARIA+) was used to categorize residences into major urban, inner regional, outer regional and remote areas, according to distance from major service centres. Standardised mortality ratios (SMRs) by ARIA+ are reported. RESULTS: During follow-up (median 6.7 years), there were 187,761 deaths (46,244 and 12,786 IHD and stroke deaths, respectively). Age-standardized all-cause, stroke and IHD mortality rates increased across ARIA+ categories in diabetes and in the general population. For all outcomes, similar patterns were observed in both sexes and diabetes type, although the rates were higher in males. For all-cause (both sexes, type 1 diabetes (T1DM) and type 2 diabetes (T2DM)), IHD mortality (T2DM only) and stroke mortality (T2DM only), SMRs varied across ARIA+ categories, showing a shallow U-shaped relationship, in which the lowest SMR was in the inner regional or outer regional areas, and the highest SMR in the major urban or remote areas. CONCLUSION: The effect of diabetes on mortality varied only modestly by location, and the impact of diabetes was greatest in the major urban and remote areas, and least in the inner and outer regional areas.

Association between serum concentration of 25-hydroxyvitamin D and the risk of hip arthroplasty for osteoarthritis: result from a prospective cohort study.

OBJECTIVES: There is ongoing debate regarding the optimal serum concentrations of 25-hydroxy-vitamin D for musculoskeletal health, including osteoarthritis (OA). The aim of this prospective cohort study was to determine whether serum 25-hydroxy-vitamin D concentrations were associated with the risk of hip arthroplasty for OA. DESIGN: This study examined 9135 participants from the Australian Diabetes, Obesity and Lifestyle Study who had serum 25-hydroxy-vitamin D measured in 1999-2000 and were aged ≥40 years at the commencement of arthroplasty data collection. The incidence of hip arthroplasty for OA during 2002-2011 was determined by linking cohort records to the Australian Orthopaedic Association National Joint Replacement Registry. RESULTS: Over an average 9.1 (standard deviation (SD) 2.7) years of follow-up, 201 hip arthroplasties for OA were identified (males n = 90; females n = 111). In males, a one-standard-deviation increase in 25-hydroxy-vitamin D was associated with a 25% increased incidence (HR 1.25, 95% CI 1.02-1.56), with a dose response relationship evident by quartiles of 25-hydroxy-vitamin D concentration (P for trend 0.04). These results were independent of age, body mass index (BMI), ethnicity, smoking status, physical activity, season of blood collection, latitude, hypertension and diabetes, area level disadvantage or after excluding those with extreme low 25-hydroxy-vitamin D concentrations. No significant association was observed in women (HR 1.10, 95% CI 0.87, 1.39). CONCLUSIONS: Increasing serum 25-hydroxy-vitamin D concentrations were associated with an increased risk of hip arthroplasty for OA in males, while no significant association was observed in females. The mechanism for the association warrants further investigation.

The metabolic syndrome and cancer: Is the metabolic syndrome useful for predicting cancer risk above and beyond its individual components?

AIMS: The metabolic syndrome (MetS) is a risk factor for cancer. However, it is not known if the MetS confers a greater cancer risk than the sum of its individual components, which components drive the association, or if the MetS predicts future cancer risk. MATERIALS AND METHODS: We linked 20,648 participants from the Australian and New Zealand Diabetes and Cancer Collaboration with complete data on the MetS to national cancer registries and used Cox proportional hazards models to estimate associations of the MetS, the number of positive MetS components, and each of the five MetS components separately with the risk for overall, colorectal, prostate and breast cancer. Hazard ratios (HR) and 95% confidence intervals (95%CI) are reported. We assessed predictive ability of the MetS using Harrell's c-statistic. RESULTS: The MetS was inversely associated with prostate cancer (HR 0.85; 95% CI 0.72-0.99). We found no evidence of an association between the MetS overall, colorectal and breast cancers. For those with five positive MetS components the HR was 1.12 (1.02-1.48) and 2.07 (1.26-3.39) for overall, and colorectal cancer, respectively, compared with those with zero positive MetS components. Greater waist circumference (WC) (1.38; 1.13-1.70) and elevated blood pressure (1.29; 1.01-1.64) were associated with colorectal cancer. Elevated WC and triglycerides were (inversely) associated with prostate cancer. MetS models were only poor to moderate discriminators for all cancer outcomes. CONCLUSIONS: We show that the MetS is (inversely) associated with prostate cancer, but is not associated with overall, colorectal or breast cancer. Although, persons with five positive components of the MetS are at a 1.2 and 2.1 increased risk for overall and colorectal cancer, respectively, and these associations appear to be driven, largely, by elevated WC and BP. We also demonstrate that the MetS is only a moderate discriminator of cancer risk.

Trends in body mass index according to educational attainment for urban Australian adults between 1980 and 2007.

BACKGROUND: We have previously demonstrated that between the years 1980 and 2000, the mean body mass index (BMI) of the urban Australian population increased, with greater increases observed with increasing BMI. The current study aimed to quantify trends over time in BMI according to level of education between 1980 and 2007. METHODS: We compared data from the 1980, 1983 and 1989 National Heart Foundation Risk Factor Prevalence Studies, 1995 National Nutrition Survey, 2000 Australian Diabetes, Obesity and Lifestyle Study and the 2007 National Health Survey. For survey comparability, analyses were restricted to urban Australian residents aged 25-64 years. BMI was calculated from measured height and weight. The education variable was dichotomised at completion of secondary school. Four age-standardised BMI indicators were compared over time by sex and education: mean BMI, mean BMI of the top 5% of the BMI distribution, prevalence of obesity (BMI⩾30 kg m(-)(2)), prevalence of class II(+) obesity (BMI⩾35 kg m(-)(2)). RESULTS: Between 1980 and 2007, the mean BMI among men increased by 2.5 and 1.7 kg m(-)(2) for those with low and high education levels, respectively, corresponding to increases in obesity prevalence of 20 (from 12-32%) and 11 (10-21%) %-points. Among women, mean BMI increased by 2.9 and 2.4 kg m(-)(2) for those with low and high education levels, respectively, corresponding to increases in obesity prevalence of 16 (12-28%) and 12 (7-19%) %-points. The prevalence of class II(+) obesity among men increased by 9 (1-10%) and 4 (1-5%) %-points for those with low and high education levels, and among women increased by 8 (4-12%) and 4 (2-6%) %-points. Absolute and relative differences between education groups generally increased over time. CONCLUSIONS: Educational differences in BMI have persisted among urban Australian adults since 1980 without improvement. Obesity prevention policies will need to be effective in those with greatest socio-economic disadvantage if we are to equitably and effectively address the population burden of obesity and its corollaries.

Retinal arteriolar narrowing and incidence of knee replacement for osteoarthritis: a prospective cohort study.

OBJECTIVES: The role of the microcirculation in the pathogenesis of osteoarthritis (OA) remains unclear. This prospective cohort study examined the association between retinal vascular calibre and incidence of knee replacement for OA. DESIGN: 1838 participants of the Australian Diabetes, Obesity and Lifestyle (AusDiab) Study had retinal vascular calibre measured using a nonmydriatic digital fundus camera in 1999-2000 and were aged ≥ 40 years at joint replacement data collection commencement. The incidence of knee replacement for OA during 2002-2011 was determined by linking cohort records to the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). RESULTS: 77 participants underwent knee replacement for OA. They had narrower retinal arteriolar calibre compared with those without knee replacement (166.1 ± 24.8 µm vs 174.3 ± 24.5 µm, P = 0.004). For every one standard deviation reduction in retinal arteriolar calibre, the incidence of knee replacement increased by 25% (HR 1.25, 95% confidence interval (CI) 1.00-1.56). Participants in the narrower two-thirds of arteriolar calibre had twice the risk of knee replacement compared with those in the widest one-third (HR 2.00, 95% CI 1.07-3.74, P = 0.03) after adjustment for sex, body mass index (BMI), physical activity and HbA1c. There was no association for retinal venular calibre. CONCLUSIONS: Retinal arteriolar narrowing is associated with increased risk of knee replacement for OA suggesting that further work is warranted to determine the role of the microcirculation in the pathogenesis of knee OA.

The utility of estimating population-level trajectories of terminal wellbeing decline within a growth mixture modelling framework.

PURPOSE: Mortality-related decline has been identified across multiple domains of human functioning, including mental health and wellbeing. The current study utilised a growth mixture modelling framework to establish whether a single population-level trajectory best describes mortality-related changes in both wellbeing and mental health, or whether subpopulations report quite different mortality-related changes. METHODS: Participants were older-aged (M = 69.59 years; SD = 8.08 years) deceased females (N = 1,862) from the dynamic analyses to optimise ageing (DYNOPTA) project. Growth mixture models analysed participants' responses on measures of mental health and wellbeing for up to 16 years from death. RESULTS: Multi-level models confirmed overall terminal decline and terminal drop in both mental health and wellbeing. However, modelling data from the same participants within a latent class growth mixture framework indicated that most participants reported stability in mental health (90.3 %) and wellbeing (89.0 %) in the years preceding death. CONCLUSIONS: Whilst confirming other population-level analyses which support terminal decline and drop hypotheses in both mental health and wellbeing, we subsequently identified that most of this effect is driven by a small, but significant minority of the population. Instead, most individuals report stable levels of mental health and wellbeing in the years preceding death.

High consumption of pulses is associated with lower risk of abnormal glucose metabolism in women in Mauritius.

AIMS: To investigate if consumption of pulses was associated with a reduced risk of developing abnormal glucose metabolism, increases in body weight and increases in waist circumference in a multi-ethnic cohort in Mauritius. METHODS: Population-based surveys were performed in Mauritius in 1992 and in 1998. Pulse consumption was estimated from a food frequency questionnaire in 1992 and outcomes were measured in 1998. At both time points, anthropometry was undertaken and an oral glucose tolerance test was performed. RESULTS: Mauritian women with the highest consumption of pulses (highest tertile) had a reduced risk of developing abnormal glucose metabolism [odds ratio 0.52; 95% CI 0.27, 0.99) compared with those with the lowest consumption, and also after multivariable adjustments. In women, a high consumption of pulses was associated with a smaller increase in BMI. CONCLUSIONS: High consumption of pulses was associated with a reduced risk of abnormal glucose metabolism and a smaller increase in BMI in Mauritian women. Promotion of pulse consumption could be an important dietary intervention for the prevention of Type 2 diabetes and obesity in Mauritius and should be examined in other populations and in clinical trials.

Influence of age and gender on fat mass, fat-free mass and skeletal muscle mass among Australian adults: the Australian diabetes, obesity and lifestyle study (AusDiab).

BACKGROUND: Bioelectrical impedance (BIA) represents a simple, inexpensive and non-invasive method that is often used to assess fat-mass (FM) and fat-free mass (FFM) in large population-based cohorts. OBJECTIVE: The aim of this study was to describe the reference ranges and examine the influence of age and gender on FM, FFM and skeletal muscle mass (SMM) as well as height-adjusted estimates of FM [fat mass index (FMI)], FFM [fat-free mass index (FFMI)] and SMM [SMM index (SMI)] in a national, population-based cohort of Australian adults. DESIGN AND PARTICIPANTS: The analytical sample included a total of 8,582 adults aged 25-91 years of Europid origin with complete data involved in the cross-sectional 1999-2000 Australian, Diabetes, Obesity and Lifestyle (AusDiab) Study. MEASUREMENTS: Bioelectrical impedance analysis was used to examine components of body composition. Demographic information was derived from a household interview. RESULTS: For both genders, FFM, SMM and SMI decreased linearly from the age of 25 years, with the exception that in men SMI was not related to age and FFM peaked at age 38 years before declining thereafter. The relative loss from peak values to ≥75 years in FFM (6-8%) and SMM (11-15%) was similar between men and women. For FM and FMI, there was a curvilinear relationship with age in both genders, but peak values were detected 6-7 years later in women with a similar relative loss thereafter. For FFMI there was no change with age in men and a modest increase in women. CONCLUSION: In Australian adults there is heterogeneity in the age of onset, pattern and magnitude of changes in the different measures of muscle and fat mass derived from BIA, but overall the age-related losses were similar between men and women.

The effect of educational status on the relationship between obesity and risk of type 2 diabetes.

OBJECTIVE: Obesity trends are likely to increase social disparities in diabetes. The magnitude of this effect depends on the strength of the relationship between obesity and diabetes across categories of disadvantage. This study aims to test the hypothesis that education level moderates the association between obesity and fasting plasma glucose (FPG), 2-h plasma glucose (2hPG), HbA1c level, and diabetes prevalence. METHODS: We used the baseline data from the Australian Obesity, Diabetes, and Lifestyle study in 2000 (n = 8646). We performed multiple linear regression analysis adjusted for confounding factors and stratified by education level. Body mass index (BMI) and waist circumference (WC) were positively associated with FPG, 2hPG, HbA1c and prevalence of diabetes. RESULTS: No moderating effect of education on these relationships was observed in the total population. In never smokers free of diagnosed diabetes at baseline the association of WC with 2hPG and HbA1c and of BMI with HbA1c was stronger in those with a lower level of education. CONCLUSIONS: Overall, these results suggest that the association between obesity and diabetes risk is independent of educational status. However, inconsistent results suggest that further analyses of an adequately powered longitudinal study of never smokers free of diabetes would be useful to further explore this hypothesis.

Persistent organic pollutants and diabetes: a review of the epidemiological evidence.

The prevalence of diabetes and obesity has increased rapidly over the last few decades in both developed and developing countries. While it is intuitively appealing to suggest that lifestyle risk factors such as decreased physical activity and adoption of poor diets can explain much of the increase, the evidence to support this is poor. Given this, there has been an impetus to look more widely than traditional lifestyle and biomedical risk factors, especially those risk factors, which arise from the environment. Since the industrial revolution, there has been an introduction of many chemicals into our environment, which have now become environmental pollutants. There has been growing interest in one key class of environmental pollutants known as persistent organic pollutants (POPs) and their potential role in the development of diabetes. This review will summarise and appraise the current epidemiological evidence relating POPs to diabetes and highlight gaps and flaws in this evidence.

Prevalence of diabetic retinopathy in Type 2 diabetes in developing and developed countries.

BACKGROUND: As the global prevalence of diabetes increases, so will the numbers of people with diabetic retinopathy. Our review aimed to provide a comprehensive picture of available studies of diabetic retinopathy and how prevalence varies around the developed and developing world. METHODS: A detailed literature search using PubMed was undertaken. The following search term was used: 'diabetic retinopathy AND prevalence'. The titles and abstracts of all publications identified by the search were reviewed and 492 studies were retrieved. Inclusion and exclusion criteria were applied. RESULTS: A total of 72 articles from 33 countries were included. There were only 26 population-based studies using fundus photography (12 in developing countries), of which only 16 (eight in developing countries) were published since 2000. Prevalence estimates varied from as low as 10% to as high as 61% in persons with known diabetes and from 1.5 to 31% in newly diagnosed diabetes. Across all the studies, the median (interquartile range) prevalence of any diabetic retinopathy in known diabetes was 27.9% (22-37%) and 10.5% (6-16%) in newly diagnosed diabetes. Prevalence of diabetic retinopathy was higher in developing countries. CONCLUSION: Significant gaps exist in that reliable population-based data from developing nations and indigenous populations in particular are lacking. Major differences in study characteristics and methodologies make comparisons very difficult. More research is required and study methodologies must be better standardized. This will provide important information for prevention and treatment strategies.

Higher heart rate increases risk of diabetes among men: The Australian Diabetes Obesity and Lifestyle (AusDiab) Study.

AIMS: A very limited number of prospective studies have reported conflicting data on the relation between heart rate and diabetes risk. Our aim therefore was to determine in a large, national, population-based cohort if heart rate predicts the development of diabetes. METHODS: The Australian Diabetes Obesity and Lifestyle study followed up 6537 people over 5 years. Baseline measurements included questionnaires, anthropometrics and blood and urine collection. Heart rate was recorded in beats per min (Dinamap). An oral glucose tolerance test was performed at baseline and follow-up, and diabetes was defined using World Health Organization criteria. RESULTS: A total of 5817 participants were eligible for analysis, 221 of whom developed diabetes. Compared with participants with a heart rate < 60 b min(-1), those with a heart rate ≥ 80 b min(-1) were more likely to develop diabetes (odds ratio 1.89, 95% CI 1.07-3.35) over 5 years, independent of traditional risk factors. This relationship was highly significant, particularly in non-obese men (odds ratio 5.61, 95% CI 1.75-17.98), but not in their obese counterparts or in women. CONCLUSIONS: Resting heart rate is associated with an increased risk of diabetes over a 5-year period, particularly among non-obese men. This suggests that sympathetic overactivity may be a contributing factor to the development of diabetes, and that resting heart rate may be useful in predicting risk of Type 2 diabetes in non-obese men.

A systematic review of the impact of including both waist and hip circumference in risk models for cardiovascular diseases, diabetes and mortality.

Both a larger waist and narrow hips are associated with heightened risk of diabetes, cardiovascular diseases and premature mortality. We review the risk of these outcomes for levels of waist and hip circumferences when terms for both anthropometric measures were included in regression models. MEDLINE and EMBASE were searched (last updated July 2012) for studies reporting the association with the outcomes mentioned earlier for both waist and hip circumferences (unadjusted and with both terms included in the model). Ten studies reported the association between hip circumference and death and/or disease outcomes both unadjusted and adjusted for waist circumference. Five studies reported the risk associated with waist circumference both unadjusted and adjusted for hip circumference. With the exception of one study of venous thromboembolism, the full strength of the association between either waist circumference or hip circumference with morbidity and/or mortality was only apparent when terms for both anthropometric measures were included in regression models. Without accounting for the protective effect of hip circumference, the effect of obesity on risk of death and disease may be seriously underestimated. Considered together (but not as a ratio measure), waist and hip circumference may improve risk prediction models for cardiovascular disease and other outcomes.