Metabolic Syndrome and its Correlates among Hypertensive Patients in Abuja, North Central Nigeria.

BACKGROUND: Metabolic syndrome is a constellation of abnormalities which includes central obesity, dyslipidaemia, elevated blood pressure and hyperglycemia. Hypertension, (which is a very common component of metabolic syndrome), and diabetes mellitus, are independently associated. Also, studies examining metabolic syndrome inAbuja, a city with affluence-driven lifestyle, are not available. This study aimed to investigate the prevalence of metabolic syndrome among hypertensive patients in Abuja, Nigeria, as well as to examine the associations between metabolic syndrome and certain factors in that cohort of hypertensive patients. METHODS: This was a retrospective study that used data from hypertensive patients who attended clinic over a period of five years. Eight hundred and fifty-eight, (858-combined), case files of pre-treated, (previously known hypertensive patients) and newly diagnosed hypertensive participants were used for the study. The student t-tests were used to compare continuous variables, while Chi-square (χ2) tests were used for relationship between qualitative variables. The likelihood ratio test was employed to further confirm the statistical significance of certain independent variables relating with metabolic syndrome. A P-value of < 0.05 was considered statistically significant. RESULTS: The mean ages were 48.70±12.18, 49.19±11.06 and 48.2±13.3 years for combined group, the pre-treated and the newly-diagnosed groups respectively. The pre-treated, group consists of those previously known hypertensive patients, while the new group consists of those who were newly diagnosed hypertensive patients and were treatment naïve. The prevalence of metabolic syndrome in this study was 45.5% in the combined group, 47.23% in the pre-treated group and 37.3% in the newly diagnosed group. The commonest component of metabolic syndrome was reduced high density lipoprotein cholesterol, HDL-C. CONCLUSION: Metabolic syndrome is prevalent among hypertensive patients in Abuja, Nigeria. Some correlates of metabolic syndrome include; elevated BMI, truncal obesity, elevated total cholesterol, the use of thiazide diuretics and beta blockers as antihypertensives.

CONTEXTE: Le syndrome métabolique est une constellation d'anomalies qui comprend l'obésité centrale, la dyslipidémie, l'élévation de la pression artérielle et l'hyperglycémie. L'hypertension, qui est un composant très courant du syndrome métabolique, et le diabète sucré sont indépendamment associés. De plus, des études examinant le syndrome métabolique à Abuja, une ville au mode de vie axé sur l'aisance, ne sont pas disponibles. Cette étude visait à enquêter sur la prévalence du syndrome métabolique parmi les patients hypertendus à Abuja, au Nigeria, ainsi qu'à examiner les associations entre le syndrome métabolique et certains facteurs dans cette cohorte de patients hypertendus. MÉTHODES: Il s'agissait d'une étude rétrospective utilisant des données de patients hypertendus ayant fréquenté la clinique sur une période de cinq ans. Huit cent cinquante-huit (858 - combinés) dossiers de cas de patients hypertendus préalablement traités (patients hypertendus connus) et nouvellement diagnostiqués ont été utilisés pour l'étude. Les tests t de Student ont été utilisés pour comparer les variables continues, tandis que les tests du chi-carré (χ2) ont été utilisés pour examiner la relation entre les variables qualitatives. Le test du rapport de vraisemblance a été utilisé pour confirmer davantage la signification statistique de certaines variables indépendantes liées au syndrome métabolique. Une valeur P < 0,05 était considérée comme statistiquement significative. RÉSULTATS: Les âges moyens étaient de 48,70 ± 12,18, 49,19 ± 11,06 et 48,21 ± 13,3 ans pour le groupe combiné, le groupe prétraité et le groupe nouvellement diagnostiqué, respectivement. La prévalence du syndrome métabolique dans cette étude était de 45,5% dans le groupe combiné, 47,23% dans le groupe prétraité et 37,3% dans le groupe nouvellement diagnostiqué. Le composant le plus courant du syndrome métabolique était une diminution du cholestérol lipoprotéique de haute densité, le HDL-C. CONCLUSION: Le syndrome métabolique est prévalent parmi les patients hypertendus àAbuja, au Nigeria. Certains corrélats du syndrome métabolique comprennent un IMC élevé, une obésité tronculaire, une augmentation du cholestérol total, l'utilisation de diurétiques thiazidiques et de bêta-bloquants comme antihypertenseurs. Mots-clés: Syndrome métabolique, corrélats, patients hypertendus, Abuja Nigeria.

Individualising Chronic Care Management by Analysing Patients' Needs - A Mixed Method Approach.

BACKGROUND: Modern health systems are increasingly faced with the challenge to provide effective, affordable and accessible health care for people with chronic conditions. As evidence on the specific unmet needs and their impact on health outcomes is limited, practical research is needed to tailor chronic care to individual needs of patients with diabetes. Qualitative approaches to describe professional and informal caregiving will support understanding the complexity of chronic care. Results are intended to provide practical recommendations to be used for systematic implementation of sustainable chronic care models. METHOD: A mixed method study was conducted. A standardised survey (n = 92) of experts in chronic care using mail responses to open-ended questions was conducted to analyse existing chronic care programs focusing on effective, problematic and missing components. An expert workshop (n = 22) of professionals and scientists of a European funded research project MANAGE CARE was used to define a limited number of unmet needs and priorities of elderly patients with type 2 diabetes mellitus and comorbidities. This list was validated and ranked using a multilingual online survey (n = 650). Participants of the online survey included patients, health care professionals and other stakeholders from 56 countries. RESULTS: The survey indicated that current care models need to be improved in terms of financial support, case management and the consideration of social care. The expert workshop identified 150 patient needs which were summarised in 13 needs dimensions. The online survey of these pre-defined dimensions revealed that financial issues, education of both patients and professionals, availability of services as well as health promotion are the most important unmet needs for both patients and professionals. CONCLUSION: The study uncovered competing demands which are not limited to medical conditions. The findings emphasise that future care models need to focus stronger on individual patient needs and promote their active involvement in co-design and implementation. Future research is needed to develop new chronic care models providing evidence-based and practical implications for the regional care setting.

[Screening and prevention of diabetes]. / Diabetesscreening und -vorsorge.

A valid and efficient screening for individual diabetes risk is a highly welcomed tool in primary care and specialist medical practice. It is needed to detect early stages of diabetes risk and prediabetes and to start interventions that have the aim to prevent diabetes and also other chronic diseases from developing. The oral glucose tolerance test is the gold standard, but it is difficult to perform in an evidence-based manner in primary care. Furthermore, measuring fasting and 2-h postprandial glucose values detects only late stages of the pathophysiological development of type 2 diabetes. Interestingly, the 1-h glucose value is highly predictive of future diabetes risk, but is rarely used in primary care. Therefore, risk scores are commonly used to evaluate diabetes risk, but unfortunately, they generally do not mirror the relevance of increased risk due to the person's own lifestyle. Measuring waist circumference is another possibility, because the waist is directly associated with the amount of visceral fat, which again directly correlates with the pathophysiology of diabetes development. A further possibility is the EZSCAN™ technology. The EZSCAN™ is based on reverse iontophoresis, a new technology to detect very early forms of peripheral neuropathies, which are commonly associated with early diabetes risk stages. It is important to perform diabetes screening in a targeted manner, in both medical and paramedical environments, and it is mandatory to add targeted interventions, based on the screening evaluated diabetes risk.

Non-invasive screening of diabetes risk by assessing abnormalities of sudomotor function.

BACKGROUND: The early detection of diabetes, and subsequent lifestyle intervention, may reduce the burden of diabetes and its complications. Several studies have identified a link between sudomotor dysfunction, insulin resistance, and pre-diabetes. The aim of this study was to evaluate the ability of a new non-invasive device EZSCAN evaluating sudomotor function to detect pre-diabetes in a German population at risk for diabetes. METHODS AND FINDINGS: 200 German subjects at risk for diabetes (mean age 56±14 years, BMI 28.4±5.4 kg/m2) were measured for anthropometric data on inflammatory parameters, including high sensitivity C reactive protein (hs-CRP). The subjects also underwent an oral glucose tolerance test with measurements of plasma glucose, insulin, proinsulin, C-peptide and free fatty acids during 2 h following glucose challenge. Indexes for sensitivity to insulin were calculated: SI using minimal model, HOMA-IR and Matsuda index. Based on the measurement of electrochemical sweat conductance, subjects were classified as no risk, moderate risk or high risk. According to this risk model classification, a significant difference was observed between OGTT-1 h (p=0.004), AUC glucose (p=0.011), AUC C-peptide (p<0.001), HOMA-IR (p=0.009), Matsuda (p=0.002), SI (p<0.001) and hs-CRP (p=0.025) after adjustment for age. Among the 54 subjects with impaired fasting glucose or impaired glucose tolerance according to WHO classification, 37 had a moderate risk and 15 a high risk according to the EZSCAN risk model classification. Among the 12 subjects with newly diagnosed diabetes, 2 had a moderate risk and 10 a high risk according to the risk model classification. No adverse event was reported during or after the study. CONCLUSIONS: These results, in accordance with a previous study performed in India, show that EZSCAN could be developed as a screening tool for diabetes risk, and could help to improve diabetes screening strategies. Results obtained from an at-risk population would have to be confirmed in a larger population.

Assessment of small C-fiber status for screening of oxidative stress in patients at risk of diabetes.

Oxidized LDL (oxLDL), anti-oxLDL antibody (anti-oxLDL) and paraoxonase (PON1) are increasingly being reported to be associated with diabetic atherosclerosis. Oxidative stress could affect also small C-fibers innervating the sweat glands even in prediabetes. Hence it could be hypothesized that sweat dysfunction may be a predictor of oxidative stress status for early detection of diabetes. Ezscan, a new device, has recently been developed to measure the sweat function. Therefore, this study was aimed to determine the relevance of this Ezscan method to identify impairment in oxidative stress parameters. Plasma levels of oxLDL and anti-oxLDL were measured by enzyme immunoassay and ELISA respectively. Small C-fiber status was assessed by measurement of hand and foot sweat function with the help of Ezscan device and subsequent calculation of a risk score. Out of 82 subjects recruited in this study, 38 had impaired glucose tolerance and 6 had newly diagnosed diabetes mellitus. Ezscan risk score was significantly (p=0.004) correlated with oxLDL/anti-oxLDL ratio (0.32). Area under the curve (AUC) of receiver operating characteristics (ROC) analysis for detection of oxLDL/anti-oxLDL ratio (>0.12) was 0.76. For an Ezscan risk score of 50%, the sensitivity and specificity were 68% and 71% respectively. After adjustment for age and BMI, PON1 activity showed significant difference among the 3 risk groups defined by Ezscan risk score. Based on these results it may be concluded that Ezscan could be a useful screening tool in daily practice to assess alterations in oxidative stress parameters in individuals at risk of developing diabetes.

Lipidomic profiling before and after Roux-en-Y gastric bypass in obese patients with diabetes.

Bariatric surgery is a well-established approach to improve metabolic disease in morbidly obese patients with high cardiovascular risk. The post-operative normalization of lipid metabolism has a central role in the prevention of future cardiovascular events. The aim of the present study therefore was to characterize changes of plasma lipidomic patterns, consisting of 229 lipid species of 13 lipid classes, 3 months after Roux-en-Y gastric bypass (RYGB) in morbidly obese patients with and without diabetes. RYGB resulted in a 15-32% decrease of body mass index, which was associated with a significant reduction of total cholesterol (TC, -28.3%; P=0.02), LDL-cholesterol (LDL-C, -26.8%; P=0.03) and triglycerides (TGs, -63.0%; P=0.05) measured by routine clinical chemistry. HDL-cholesterol remained unchanged. The effect of RYGB on the plasma lipidomic profile was characterized by significant decreases of 87 lipid species from triacylglycerides (TAGs), cholesterol esters (CholEs), lysophosphatidylcholines (LPCs), phosphatidylcholines (PCs), phosphatidylethanolamine ethers (PEOs), phosphatidylinositols (PIs) and ceramides (Cers). The total of plasma lipid components exhibited a substantial decline of 32.6% and 66 lipid species showed a decrease by over 50%. A direct correlation with HbA1C values could be demonstrated for 24 individual lipid species (10 TAG, three CholE, two LPC, one lysophosphatidylcholine ethers (LPCO) (LPC ether), one PC, two phosphatidylcholine ethers (PCO) and five Cer). Notably, two lipid species (TAG 58:5 and PEO 40:5) were inversely correlated with HbA1C. LPCO, as single whole lipid class, was directly related to HbA1C. These data indicate that RYGB-induced modulation of lipidomic profiles provides important information about post-operative metabolic adaptations and might substantially contribute to improvements of glycemic control. These striking changes in the human plasma lipidome may explain acute, weight independent and long-term effects of RYGB on the cardiovascular system, mental status and immune regulation.

Assessment of small fiber neuropathy to predict future risk of type 2 diabetes.

OBJECTIVE: Sudomotor dysfunction due to small fiber neuropathy can be observed very early in pre-diabetes. The aim of this study was to assess the predictive power of EZSCAN, a non invasive, quick and simple measurement of sudomotor function to identify glucose impairment. RESEARCH DESIGN AND METHODS: The study was performed in 76 German subjects at risk of diabetes. Glucose metabolism was assessed by using, oral glucose tolerance test (OGTT) at baseline and after 2 year follow-up. Sudomotor function was evaluated by measuring hand and foot electrochemical sweat conductances to calculate a risk score. RESULTS: At baseline, 38 patients had normal glucose tolerance (NGT), 34 had pre-diabetes (impaired fasting glucose, IFG and/or impaired glucose tolerance, IGT) and 4 had newly diagnosed type 2 diabetes. The AUC values for FPG, 2h-OGTT glucose, 1h-OGTT glucose, HbA1C and EZSCAN score to predict pre-diabetes were 0.50, 0.65, 0.64, 0.72 and 0.76, respectively. Subjects having a moderate or high EZSCAN score (>50) at baseline had a substantially increased risk for having IFG and/or IGT at follow-up visit presented by an odds ratio of 12.0 [1.4-100.5], the OR for having 1h-OGTT ≥ 8.6mmol/L at follow-up was 9.8 [1.0-92.8] and for having HbA1C ≥ 5.7% was 15.7 [1.9-131.5] compared to subjects with low EZSCAN risk. CONCLUSIONS: This preliminary study, which must be confirmed in a larger population, shows that EZSCAN risk score is associated with diabetes progression which have implications for prevention and disease management.

The European perspective of diabetes prevention: the need for individualization of diabetes prevention.

Over the last decade the situation for people with diabetes mellitus in Europe has changed significantly. The number of patients increases continuously, the age of diagnosis decreases and effective management grows to become a burden for European healthcare systems. In this situation numerous stakeholders try to develop concepts for innovative chronic care management as well as individualized and personalized diabetes management. A major focus is set to activities for early screening and prevention of the diabetes and associated diseases. The present article will give an overview about current achievements in European projects addressing the unmet needs in diabetes management and also to introduce undergoing projects in the field of diabetes prevention and care. Furthermore, the SweetSmart concept will be presented, which is the initiation of a strategy to individualize interventions for the prevention of diabetes and care management. In the current discussion about the management of health care resources it is important to have a strategic vision about a realistic future of innovative chronic care management.

Single whole blood dextran sulfate adsorption favorably affects systemic oxidative balance in lipoprotein apheresis patients.

OBJECTIVE AND METHODS: The acute changes of circulating oxidative stress parameters were compared in 16 patients undergoing two different apheresis techniques: plasma lipidfiltration (LF) or whole blood dextran sulfate adsorption (DSA). RESULTS: Immediately after apheresis LF was associated with an increase in systemic phagocyte count, enhanced formation of reactive oxygen species and decreased activity of the antioxidant enzyme paraoxonase. After DSA, circulating phagocyte oxidant generating activity was significantly lower. Compared to LF, the systemic level of oxidized LDL and antioxLDL antibodies showed a larger decrease in DSA. All measured oxidative stress parameters returned to nearly pre-apheresis level at day three after apheresis, CONCLUSION: The data show a more pronounced leukocyte activation immediately after LF in contrast to DSA, possibly as a consequence of necessity of prior separation of blood plasma. The pathophysiological importance of the short-term oxidative burden after a single apheresis session remains to be determined.

Circulating very-low-density lipoprotein from subjects with impaired glucose tolerance accelerates adrenocortical cortisol and aldosterone synthesis.

Apart from their role in cardiovascular homeostasis and immunomodulation, aldosterone and cortisol are also implicated in the pathogenesis of insulin resistance and type 2 diabetes mellitus (T2DM). Furthermore, glycoxidative modifications of lipoproteins are increasingly recognized as an etiological factor for increased cardiovascular morbidity and mortality in prediabetic individuals. The causative relationship between in vivo lipoprotein modifications and steroidogenesis in subjects with impaired glucose tolerance (IGT), however, is not well defined. Therefore, we aimed to investigate the impact of in vivo modified lipoproteins on aldosterone and cortisol release from human adrenocortical H295R cells. Following an oral glucose tolerance test, 20 individuals with normal glucose tolerance (NGT) and 20 IGT subjects were randomly selected from the ongoing PRAEDIAS prevention study in our department. Cells were incubated for 24 h with lipoproteins isolated from NGT and IGT individuals and aldosterone and cortisol release was measured in the supernatants. VLDL induced a greater stimulating effect on adrenocortical aldosterone and cortisol release compared to HDL and LDL. Moreover, IGT-VLDL evoked a significantly higher effect (p<0.05) on hormone release than NGT-VLDL. Incubation of cells with in vitro modified lipoproteins and specific pharmacological inhibitors suggests that VLDL presumably recruits ERK1/2 as one of the downstream effectors of Jak-2. In summary, in vivo modified VLDL are able to promote prediabetic hormonal dysregulation by modulating adrenocortical steroidogenesis via Jak-2-ERK dependent pathway.

Assessment of small fiber neuropathy through a quick, simple and non invasive method in a German diabetes outpatient clinic.

INTRODUCTION: Sudomotor dysfunction is one of the earliest neurophysiologic abnormalities to manifest in distal small fiber neuropathy. SUDOSCAN® was developed to provide a non invasive, quick, simple and quantitative measurement of sweat function. The aim of this observational study was to assess sweat function in a diabetes outpatient consult clinic in Germany. METHODS: The study was conducted from February 2009 to March 2011 on patients of a diabetes outpatient clinic in Germany with type 1 and type 2 diabetes, and was conducted parallel to standard care. Sweat function was evaluated by measuring the electrochemical conductance (ESC) of the hands and feet. The method's reproducibility between 2 devices and a follow-up according to insulin administration were also assessed. RESULTS: 52 patients with type 1 diabetes and 115 patients with type 2 diabetes (69 receiving insulin) were involved in this observational study. Hand and foot conductances were lower in patients with type 2 diabetes when compared to patients with type 1 diabetes. A slight decrease in hand and foot conductances was observed in patients with type 2 diabetes without insulin, while an increase was observed in patients receiving insulin (-3.8±9.7 vs. 1.0±9.7 µS, p=0.02 for the hands and -2.2±7.5 vs. 4.1±8.8 µS, p<0.001 for the feet). Coefficient of correlation between measurements performed with the 2 different devices was 0.85 for hands and 0.93 for feet, p<0.001. No safety concern was reported and none of the subjects experienced discomfort during the tests. CONCLUSION: This preliminary study shows that the assessment of small C fiber neuropathy can be performed non invasively, quickly and effectively in standard diabetes outpatient practice with very good reproducibility. The observation that electrochemical skin conductance improves with intensified insulin treatment must be confirmed in a clinical study performed on a larger population.

Prevention of type 2 diabetes: the strategic approach for implementation.

A growing need exists to deliver effective and affordable prevention programs and to take urgent action to address the major public health challenge that diabetes represents. Achieving prevention of type 2 diabetes requires moving through a series of steps from basic science discovery to widespread distribution of effective interventions. Understanding the cellular level influences on diabetes prevention will help target particular interventions to those who may be most responsive. Several randomized controlled trials conducted throughout the world have demonstrated that type 2 diabetes can be prevented or delayed. Subsequent real-world translation studies have provided important information necessary to reduce cost and increase access. Ultimately achieving a population impact in diabetes prevention requires widespread distribution of effective interventions, which is supported by policies that help achieve sustainability and reach. The use of a global stakeholder network can help to share experiences and build on partner knowledge gained.

Take action to prevent diabetes--the IMAGE toolkit for the prevention of type 2 diabetes in Europe.

When we ask people what they value most, health is usually top of the list. While effective care is available for many chronic diseases, the fact remains that for the patient, the tax payer and the whole of society: prevention is better than cure. Diabetes and its complications are a serious threat to the survival and well-being of an increasing number of people. It is predicted that one in ten Europeans aged 20-79 will have developed diabetes by 2030. Once a disease of old age, diabetes is now common among adults of all ages and is beginning to affect adolescents and even children. Diabetes accounts for up to 18 % of total healthcare expenditure in Europe. The good news is that diabetes is preventable. Compelling evidence shows that the onset of diabetes can be prevented or delayed greatly in individuals at high risk (people with impaired glucose regulation). Clinical research has shown a reduction in risk of developing diabetes of over 50 % following relatively modest changes in lifestyle that include adopting a healthy diet, increasing physical activity, and maintaining a healthy body weight. These results have since been reproduced in real-world prevention programmes. Even a delay of a few years in the progression to diabetes is expected to reduce diabetes-related complications, such as heart, kidney and eye disease and, consequently, to reduce the cost to society. A comprehensive approach to diabetes prevention should combine population based primary prevention with programmes targeted at those who are at high risk. This approach should take account of the local circumstances and diversity within modern society (e.g. social inequalities). The challenge goes beyond the healthcare system. We need to encourage collaboration across many different sectors: education providers, non-governmental organisations, the food industry, the media, urban planners and politicians all have a very important role to play. Small changes in lifestyle will bring big changes in health. Through joint efforts, more people will be reached. The time to act is now.

A European evidence-based guideline for the prevention of type 2 diabetes.

BACKGROUND: The prevalence and socioeconomic burden of type 2 diabetes (T2DM) and associated co-morbidities are rising worldwide. AIMS: This guideline provides evidence-based recommendations for preventing T2DM. METHODS: A European multidisciplinary consortium systematically reviewed the evidence on the effectiveness of screening and interventions for T2DM prevention using SIGN criteria. RESULTS: Obesity and sedentary lifestyle are the main modifiable risk factors. Age and ethnicity are non-modifiable risk factors. Case-finding should follow a step-wise procedure using risk questionnaires and oral glucose tolerance testing. Persons with impaired glucose tolerance and/or fasting glucose are at high-risk and should be prioritized for intensive intervention. Interventions supporting lifestyle changes delay the onset of T2DM in high-risk adults (number-needed-to-treat: 6.4 over 1.8-4.6 years). These should be supported by inter-sectoral strategies that create health promoting environments. Sustained body weight reduction by >or= 5 % lowers risk. Currently metformin, acarbose and orlistat can be considered as second-line prevention options. The population approach should use organized measures to raise awareness and change lifestyle with specific approaches for adolescents, minorities and disadvantaged people. Interventions promoting lifestyle changes are more effective if they target both diet and physical activity, mobilize social support, involve the planned use of established behaviour change techniques, and provide frequent contacts. Cost-effectiveness analysis should take a societal perspective. CONCLUSIONS: Prevention using lifestyle modifications in high-risk individuals is cost-effective and should be embedded in evaluated models of care. Effective prevention plans are predicated upon sustained government initiatives comprising advocacy, community support, fiscal and legislative changes, private sector engagement and continuous media communication.

Quality indicators for the prevention of type 2 diabetes in Europe--IMAGE.

BACKGROUND: The marked increase of type 2 diabetes necessitates active development and implementation of efficient prevention programs. A European level action has been taken by launching the IMAGE project to unify and improve the various prevention management concepts, which currently exist within the EU. This report describes the background and the methods used in the development of the IMAGE project quality indicators for diabetes primary prevention programs. It is targeted to the persons responsible for diabetes prevention at different levels of the health care systems. METHODS: Development of the quality indicators was conducted by a group of specialists representing different professional groups from several European countries. Indicators and measurement recommendations were produced by the expert group in consensus meetings and further developed by combining evidence and expert opinion. RESULTS: The quality indicators were developed for different prevention strategies: population level prevention strategy, screening for high risk, and high risk prevention strategy. Totally, 22 quality indicators were generated. They constitute the minimum level of quality assurance recommended for diabetes prevention programs. In addition, 20 scientific evaluation indicators with measurement standards were produced. These micro level indicators describe measurements, which should be used if evaluation, reporting, and scientific analysis are planned. CONCLUSIONS: We hope that these quality tools together with the IMAGE guidelines will provide a useful tool for improving the quality of diabetes prevention in Europe and make different prevention approaches comparable.