Orthostatic hypotension, diabetes, and falling in older patients: a cross-sectional study.

BACKGROUND: Although orthostatic hypotension (OH) is more prevalent in old age, and in patients with diabetes, the prevalence of OH in older patients with type 2 diabetes mellitus is unknown. AIM: To establish the prevalence of OH, and its association with falling, in home-dwelling older participants with and without type 2 diabetes. DESIGN AND SETTING: A cross-sectional study in primary care in the Netherlands. METHOD: A total of 352 patients with type 2 diabetes, and 211 without participated in this study. OH was defined as a fall in blood pressure of at least 20 mmHg systolic or 10 mmHg diastolic after either 1 or 3 minutes in an upright position. Feelings of dizziness, light-headedness, or faintness during the standing period were documented as orthostatic complaints. Fall risk was assessed with a validated risk profile instrument. RESULTS: The prevalence of OH was 28% (95% CI = 24% to 33%) and 18% (95% CI = 13% to 23%) in participants with and without type 2 diabetes, respectively. OH was not related to falling, while the presence of orthostatic complaints in itself was associated with both previous fall incidents as well as a high fall risk, even after adjustment for OH. The adjusted odds ratios were 1.65 (95% CI = 1.00 to 2.72) and 8.21 (95% CI = 4.17 to 16.19), respectively. CONCLUSION: OH is highly prevalent in home-dwelling older people with and without type 2 diabetes. Those with orthostatic complaints had an increased risk for falling, whereas those with OH were not.

Life expectancy in a large cohort of type 2 diabetes patients treated in primary care (ZODIAC-10).

BACKGROUND: Most longitudinal studies showed increased relative mortality in individuals with type 2 diabetes mellitus until now. As a result of major changes in treatment regimes over the past years, with more stringent goals for metabolic control and cardiovascular risk management, improvement of life expectancy should be expected. In our study, we aimed to assess present-day life expectancy of type 2 diabetes patients in an ongoing cohort study. METHODOLOGY AND PRINCIPAL FINDINGS: We included 973 primary care type 2 diabetes patients in a prospective cohort study, who were all participating in a shared care project in The Netherlands. Vital status was assessed from May 2001 till May 2007. Main outcome measurement was life expectancy assessed by transforming actual survival time to standardised survival time allowing adjustment for the baseline mortality rate of the general population. At baseline, mean age was 66 years, mean HbA(1c) 7.0%. During a median follow-up of 5.4 years, 165 patients died (78 from cardiovascular causes), and 17 patients were lost to follow-up. There were no differences in life expectancy in subjects with type 2 diabetes compared to life expectancy in the general population. In multivariate Cox regression analyses, concentrating on the endpoints 'all-cause' and cardiovascular mortality, a history of cardiovascular disease: hazard ratio (HR) 1.71 (95% confidence interval (CI) 1.23-2.37), and HR 2.59 (95% CI 1.56-4.28); and albuminuria: HR 1.72 (95% CI 1.26-2.35), and HR 1.83 (95% CI 1.17-2.89), respectively, were significant predictors, whereas smoking, HbA(1c), systolic blood pressure and diabetes duration were not. CONCLUSIONS: This study shows a normal life expectancy in a cohort of subjects with type 2 diabetes patients in primary care when compared to the general population. A history of cardiovascular disease and albuminuria, however, increased the risk of a reduction of life expectancy. These results show that, in a shared care environment, a normal life expectancy is achievable in type 2 diabetes patients.

Prediction of mortality in type 2 diabetes from health-related quality of life (ZODIAC-4).

OBJECTIVE: To investigate the relationship between health-related quality of life (HRQOL) and mortality in type 2 diabetes. RESEARCH DESIGN AND METHODS: In 1998, 1,143 primary care patients with type 2 diabetes participated in the Zwolle Outpatient Diabetes project Integrating Available Care (ZODIAC) study. At baseline, HRQOL was assessed with the RAND-36 and, after almost 6 years, life status was retrieved. Cox proportional hazards modeling was used to investigate the association between HRQOL (continuous data) and mortality with adjustment for selected confounders (smoking, age, sex, diabetes duration, A1C, renal function, BMI, blood pressure, HDL cholesterol, and macrovascular complications). RESULTS: The Physical Component Summary of the RAND-36 was inversely associated with mortality (hazard ratio [HR] 0.979 [95% CI 0.966-0.992]), as were two separate RAND-36 dimensions. CONCLUSIONS: This study found that HRQOL is an independent marker of mortality and emphasizes the importance of looking beyond clinical parameters in patients with type 2 diabetes.

Skin autofluorescence as a noninvasive marker of vascular damage in patients with type 2 diabetes.

OBJECTIVE: Advanced glycation end products (AGEs) are thought to have a role in the pathogenesis of diabetes complications. We recently reported the association between skin autofluorescence, as a measure of tissue AGE accumulation, and diabetic neuropathy in a selected diabetic population. In this study, we investigated the relation between skin autofluorescence and clinical variables including micro- and macrovascular complications in a type 2 diabetes primary care population. RESEARCH DESIGN AND METHODS: Clinical data and skin autofluorescence were obtained in the type 2 diabetes group (n = 973) and in a control group (n = 231). Skin autofluorescence was assessed by illumination of the lower arm with a fluorescent tube (peak intensity approximately 370 nm). RESULTS: Skin autofluorescence was significantly higher in type 2 diabetic patients compared with control subjects in each age category. Multiple regression analysis showed significant correlation of skin autofluorescence with age, sex, diabetes duration, BMI, smoking, HbA1c, plasma creatinine, HDL cholesterol, and albumin-to-creatinine ratio in the type 2 diabetes group (R2 = 25%) and with age and smoking in the control group (R2 = 46%). Skin autofluorescence was significantly higher in the type 2 diabetes group, with both micro- and macrovascular disease, compared with the group without complications and the group with only microvascular complications. CONCLUSIONS: This study confirms in a large group of type 2 diabetic patients that skin autofluorescence is higher compared with age-matched control subjects and is associated with the severity of diabetes-related complications. Skin autofluorescence reflecting vascular damage might be a rapid and helpful tool in the diabetes outpatient clinic for identifying diabetic patients who are at risk for developing complications.

Challenges in preventing cardiovascular complications in type 2 diabetes in primary care.

BACKGROUND: Prevalence of type 2 diabetes mellitus (DM2) continues to increase worldwide. The associated cardiovascular morbidity and mortality are high. OBJECTIVES: To study daily practice in preventing cardiovascular disease (CVD) in an unselected primary care patient population with DM2, and to study factors influencing the care delivered. METHODS: Cross-sectional univariate and multivariate analyses of baseline data from a primary care population-based sample of patients with DM2, participating in a shared care project in the Netherlands. RESULTS: Of 1269 patients invited, 1149 (91%) participated. Hypertension was present in 78% of patients, 63% whom were treated, 41% successfully. Lipid profile abnormalities were present in 51% of patients, 22% of whom were treated, 54% successfully. The treatment rates for lipid profile abnormalities were positively correlated with younger age and the registration of the lipid profile by the GP. For hypertension the treatment rates were higher for patients who were female, of an advanced age, in the presence of CVD, and/or whose blood pressure had been registered by the GP. CONCLUSION: A gap exists between recommended care and the care patients with DM2 in the primary care setting. Diagnosed CVD and the accurate registration with higher treatment rates. Improvement strategies could be directed at primary prevention of CVD and improving the registration of cardiovascular risk factors.

Cardiovascular risk factors in Turkish immigrants with type 2 diabetes mellitus: comparison with Dutch patients.

BACKGROUND: Based on recent epidemiological studies the need for a similar approach towards management of cardiovascular risk factors in type 2 diabetics with different ethnic background can be questioned. We compared the prevalence of cardiovascular risk factors and 10-year absolute risk for a coronary heart disease between Turkish and Dutch type 2 diabetes patients. METHODS: A cross-sectional study was performed using databases from three Dutch studies on type 2 diabetes, comparing 147 Turkish to 294 Dutch diabetes patients, matched for age and gender. Main outcome measures were: total (t-) cholesterol, high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), triglyceride, blood pressure, and smoking. The 10-year absolute risk for a coronary event was calculated by means of the Framingham risk equation. RESULTS: In Turkish diabetics t-cholesterol was lower than in Dutch (5.4 vs. 5.9 mmol/l; p < 0.001), in Turkish males HDL was lower than in Dutch male patients (0.94 vs. 1.08 mmol/l; p = 0.04). The total/HDL-cholesterol ratio in Turkish and Dutch diabetics was equal (5.4 vs. 5.4). Less Turkish than Dutch females smoked (9% vs. 23%; p<0.01). The 10-year absolute risk for a coronary event in both Turkish and Dutch male patients was 24%; the risk in Turkish vs. Dutch females was 13% vs. 15% (not significant). CONCLUSION: The absolute risk for a coronary event in Turkish type 2 diabetes patients is similar to the risk in Dutch diabetes patients, although important differences in the risk profile exist, in particular, the lipid profile and smoking habits differ.