קהילת הורות

Merri Pendergrass, MD, PHD

From the Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts. E-mail: mpendergrass@partners.org.

Lindstrom J, Ilanne-Parikka P, Peltonen M, Aunola S, Eriksson JG, Hemio K, Hamalainen H, Harkonen P, Keinanen-Kiukaanniemi S, Laakso M, Louheranta A, Mannelin M, Paturi M, Sundvall J, Valle TT, Uusitupa M, Tuomilehto J, the Finnish Diabetes Prevention Study Group: Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet 368:1673-1679, 2006

Findings. This study was an extended follow-up of the Finnish Diabetes Prevention Study, a randomized controlled trial aimed at prevention of type 2 diabetes by lifestyle intervention. In the original study, overweight (mean BMl 31.1 kg/m^sup 2^) middle-aged (mean age 55 years) men (n = 172) and women (n = 350) with impaired glucose tolerance were randomly assigned to intensive lifestyle intervention or a control group for a median of 4 years. At the end of the study, participants who remained free of diabetes were followed up for an additional 3 years without intervention, resulting in a median total follow-up of 7 years. During the total follow-up, the incidence of type 2 diabetes was 4.3 (95% CI 3.4-5.4) and 7.4 (6.1-8.9) per 100 person-years in the intervention and control groups, respectively (P = 0.0001 by log-rank test), indicating a 43% reduction in relative risk (compared with 58% reduction in the original study). The cumulative incidence of diabetes at year 6 was 23% in the intervention group and 38% in the control group, with an absolute risk reduction of 15% (7.2-23.2). Twenty-two individuals were needed to be treated for 1 year to prevent one case of type 2 diabetes by lifestyle intervention. The risk reduction was related to the success in achieving the five intervention goals of weight loss, reduced intake of total and saturated fat, increased intake of dietary fiber, and increased physical activity. When all five variables for lifestyle goals were simultaneously analyzed, the adjusted hazard ratios were 0.52 (95% CI 0.28-0.96) for weight reduction from baseline, 0.67 (0.35-1.31) for the intake of fat, 1.62 (0.68-3.85) for the intake of saturated fat, 0.77 (0.38-1.57) for the intake of fiber, and 0.82 (0.46-1.48) for physical activity.

Significance. These encouraging results demonstrate that the effect of lifestyle intervention on diabetes risk does not disappear after active lifestyle counseling is stopped.

Impact. A population-based strategy to fight the epidemic of type 2 diabetes is urgently needed. Nevertheless, it may also be beneficial to provide individualized counseling regarding diabetes risk reduction strategies. Physicians should continue to counsel their high-risk patients to lose weight, eat a healthy diet, and remain physically active.

Johnson JA, Majumdar SR, Bowker SL, Toth EL, Edwards A: Self-monitoring in type 2 diabetes: a randomized trial of reimbursement policy. Diabet Med 23:1247-1251, 2006

Findings. A total of 262 adults with type 2 diabetes (48% male, mean duration of diabetes 8.2 years, 97% of patients on oral glucose-lowering agents at baseline) who were not treated with insulin and who did not have private insurance coverage for testing supplies were randomized to receive or not receive free testing strips for 6 months. All patients received similar baseline education and a free glucose meter. Following randomization, 36% of patients from the intervention group and 45% from the control group did not complete the study. Intervention patients were slightly older (70 vs. 67 years; P = 0.04) and had a lower BMI (29.1 vs. 31.7 kg/m2; P = 0.001). Baseline AlC was similar in the intervention (7.5 ± 1.6%) and control (7.3 ± 1.2%) patients. After 6 months, there was no difference in AlC between the intervention (7.3 ± 1.5%) and control (7.1 ± 1.2%) patients, after adjusting for baseline AlC (adjusted difference 0.03 [95% CI -0.16 to 0.221 ; P = 0.78). An analysis of study completers (152 of 262; 60%) yielded similar results. Although intervention patients reported testing 0.64 days per week more often than control subjects (95% CI 0.18-1.10; P = 0.007), testing was not associated with better glycemic control (Pearson r = -0.10; P = 0.12).

Significance. The precise benefits of self-monitoring of blood glucose in patients with type 2 diabetes remains unclear. Provision of free testing strips does not seem to improve glycemic control in patients with type 2 diabetes who are not using insulin.

Impact. Self-monitoring of blood glucose is expensive, both to individuals and to health care systems. Further research is needed to determine the relative cost-effectiveness of self-monitoring of blood glucose compared with other interventions, such as antihypertensive and lipid-lowering therapies, which are known to improve diabetes outcomes.

Anand SG, Mehta SD, Adams WG: Diabetes mellitus screening in pediatric primary care. Pediatrics 118:1888-1895, 2006

Findings. The study was a retrospective chart review of electronic health record data from all encounters that occurred between 1 September 2002 and 1 September 2004 for children aged 10-19 years in a hospital-based urban primary care setting. Records from 7,710 patients were reviewed. Patients were 73.0% black or Hispanic and 47.0% female. A total of 18.2% were at risk for overweight (BMI of 85th to 94th percentile for age and sex), and 23.8% were overweight (BMl of 95th percentile for age and sex). In addition, 17.7% had a BMI value >97th percentile. Family history was positive for type 2 diabetes for 19.6% of patients. On the basis of BMI, family history, and/or race, 8.7% of patients met American Diabetes Association (ADA) criteria for screening. Overall, 21.3% (n = 1,642) of patients were screened for diabetes by using fasting plasma glucose, random plasma glucose, oral glucose tolerance tests, AlC, or a combination of tests. White, black, Hispanic, and Asian patients were all screened at similar rates (20.1-24.4%). Screening was significantly more common for the 16- to 19-year-old age-group, female patients, and patients with a family history of diabetes. Increasing BMI percentile was associated with screening, exhibiting a dose-response relationship. Screening rates were significantly higher (45.4 vs. 19.0%) for patients who met the ADA criteria. Among 1,642 screened subjects, 9.2% (n = 151) had some laboratory evidence of abnormal glucose metabolism. Of those patients, 13 (0.8% of the overall sample) met the criteria for diabetes.

Significance. These results confirm the increasing problem of obesity and abnormal glucose tolerance in urban minority youth. Despite having high risk for diabetes, less than half of the adolescents in this population who met ADA criteria for screening were actually screened. Moreover, many children not meeting the ADA criteria were also screened. Although more research is needed to elucidate the cost-benefits of diabetes screening for asymptomatic children and screening criteria may also need to be refined, screening may identify children who warrant diabetes treatment and/or more aggressive diabetes risk reduction interventions.

Impact. All children should be encouraged to maintain a healthy body weight, eat a healthy diet, and be physically active. Screening for diabetes should be considered in children with significant diabetes risk factors.

Targher G, Bertolini L, Padovani R, Zenari L, Scala L, Cigolini M, Arcaro G: Serum 25-hydroxyvitamin D3 concentrations and carotid artery intima-media thickness among type 2 diabetic patients. CHn Endocrinol (Oxf) 65:593-597, 2006

Findings. Study subjects included 390 type 2 diabetic patients consecutively presenting to an outpatient clinic during the winter months (November-March) and 390 nondiabetic age- and sex-matched control subjects. The prevalence of hypovitaminosis D [i.e., 25(OH)D ≤37.5 nmol/l] was higher in diabetic patients (34.0 vs. 16.4%; P < 0.001) than in control subjects. Among diabetic patients, those with hypovitaminosis D (n = 130) had a marked increase in common carotid intima-media thickness (IMT) (1.10 ± 0.15 vs. 0.87 ± 0.14 mm; P < 0.001) when compared with their vitamin D-sufficient counterparts (n = 260). Diabetic patients with hypovitaminosis D also had significantly higher AlC, fibrinogen, and C-reactive protein concentrations. In multivariate regression analysis adjusted for diabetes risk factors, diabetes duration, AlC, calcium, renal function tests, inflammatory markers, use of medications, and presence of the metabolic syndrome, low 25(OH)D concentrations independently predicted carotid IMT (P < 0.001).

Significance. In addition to its well-recognized effects on skeletal health, it recently has been suggested that vitamin D deficiency may be associated with an increased risk of other problems including cancer, psoriasis, multiple sclerosis, diabetes, and cardiovascular disease. The results of this study confirm that hypovitaminosis D is common in individuals with type 2 diabetes and is related to cardiovascular disease in these patients.

Impact. Patients with diabetes should be evaluated in terms of their vitamin D status. At least 800 IU/day vitamin D, either in the diet or as a supplement, has been recommended by many authorities.

Charron-Prochownik D, Sereika SM, Falsetti D, Wang SL, Becker D, Jacober S, Mansfield J, White NH: Knowledge, attitudes and behaviors related to sexuality and family planning in adolescent women with and without diabetes. Pediatr Diabetes 7:267-273, 2006

Findings. Structured telephone interviews were conducted with 80 adolescent women with diabetes and 37 matched control subjects without diabetes (nondiabetes) who were recruited from four major university-based diabetes clinics located in the northeast and Midwest. Diabetic subjects ranged in age from 16 to 20 years (mean 17.6 ± 1.0), and 40% had boyfriends. Nondiabetic subjects ranged in age from 16 to 20 years (mean 18.1 ± 1.1), and 60% had boyfriends. In both groups, ~90% were Caucasian and 50% were Catholic. The majority were high school students, living with their parents in middle-income households. Teens with diabetes appeared to lack an understanding of critical information, which could prevent unplanned pregnancies and pregnancy-related complications. Although they scored significantly higher than the nondiabetic group on diabetes-related information, the diabetic group did not appear to have greater protective attitudes regarding reproductive health issues than the nondiabetic group. The diabetes group felt that they were only moderately susceptible to becoming pregnant and that severe complications would not happen to them. Several teens had at least one episode of unprotected sex (with diabetes 23% vs. nondiabetes 19%) and greater than one sexual partner (21 vs. 30%, respectively). Of those sexually active in the diabetes group, only 77% used birth control all the time when having sex and 38% used a birth control method that was <94% effective (e.g., condom alone or withdrawal).

Significance. Since diabetes is becoming increasingly common in reproductive-age women, an increasing number of young women are at high risk for unplanned pregnancies and associated diabetes complications.

Impact. Health care providers should regularly counsel all reproductive-age women regarding the risks of diabetes in pregnancy. They should also counsel their diabetic patients about how to decrease their risk of unplanned pregnancies and sexually transmitted diseases.