Lisa R. Staimez

Evidence of reduced β-cell function in Asian Indians with mild dysglycemia.

OBJECTIVE To examine β-cell function across a spectrum of glycemia among Asian Indians, a population experiencing type 2 diabetes development at young ages despite low BMI. RESEARCH DESIGN AND METHODS One-thousand two-hundred sixty-four individuals without known diabetes in the Diabetes Community Lifestyle Improvement Program in Chennai, India, had a 75-g oral glucose tolerance test, with glucose and insulin measured at 0, 30, and 120 min. Type 2 diabetes, isolated impaired fasting glucose (iIFG), isolated impaired glucose tolerance (iIGT), combined impaired fasting glucose and impaired glucose tolerance, and normal glucose tolerance (NGT) were defined by American Diabetes Association guidelines. Measures included insulin resistance and sensitivity (homeostasis model assessment of insulin resistance [HOMA-IR], modified Matsuda Index, 1/fasting insulin) and β-cell function (oral disposition index = [Δinsulin0–30/Δglucose0–30] × [1/fasting insulin]). RESULTS Mean age was 44.2 years (SD, 9.3) and BMI 27.4 kg/m2 (SD, 3.8); 341 individuals had NGT, 672 had iIFG, IGT, or IFG plus IGT, and 251 had diabetes. Patterns of insulin resistance or sensitivity were similar across glycemic categories. With mild dysglycemia, the absolute differences in age- and sex-adjusted oral disposition index (NGT vs. iIFG, 38%; NGT vs. iIGT, 32%) were greater than the differences in HOMA-IR (NGT vs. iIFG, 25%; NGT vs. iIGT, 23%; each P < 0.0001). Compared with NGT and adjusted for age, sex, BMI, waist circumference, and family history, the odds of mild dysglycemia were more significant per SD of oral disposition index (iIFG: odds ratio [OR], 0.36; 95% CI, 0.23–0.55; iIGT: OR, 0.37; 95% CI, 0.24–0.56) than per SD of HOMA-IR (iIFG: OR, 1.69; 95% CI, 1.23–2.33; iIGT: OR, 1.53; 95% CI, 1.11–2.11). CONCLUSIONS Asian Indians with mild dysglycemia have reduced β-cell function, regardless of age, adiposity, insulin sensitivity, or family history. Strategies in diabetes prevention should minimize loss of β-cell function.

Association of persistent organic pollutants and non-persistent pesticides with diabetes and diabetes-related health outcomes in Asia: A systematic review.

BACKGROUND Over half of the people with diabetes in the world live in Asia. Emerging scientific evidence suggests that diabetes is associated with environmental pollutants, exposures that are also abundant in Asia. OBJECTIVE To systematically review the literature concerning the association of persistent organic pollutants (POPs) and non-persistent pesticides with diabetes and diabetes-related health outcomes in Asia. METHODS PubMed and Embase were searched to identify studies published up to November 2014. A secondary reference review of all extracted articles and the National Toxicology Program Workshop on the association of POPs with diabetes was also conducted. A total of 19 articles met the inclusion criteria and were evaluated in this review. RESULTS To date, the evidence relating POPs and non-persistent pesticides with diabetes in Asian populations is equivocal. Positive associations were reported between serum concentrations of polychlorinated dibenzodioxins and dibenzofurans (PCDD/Fs), polychlorinated biphenyls (PCBs), and several organochlorine pesticides (DDT, DDE, oxychlordane, trans-nonachlor, hexachlorobenzene, hexachlorocyclohexane) with diabetes. PCDD/Fs were also associated with blood glucose and insulin resistance, but not beta-cell function. There were substantial limitations of the literature including: most studies were cross-sectional, few studies addressed selection bias and confounding, and most effect estimates had exceptionally wide confidence intervals. Few studies evaluated the effects of organophosphates. CONCLUSIONS Well-conducted research is urgently needed on these pervasive exposures to inform policies to mitigate the diabetes epidemic in Asia.

The Stepwise Approach to Diabetes Prevention: Results From the D-CLIP Randomized Controlled Trial

OBJECTIVE This study tests the effectiveness of expert guidelines for diabetes prevention: lifestyle intervention with addition of metformin, when required, among people with prediabetes. RESEARCH DESIGN AND METHODS The Diabetes Community Lifestyle Improvement Program (D-CLIP) is a randomized, controlled, translation trial of 578 overweight/obese Asian Indian adults with isolated impaired glucose tolerance (iIGT), isolated impaired fasting glucose (iIFG), or IFG+IGT in Chennai, India. Eligible individuals were identified through community-based recruitment and randomized to standard lifestyle advice (control) or a 6-month, culturally tailored, U.S. Diabetes Prevention Program–based lifestyle curriculum plus stepwise addition of metformin (500 mg, twice daily) for participants at highest risk of conversion to diabetes at ≥4 months of follow-up. The primary outcome, diabetes incidence, was assessed biannually and compared across study arms using an intention-to-treat analysis. RESULTS During 3 years of follow-up, 34.9% of control and 25.7% of intervention participants developed diabetes (P = 0.014); the relative risk reduction (RRR) was 32% (95% CI 7–50), and the number needed to treat to prevent one case of diabetes was 9.8. The RRR varied by prediabetes type (IFG+IGT, 36%; iIGT, 31%; iIFG, 12%; P = 0.77) and was stronger in participants 50 years or older, male, or obese. Most participants (72.0%) required metformin in addition to lifestyle, although there was variability by prediabetes type (iIFG, 76.5%; IFG+IGT, 83.0%; iIGT, 51.3%). CONCLUSIONS Stepwise diabetes prevention in people with prediabetes can effectively reduce diabetes incidence by a third in community settings; however, people with iIFG may require different interventions.

Glucose challenge test screening for prediabetes and early diabetes

To test the hypothesis that a 50‐g oral glucose challenge test with 1‐h glucose measurement would have superior performance compared with other opportunistic screening methods.

Multimorbidity of four cardiometabolic and chronic pulmonary disease groups: prevalence and attributable fraction in US adults, 2007–2012

Background Cardiometabolic and chronic pulmonary diseases may be associated with modifiable risk factors that can be targeted to prevent multimorbidity. Objectives (i) Estimate the prevalence of multimorbidity across four cardiometabolic and chronic pulmonary disease groups; (ii) compare the prevalence of multimorbidity to that of one disease and no disease; and (iii) quantify population attributable fractions (PAFs) for modifiable risk factors of multimorbidity. Design Data from adults aged 18–79 years who participated in the US National Health and Nutrition Examination Survey 2007–2012 were examined. Multimorbidity was defined as ≥2 co-occurring diseases across four common cardiometabolic and chronic pulmonary disease groups. Multivariate-adjusted PAFs for poverty, obesity, smoking, hypertension, and low high-density lipoprotein (HDL) cholesterol were estimated. Results Among 16,676 adults, the age-standardized prevalence of multimorbidity was 9.3%. The occurrence of multimorbidity was greater with age, from 1.5% to 5.9%, 15.0% and 34.8% for adults aged 18–39, 40–54, 55–64 and 65–79 years, respectively. Multimorbidity was greatest among the poorest versus non-poorest adults and among blacks versus other races/ethnicities. Multimorbidity was also greater in adults with obesity, hypertension, and low HDL cholesterol. Risk factors with greatest PAFs were hypertension (38.8%; 95% confidence interval [CI] 29.4–47.4) and obesity (19.3%; 95% CI 10.2–28.2). Conclusions In the USA, 9.3% of adults have multimorbidity across four chronic disease groups, with a disproportionate burden among older, black, and poor adults. Our results suggest that targeting two intermediate modifiable risk factors, hypertension and obesity, might help to reduce the prevalence of multimorbidity in US adults.

Reduced Cardiovascular Disease Incidence With a National Lifestyle Change Program

INTRODUCTION Lifestyle change programs implemented within healthcare systems could reach many Americans, but their impact on cardiovascular disease (CVD) remains unclear. The MOVE! program is the largest lifestyle change program implemented in a healthcare setting in the U.S. This study aimed to determine whether MOVE! participation was associated with reduced CVD incidence. METHODS This retrospective cohort study, analyzed in 2013-2015, used national Veterans Health Administration databases to identify MOVE! participants and eligible non-participants for comparison (2005-2012). Patients eligible for MOVE!-obese or overweight with a weight-related health condition, and no baseline CVD-were examined (N=1,463,003). Of these, 169,248 (12%) were MOVE! PARTICIPANTS Patients were 92% male, 76% white, with mean age 52 years and BMI of 32. The main outcome was incidence of CVD (ICD-9 and procedure codes for coronary artery disease, cerebrovascular disease, peripheral vascular disease, and heart failure). RESULTS Adjusting for age, race, sex, BMI, statin use, and baseline comorbidities, over a mean 4.9 years of follow-up, MOVE! participation was associated with lower incidence of total CVD (hazard ratio [HR]=0.83, 95% CI=0.80, 0.86); coronary artery disease (HR=0.81, 95% CI=0.77, 0.86); cerebrovascular disease (HR=0.87, 95% CI=0.82, 0.92); peripheral vascular disease (HR=0.89, 95% CI=0.83, 0.94); and heart failure (HR=0.78, 95% CI=0.74, 0.83). The association between MOVE! participation and CVD incidence remained significant when examined across categories of race/ethnicity, BMI, diabetes, hypertension, smoking status, and statin use. CONCLUSIONS Although participation was limited, MOVE! was associated with reduced CVD incidence in a nationwide healthcare setting.

Participation in a National Lifestyle Change Program is associated with improved diabetes Control outcomes.

AIMS Clinical trials show lifestyle change programs are beneficial, yet large-scale, successful translation of these programs is scarce. We investigated the association between participation in the largest U.S. lifestyle change program, MOVE!, and diabetes control outcomes. METHODS This longitudinal, retrospective cohort study used Veterans Health Administration databases of patients with diabetes who participated in MOVE! between 2005 and 2012, or met eligibility criteria (BMI ≥25kg/m2) but did not participate. Main outcomes were diabetic eye disease, renal disease, and medication intensification. RESULTS There were 400,170 eligible patients with diabetes, including 87,366 (22%) MOVE! PARTICIPANTS Included patients were 96% male, 77% white, with mean age 58years and BMI 34kg/m2. Controlling for baseline measurements and age, race, sex, BMI, and antidiabetes medications, MOVE! participants had lower body weight (-0.6kg), random plasma glucose (-2.8mg/dL), and HbA1c (-0.1%) at 12months compared to nonparticipants (each p<0.001). In multivariable Cox models, MOVE! participants had lower incidence of eye disease (hazard ratio 0.80, 95% CI 0.75-0.84) and renal disease (HR 0.89, 95% CI 0.86-0.92) and reduced medication intensification (HR 0.82, 95% CI 0.80-0.84). CONCLUSIONS If able to overcome participation challenges, lifestyle change programs in U.S. health systems may improve health among the growing patient population with diabetes.

Self-efficacy and diabetes prevention in overweight South Asians with pre-diabetes

Objective We evaluated the effects of a diabetes prevention itervention on self-efficacy (SE) and the associations between SE and diabetes-related outcomes among overweight Asian Indian adults with pre-diabetes in a randomized controlled translational trial (the Diabetes Community Lifestyle Improvement Program, D-CLIP). Research design and methods Data were obtained from 550 adults who were randomized to a diabetes prevention program or standard of care. Dietary and exercise-related SEs were measured at baseline, core intervention completion (4  months), and annually until the end of follow-up (3 years or diabetes diagnosis). Mixed-effects regressions described changes in SE over time by treatment group. Among treatment participants, multivariable-adjusted models described associations of SE at baseline and intervention completion with diabetes incidence and other secondary outcomes (weight, waist circumference (WC), exercise, and energy intake). Results From baseline to 4  months, dietary (β=10.3, p=0.04) and exercise (β=0.49, p=0.04) SE increased significantly in the treatment arm only; however, this increase from baseline was no longer significant at later time points. Among treatment participants, there was no association of dietary or exercise SE with diabetes incidence, but baseline exercise SE was independently associated with improved weight, WC, and exercise at 4  months (p<0.05). Change in exercise SE from baseline to intervention completion also predicted increased exercise at 4, 12, and 24 months (p<0.05). Conclusions Exposure to D-CLIP resulted in improved SE at treatment completion, but this effect was not sustained over longer follow-up. Several short-term and long-term secondary outcomes, but not diabetes risk, were significantly associated with exercise SE, suggesting this psychosocial trait may facilitate success in achieving certain health goals. Trial registration number NCT01283308.