Rattana Leelawattana

Postprandial plasma glucose: a good index of glycemic control in type 2 diabetic patients having near-normal fasting glucose levels.

To investigate the effect of postprandial plasma glucose (PG) concentrations on HbA1c levels in type 2 diabetic patients, we evaluated the relationship between HbA1c levels and postprandial PG concentrations after a meal tolerance test in 35 type 2 diabetic patients who had fasting PG concentrations persistently < 7.8 mmol/l and stable HbA1c levels. Two-hour postprandial PG concentrations were found to be more strongly correlated (r = 0.51) with HbA1c levels than 1-h postprandial PG (r = 0.35) and fasting PG (r = 0.46) concentrations. Patients whose HbA1c levels were high (HbA1c > or = 7%) had significantly higher 2-h postprandial PG concentrations and areas under the glucose curve than those whose HbA1c levels were lower (8.12+/-1.10 (SD) vs 6.70+/-2.22 mmol l(-1), P = 0.004 and 17.43+/-1.92 vs 15.58+/-3.26 mmol h(-1) l(-1), P = 0.02, respectively). Although fasting PG concentrations of patients with higher HbA1c levels were slightly higher, they did not differ significantly from those with lower HbA1c levels (6.21+/-0.89 vs 5.73+/-0.68 mmol l(-1)). Age, duration of diabetes, body mass index, serum C-peptide, both fasting and postprandial, did not differ between these two groups. This study suggests that postprandial hyperglycemia, particularly 2-h postprandial PG concentrations, is associated with high HbA1c levels in type 2 diabetic patients whose fasting PG levels were within normal or near-normal levels.

Regional Abdominal Fat Distribution in Lean and Obese Thai Type 2 Diabetic Women: Relationships With Insulin Sensitivity and Cardiovascular Risk Factors

To determine the relationships of body fat distribution and insulin sensitivity and cardiovascular risk factors in lean and obese Thai type 2 diabetic women, 9 lean and 11 obese subjects, with respective mean age 41.7 +/- 6.3 (SD) and 48.0 +/- 8.5 years, and mean body mass index (BMI) 23.5 +/- 1.8 and 30.3 +/- 3.7 kg/m2, were studied. The amount of total body fat (TBF) and total abdominal fat (AF) were measured by dual-energy x-ray absorptiometer, whereas subcutaneous (SAF) and visceral abdominal fat areas (VAF) were measured by computerized tomography (CT) of the abdomen at the L4-L5 level. Insulin sensitivity was determined by euglycemic hyperinsulinemic clamp. Cardiovascular risk factors, which included fasting and post-glucose challenged plasma glucose and insulin, systolic (SBP) and diastolic blood pressure (DBP), lipid profile, fibrinogen, and uric acid, were also determined. VAF was inversely correlated with insulin sensitivity as determined by glucose infusion rate (GIR) during the clamp, in both lean (r=-0.8821; P=.009) and obese subjects (r=-0.582; P=.078) independent of percent TBF. SAF and TBF were not correlated with GIR. With regards to cardiovascular risk factors, VAF was correlated with SBP (r=0.5279; P=.024) and DBP (r=0.6492; P=.004), fasting insulin (r=0.7256; P=.001) and uric acid (r=0.4963; P=.036) after adjustment for percent TBF. In contrast, TBF was correlated with fasting insulin (r=0.517; P=.023), area under the curve (AUC) of insulin (r=0.625; P=.004), triglyceride (TG) (r=0.668; P=.002), and uric acid (r=0.49; P=.033). GIR was not correlated with any of cardiovascular risk factors independent of VAF. In conclusion, VAF was a strong determinant of insulin sensitivity and several cardiovascular risk factors in both lean and obese Thai type 2 diabetic women.

Effect of switching hepatic enzyme-inducer antiepileptic drug to levetiracetam on bone mineral density, 25 hydroxyvitamin D, and parathyroid hormone in young adult patients with epilepsy

We sought to determine the effect of changing phenytoin therapy on bone mineral density (BMD) and 25‐hydroxyvitamin D in patients with epilepsy. Of the 90 patients, 54 patients had switched to levetiracetam, 19 patients had stopped, and 17 patients continued taking phenytoin. We proposed a 2‐year period to examine 25‐hydroxyvitamin D, parathyroid hormone, and BMD. The patients who switched or stopped phenytoin showed a significant increase in BMD of the lumbar spine and left femur, and in 25‐hydroxyvitamin D. In contrast, those who continued phenytoin had a significant decrease in BMD at both sites and in 25‐hydroxyvitamin D. Patients who were taken off phenytoin and those switching to levetiracetam did not show a significant difference in BMD, 25‐hydroxyvitamin D, parathyroid, or calcium at follow‐up. Compared with those who continued phenytoin, the BMD was significantly higher in patients switching to levetiracetam and those who stopped using phenytoin. Switching medications may be necessary in some cases to avoid low BMD.

Relationships of body fat distribution, insulin sensitivity and cardiovascular risk factors in lean, healthy non-diabetic Thai men and women

In order to study the relationships of body fat distribution, insulin sensitivity and cardiovascular risk factors in lean, healthy non-diabetic Thai men and women, 32 healthy, non-diabetic subjects, 16 men and 16 women, with respective mean age 28.4+/-6.6 (S.D.) and 32.8+/-8.9 years, mean BMI 21.0+/-2.8 and 21.2+/-3.7 kg/m(2), were measured for total body fat and abdominal fat by dual energy X-ray absorptiometry (DEXA), anthropometry and insulin sensitivity by euglycemic hyperinsulinemic clamp. Cardiovascular risk factors included fasting and post-glucose challenge plasma glucose and insulin, blood pressure, lipid profile, fibrinogen and uric acid. For similar age and BMI, men had a lower amount and percent of total body fat, but had a higher proportion of abdominal/total body fat than women. In men, insulin sensitivity, as determined by glucose infusion rate during euglycemic hyperinsulinemic clamp, was inversely correlated with total body fat, abdominal fat, BMI and waist circumference, whereas only total body fat, but not abdominal fat, BW and hip circumference were inversely correlated with insulin sensitivity in women. No cardiovascular risk factors, except area under the curve (AUC), of plasma insulin in women correlated with insulin sensitivity when adjusted for total body fat. After age adjustment, total body fat was better correlated with fasting and AUC of plasma glucose and insulin in men and with systolic blood pressure as well as triglyceride levels in women. Only HDL-C in men was better correlated with abdominal fat. In conclusion, there were sex-differences in body fat distribution and its relationship with insulin sensitivity and cardiovascular risk factors in lean, healthy non-diabetic Thai subjects. Total body fat was a major determinant of insulin sensitivity in both men and women, abdominal fat may play a role in men only. Body fat, not insulin sensitivity, was associated with cardiovascular risk factors in these lean subjects.

Prevalence and risk factors of low bone mineral density and 25-hydroxyvitamin D status in young healthy epileptic adult patients in a tropical Asian country taking antiepileptic drug

PURPOSE Antiepileptic drugs have been reported to reduce bone mineral density (BMD) in several countries with varying prevalence but in studies with small sample size and inadequate assessment of confounders, and rarely including young adults. We sought to determine the prevalence, vitamin D status and risk factors for low BMD in young adult epileptic patients in a tropical setting. METHODS We prospectively examined left femoral neck and spine with dual-energy X-ray absorption. Demographic data, basic laboratory studies, history of clinical epilepsy, parathyroid hormone and vitamin D level were obtained. RESULTS One hundred and twenty three patients were included. The mean (+/-SD) T-score was -0.31+/-1.24 at the spine and -0.19+/-1.11 at the left femoral neck. 36% had osteopenia and 4.1% had osteoporosis at either site. Four patients had vitamin D deficiency. Vitamin D levels were not correlated with BMD. Twenty-five patients had vitamin D insufficiency. Multivariate logistic regression analysis identified low body mass index (BMI) and male sex as risk factors for low BMD at the spine and low BMI and duration of treatment as risk factors for low BMD at the left femoral neck. CONCLUSION Chronic use of antiepileptic drug (AED) in young adult patients is associated with low BMD.

Causes of death, incidence and risk factors of cardiovascular diseases in Thai type 2 diabetic patients: a 5-year follow-up study

There appear to be ethnic disparities in frequencies of diabetic complications in type 2 diabetic patients and such data from Asian countries are relatively few and limited. Thai type 2 diabetic patients who attended the diabetic clinic at Prince of Songkla University hospital during January-December 1997 and had no history of coronary heart disease (CHD) and stroke were studied to determine cause of death and to establish the incidence of and risk factors for cardiovascular disease (CVD). All patients were followed to death or to the end of year 2001. End-points included death from any cause, fatal and nonfatal CHD, fatal and nonfatal stroke and lower-extremity amputation. There were 229 patients who were followed for 4.2+/0.7 (S.D.) years (range: 0.6-5.0) with total follow-up period 958.2 patient-years. Twenty-nine patients died during follow-up; the total mortality rate was 30.3 (95%CI 20.2-43.4)/1000 patient-years. Of these, 9(9.4/1000 patient-years; 95%CI 4.3-17.8) died from sepsis, 7(7.3/1000 patient-years; 95%CI 2.9-15.0) from CVD, 5(5.2/1000 patient-years; 95%CI 2.7-12.2) from end-stage renal disease, 3(3.1/1000 patient-years; 95%CI 0.6-9.2) from malignancy and 1(1.0/1000 patient-years; 95%CI 0.03-5.8) from peripheral vascular disease. The incidences of fatal and nonfatal CHD as well as fatal and nonfatal stroke were 21.4(95%CI 13.0-33.0)/1000 and 12.8(95%CI 6.6-22.4)/1000 patient-years, respectively whereas the incidence of lower-extremity amputation was 4.3(95%CI 1.2-10.9)/1000 patient-years. Age, the presence of proteinuria and serum HDL-C < or = 0.9 mmol/l were independent risk factors of CHD with the respective Hazard ratios 1.09(95%CI: 1.02-1.17; P=0.016), 4.41(95%CI: 1.18-16.45; P=0.027) and 3.91(95%CI: 1.20-12.80; P=0.024). In conclusion, sepsis and CVD were the major causes of death accounting for approximately 50% of total mortality in Thai type 2 diabetic patients. Age, the presence of proteinuria and low HDL-C were independent risk factors for the development of CHD. The mortality from and the incidence of CHD in Thai type 2 diabetic patients are lower than those reported from Caucasian populations but the incidence of stroke appears to be higher. These findings need to be confirmed by a large-scale population-based study.

Bone mineral density following long-term use of antiepileptic drugs in a tropical Asian country

The objective of this study was to investigate bone mineral density (BMD) in Thai epileptics who had been receiving long-term, antiepileptic drugs. Subjects were epileptic patients aged 15 to 50 years who had been taking antiepileptic drugs for longer than six months. All were free of disease and none was taking any medication that might interfere with bone metabolism other than antiepileptic drugs. BMD at the left femoral neck and spine was measured with dual energy X-ray absorptiometry. Demographic data, basic laboratory studies and history of clinical epilepsy were obtained. One hundred and thirty patients (63 males and 67 females) were included. Mean age (+ SD) was 31.9 +/- 9.7 year. There were 79 patients receiving monotherapy and 51 patients receiving polytherapy. All patients had normal serum calcium. Thirteen patients had slightly low serum phosphate levels. The BMD at the femoral neck had a mean Z-score - 0.15 +/- 1.17 and the mean Z-score at the lumbar spine was - 0.56 +/- 1.03. Thirty one patients had osteopenia at the spine and 30 patients at the femoral neck. Three patients had osteoporosis of the spine and 1 patient of the femoral neck. There was found to be no significant correlation between age, sex, body mass index, duration of treatment and type of antiepileptic drug with bone mineral density at the femur and spine. The mean BMD of long-term antiepileptic users was lower than that of the sex and age-adjusted mean.

Apolipoprotein B as an independent predictor of arterial stiffness in systemic lupus erythematosus patients.

To determine the relationship of apolipoprotein B (Apo‐B) and arterial stiffness determined by brachial‐ankle pulse wave velocity (baPWV) in systemic lupus erythematosus (SLE) subjects.

The association between CYP 2C9 polymorphism and bone health.

PURPOSE There is a strong scientific rationale to support the view that cytochrome P450 (CYP P450) enzyme-inducing AEDs induce bone loss in patients with epilepsy. However, no study has investigated the association between CYP 2C9 polymorphism and bone mineral density (BMD), 25-hydroxyvitamin D or parathyroid hormone levels in patients with epilepsy. This study sought to determine the association between BMD and CYP 2C9 polymorphism. METHODS Ninety-three patients taking phenytoin as monotherapy were examined for CYP 2C9 polymorphism, vitamin D level and parathyroid hormone level and underwent basic chemistry testing. The bone mineral density of the lumbar spine and left femur were measured using dual-energy X-ray absorptiometry. RESULTS The results indicated that about 18.3% of the patients with epilepsy were positive for CYP2C9*3. Furthermore, bone mineral density was associated with CYP 2C9 polymorphism epileptic patients. Specifically, patients with 2C9 polymorphism had higher T-scores and Z-scores of the femoral neck (p=0.02 and 0.04, respectively), but not of the lumbar spine (p=0.27 and 0.06, respectively). There was also a trend of having higher serum PTH levels and statistically significantly lower 25-hydroxyvitamin D levels in patients with wild type than in those compared with CYP 2C9 polymorphism (p=0.05 and 0.03, respectively). Additionally, the patients with CYP 2C9 polymorphism had higher plasma levels of phenytoin, particularly when compared with those with wild type (p=0.01). However, there was no association between serum levels of phenytoin and low BMD at femoral neck or lumbar spine. CONCLUSION CYP 2C9 polymorphism is associated with higher BMD, independent of plasma levels of phenytoin.

Comparison of autoantibodies to IA-2 and GAD65 in the rapid- and the slow-onset, adult Type 1 diabetes in Thailand

The population of Crete is of great interest because in previous epidemiological studies a very low coronary heart disease (CHD) prevalence, incidence and mortality rates have been reported [1]. Nevertheless, the morbidity and mortality rates for a rural population were assessed using data from the medical records-based information system [2] of the Cretan network of Primary Health Care (PHC) Centres. General practitioners working at the Archanes Regional Surgery have treated many people with diabetes mellitus (DM) and the initial observation on the standardized mortality rate from CHD was found to be higher in comparison with other PHC Centres within the Cretan Network. These ®ndings prompted us to study the prevalence of DM in this well-de®ned population in order to examine its contribution to the increase in CHD. This letter seeks to establish the current prevalence of known diabetes in this rural area of Crete. The study was conducted in the area of Archanes Municipality. The study population consisted of 4282 permanent inhabitants of whom 727 were aged > 65 years. The diagnosis of diabetes was documented retrospectively by analysing all the computerized medical records of patients seen by doctors at the Regional Surgery since 1996. The records were reviewed in December 1999 and subjects with DM were identi®ed. The 1985 WHO diagnostic criteria were used in the study [3], and the new criteria [4] are well known in this locality. Subjects with a veri®ed history of diabetes were classi®ed as known diabetic. Diabetes was also de®ned by the new diagnostic criteria. Only patients alive at the time of the collection of data were included. The medical records of patients with DM were reviewed at a second stage and information concerning weight, height, hypertension and coronary artery disease was obtained. Hypertension was de®ned as systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg under basal conditions on three or more occasions. A diagnosis of coronary artery disease was considered when evidence from thallium scintiscan was available in the health chart of the patients with DM. Scintiscan is a standard practice for all people with symptoms and signs indicating CHD in the Archanes Regional Surgery. Body mass index (BMI) was calculated as the measured weight in kg divided by the height in metres squared (kg/m). Two hundred and ninety-six patients with DM were identi®ed and represent a prevalence of 6.9%. One hundred and sixty-one were female. The differences between males and females in the different age categories were not statistically signi®cant (P > 0.05). DM was more frequent in patients aged > 65 years (215 subjects, prevalence 29.6%) (Table 1). Only two males and one female were found with IDDM. The prevalence of DM, after age and sex standardization with that for the European population, was estimated at 5.2%. Seventy-three (54.1%) of males and 100 (62.1%) of females with DM were overweight (BMI > 25 kg/m). The difference between males and females was statistically signi®cant in all age groups (P < 0.01). In 213 patients with DM (72% of the total number), the diagnosis of hypertension was con®rmed, 129 of them female (P < 0.001). A diagnosis of coronary artery disease was reported in 65 patients with DM (22%), 38 of them males (P < 0.05). Twentyeight male patients with DM and 25 females were diagnosed as having both hypertension and coronary artery disease.