Richard I. G. Holt

Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross‐national benchmarking of diabetes‐related psychosocial outcomes for people with diabetes

The second Diabetes Attitudes, Wishes and Needs (DAWN2) study aimed to assess psychosocial outcomes in people with diabetes across countries for benchmarking.

First- v. second-generation antipsychotics and risk for diabetes in schizophrenia: systematic review and meta-analysis

BACKGROUND The increased prevalence of diabetes in schizophrenia is partly attributed to antipsychotic treatment, in particular second-generation antipsychotics, but the evidence has not been systematically reviewed. AIMS Systematic review and meta-analysis comparing diabetes risk for different antipsychotics in people with schizophrenia. METHOD We searched MEDLINE, PsycINFO, EMBASE, International Pharmaceutical Abstracts, CINAHL and Web of Knowledge until September 2006. Studies were eligible for inclusion if the design was cross-sectional, case-control, cohort or a controlled trial in individuals with schizophrenia or related psychotic disorders, where second-generation antipsychotics (defined as clozapine, olanzapine, risperidone and quetiapine) were compared with first-generation antipsychotics and diabetes was an outcome. Data were pooled using random effects inverse variance weighted meta-analysis. RESULTS Of the studies that met the inclusion criteria (n=14), 11 had sufficient data to include in the meta-analysis. Four of these were retrospective cohort studies. The relative risk of diabetes in patients with schizophrenia prescribed one of the second-generation v. first-generation antipsychotics was 1.32 (95% CI 1.15-1.51). There were insufficient data to include aripiprazole, ziprasidone and amisulpride in this analysis. CONCLUSIONS There is tentative evidence that the second-generation antipsychotics included in this study are associated with a small increased risk for diabetes compared with first-generation antipsychotics in people with schizophrenia. Methodological limitations were found in most studies, leading to heterogeneity and difficulty interpreting data. Regardless of type of antipsychotic, screening for diabetes in all people with schizophrenia should be routine.

The role of the growth hormone-insulin-like growth factor axis in glucose homeostasis

Homeostatic mechanisms normally maintain the plasma glucose concentration within narrow limits despite major fluctuations in supply and demand. There is increasing evidence that the growth hormone (GH)–insulin‐like growth factor (IGF) axis may play an important role in glucose metabolism. GH has potent effects on intermediary metabolism, some of which antagonize the actions of insulin. In contrast, IGF‐I has insulin‐like actions, which are, in the case of glucose metabolism, opposite to those of GH. There is often deranged glucose metabolism in situations where GH is deficient or in excess. The clinical administration of GH or IGF‐I results in altered glucose metabolism and changes in insulin resistance. Despite these observations, the precise role of GH and IGF‐I and their interactions with insulin in controlling normal glucose homeostasis are unknown. In diabetes, GH secretion is abnormally increased as a result of reduced portal insulin resulting in impaired hepatic IGF‐I generation. Evidence suggests that this may contribute to the development of diabetic microvascular complications. IGF‐I ‘replacement’ in diabetes is under investigation and new methods of delivering IGF‐I as a complex with IGFBP‐3 offer exciting new prospects.

Fetal programming of the growth hormone–insulin-like growth factor axis

Epidemiological studies have shown that small body size at birth and during infancy is associated with increased rates of chronic diseases in adulthood, including cardiovascular disease and osteoporosis. Fetal programming of the growth hormone-insulin-like growth factor (GH-IGF) axis has been proposed as a potential candidate mechanism to explain the link between low birth weight and adult disease. The IGFs and IGF-binding proteins are nutritionally regulated in the fetus and fetal growth retardation leads to abnormalities in the GH-IGF axis. There are also abnormalities in the GH-IGF axis in many of the adult diseases that are associated with low birth weight, including cardiovascular disease and osteoporosis. Finally, there are data from both animals and humans suggesting that programming of the GH-IGF axis might exist.

Diabetes Attitudes Wishes and Needs 2 (DAWN2): A multinational, multi-stakeholder study of psychosocial issues in diabetes and person-centred diabetes care

AIMS The Diabetes Attitudes Wishes and Needs 2 (DAWN2) study aims to provide a holistic assessment of diabetes care and management among people with diabetes (PWD), family members (FM), and healthcare professionals (HCPs) and explores potential drivers leading to active management. METHODS DAWN2 survey over 16,000 individuals (∼9000 PWD, ∼2000 FM of PWD, and ∼5000 HCPs) in 17 countries across 4 continents. Respondents complete a group-specific questionnaire; items are designed to allow cross-group comparisons on common topics. The questionnaires comprise elements from the original DAWN study (2001), as well as psychometrically validated instruments and novel questions developed for this study to assess self-management, attitudes/beliefs, disease impact/burden, psychosocial distress, health-related quality of life, healthcare provision/receipt, social support and priorities for improvement in the future. The questionnaires are completed predominantly online or by telephone interview, supplemented by face-to-face interviews in countries with low internet access. In each country, recruitment ensures representation of the diabetes population in terms of geographical distribution, age, gender, education and disease status. DISCUSSION DAWN2 aims to build on the original DAWN study to identify new avenues for improving diabetes care. This paper describes the study rationale, goals and methodology.

Growth hormone, IGF‐I and insulin and their abuse in sport

There is widespread anecdotal evidence that growth hormone (GH) is used by athletes for its anabolic and lipolytic properties. Although there is little evidence that GH improves performance in young healthy adults, randomized controlled studies carried out so far are inadequately designed to demonstrate this, not least because GH is often abused in combination with anabolic steroids and insulin. Some of the anabolic actions of GH are mediated through the generation of insulin‐like growth factor‐I (IGF‐I), and it is believed that this is also being abused. Athletes are exposing themselves to potential harm by self‐administering large doses of GH, IGF‐I and insulin. The effects of excess GH are exemplified by acromegaly. IGF‐I may mediate and cause some of these changes, but in addition, IGF‐I may lead to profound hypoglycaemia, as indeed can insulin. Although GH is on the World Anti‐doping Agency list of banned substances, the detection of abuse with GH is challenging. Two approaches have been developed to detect GH abuse. The first is based on an assessment of the effect of exogenous recombinant human GH on pituitary GH isoforms and the second is based on the measurement of markers of GH action. As a result, GH abuse can be detected with reasonable sensitivity and specificity. Testing for IGF‐I and insulin is in its infancy, but the measurement of markers of GH action may also detect IGF‐I usage, while urine mass spectroscopy has begun to identify the use of insulin analogues.

Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross‐national benchmarking indicators for family members living with people with diabetes

The second Diabetes Attitudes, Wishes and Needs (DAWN2) study examined the experiences of family members of people with diabetes for benchmarking and identifying unmet needs or areas for improvement to assist family members and those with diabetes to effectively self‐manage.

Schizophrenia, the metabolic syndrome and diabetes

The prevalence of diabetes is increased in patients with schizophrenia. Although many reasons, including hereditary and lifestyle factors, contribute to this association, recently there has been heightened interest in the subject because of the link between the use of the newer atypical anti‐psychotic drugs and the development of diabetes. These drugs cause significant weight gain and this may be one of the mechanisms by which they increase incident diabetes. The increased prevalence of diabetes among people with schizophrenia has implications for the delivery of care by psychiatrists, diabetologists and primary care.

Screening tools used for measuring depression among people with Type 1 and Type 2 diabetes: a systematic review

Diabet. Med. 29, 164–175 (2012)

Diabetes and Depression

Diabetes and depression occur together approximately twice as frequently as would be predicted by chance alone. Comorbid diabetes and depression are a major clinical challenge as the outcomes of both conditions are worsened by the other. Although the psychological burden of diabetes may contribute to depression, this explanation does not fully explain the relationship between these 2 conditions. Both conditions may be driven by shared underlying biological and behavioral mechanisms, such as hypothalamic-pituitary-adrenal axis activation, inflammation, sleep disturbance, inactive lifestyle, poor dietary habits, and environmental and cultural risk factors. Depression is frequently missed in people with diabetes despite effective screening tools being available. Both psychological interventions and antidepressants are effective in treating depressive symptoms in people with diabetes but have mixed effects on glycemic control. Clear care pathways involving a multidisciplinary team are needed to obtain optimal medical and psychiatric outcomes for people with comorbid diabetes and depression.