SA Journal of Diabetes & Vascular Disease: Vol 11, Issue 2, June 2014

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SAJDVD: VOLUME 11, ISSUE 2, JUNE 2014

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The Internet is underutilised for diabetes education : editorial
Authors: Lombard, Landi
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 2, Jun 2014
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Abstract: The USA has reached a diabetes prevalence of 10% in the adult population and it is increasing exponentially. If no changes are made, it is feared the USA health system will be bankrupt. In South Africa, we are in the top five (currently number three) leading countries in the obesity race and we will soon see a similar increase in diabetes prevalence.
Treatment of hypercholesterolaemia in patients with diabetes mellitus : research article
Authors: Aronow, Wilbert S.
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 2, Jun 2014
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Abstract: Numerous studies have shown that statins reduce cardiovascular events, including stroke and mortality in diabetics. The American Diabetes Association 2013 guidelines recommend that diabetics at high risk for cardiovascular events should have their serum low-density lipoprotein (LDL) cholesterol reduced to < 70 mg/dl (1.8 mmol/l) with statins. Lower-risk diabetics should have their serum LDL cholesterol reduced to < 100 mg/dl (2.6 mmol/l). The 2013 American College of Cardiology/American Heart Association lipid guidelines recommend giving high-dose statins to adult diabetics aged ≤ 75 years with atherosclerotic vascular disease (ASCVD) unless contraindicated with a class I indication and moderate-dose or high-dose statins to diabetics with ASCVD ≥ 75 years with a class IIa indication. Diabetics ≥ 21 years with a serum LDL cholesterol of ≥ 190 mg/dl (4.9 mmol/l) should be treated with high-dose statins with a class I indication. For primary prevention in diabetics aged 40 to 75 years and serum LDL cholesterol between 70 and 189 mg/dl (1.8 and 4.9 mmol/l), moderate-dose statins should be given with a class I indication. For primary prevention in diabetics aged 40 to 75 years, a serum LDL cholesterol between 70 and189 mg/dl (1.8 and 4.9 mmol/l), and a 10-year risk of ASCVD of ≥ 7.5% calculated from the Pooled Heart Equation, high-dose statins should be given with a class IIa indication. For primary prevention in diabetics aged 21 to 39 years or older than 75 years and a serum LDL cholesterol between 70 and 189 mg/dl (1.8 and 4.9 mmol/l), moderate-dose statins or high-dose statins should be given with a class IIa indication. There is no additional ASCVD reduction from adding non-statin therapy to further lower non-high-density lipoprotein (HDL) cholesterol once an LDL cholesterol goal has been reached. Clinical trials have found no lowering of cardiovascular events or mortality in diabetics treated with statins with the addition of nicotinic acid, fibric acid derivatives, ezetemibe, or drugs that raise serum HDL cholesterol
Coronary endothelial dysfunction, obesity and the metabolic syndrome : research article
Authors: Halcox, Julian P.J.; Ozkor, Muhiddin A.; Mekonnen, Girum; Quyyumi, Arshed A.
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 2, Jun 2014
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Abstract: Objective : To define the impact of the metabolic syndrome (MetS) and obesity on coronary vascular function, with the hypothesis that subjects with MetS will have endothelial dysfunction.
Background : Obesity or the metabolic syndrome is associated with a higher risk of diabetes and coronary artery disease (CAD). Endothelial dysfunction is a common causal pathway in the initiation and progression of CAD.
Methods : A total of 418 patients (165 obese, 239 MetS) with and without angiographic evidence of CAD underwent coronary vascular function testing by measuring coronary blood flow (CBF) velocity in response to intracoronary infusion of acetylcholine (ACH) and sodium nitroprusside (SNP) and coronary flow reserve with adenosine.
Results : Endothelium-dependent microvascular vasodilation correlated with body mass index (BMI) (r = -0.12, p = 0.02), with ACH responses significantly lower in overweight, obese and MetS subjects (p = 0.003). The number of MetS components correlated with the response to ACH in both the coronary microcirculation and the epicardial coronary arteries, and with impaired coronary microcirculatory responses to adenosine. No significant correlation was observed with SNP. In multivariable analysis, beyond age, only the total number of MetS components, and not BMI, emerged as an independent predictor of impaired microvascular response to ACH (CBF: β = -0.18, p < 0.001). Low-grade inflammation (C-reactive protein) was higher in patients with MetS, but was not associated with coronary vascular function.
Conclusions : We demonstrate that the clustering of MetS components is an important and independent determinant of coronary endothelial dysfunction in subjects with and without CAD.
Barriers to self-management of diabetes: a qualitative study among low-income minority diabetics : research article
Authors: Onwudiwe, Nneka C ; Mullins, C Daniel ; Winston, Reed A ; Shaya, Aida T ; Pradel, Francoise G ; Laird, Aurelia ; Saunders, Elijah
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 2, Jun 2014
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Abstract: Objectives: Diabetes self-management is a key element in the overall management of diabetes. Identifying barriers to disease self-management is a critical step in achieving optimal health outcomes. Our goal was to explore patients’ perceptions about barriers to self-management of diabetes that could possibly help explain poor health outcomes among minority patients.
Study design: Four focus groups were conducted among 31 predominately African-American patients with diabetes who were enrolled in the Baltimore Cardiovascular Partnership Study, a NIH-funded multi-year prospective partnership study. The topic guide consisted of a series of open-ended questions about knowledge of current health status, medication use, continuity of care, blood glucose level and nutrition.
Results: The focus groups confirmed that previously reported barriers to self-management persisted, and identified new concerns that could be associated with poor health outcomes among minority patients with diabetes. Attitudes, perceptions and behaviours surrounding diabetes and self-management of the condition did vary across individuals, however, the variation appeared to reflect the individual’s knowledge and opinions rather than patient’s age, gender or culture. The primary barrier to diabetes self-management resulted from lack of knowledge of target blood glucose level and blood pressure. Several participants found some of the health information quite confusing.
Conclusions: Diabetes is a major public health concern and the lack of awareness of target blood glucose level and blood pressure further complicates the problem. The limited health literacy seen in this study could help explain several of the barriers to self-management. The barriers to self-management identified in this qualitative study are amenable to intervention that could improve health outcomes.
Optimal utilisation of sulphonylureas in resource-constrained settings : review
Authors: Naidoo, Poobalan ; Rambiritch, Virendra ; Butkow, Neil ; Saman, Selvarajah
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 2, Jun 2014
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Abstract: Sulphonylureas (SUs) are oral anti-diabetic drugs (OADs) that were introduced more than 60 years ago. Clinicians are familiar with their use and they remain extensively used. However, the SU class is associated with adverse effects of weight gain and hypoglycaemia. In addition, their effects on cardiovascular events remain contentious. Newer classes of anti-diabetic agents have been developed and these agents are weight neutral (di-peptidyl peptidase IV inhibitors), while others reduce weight (glucagon-like peptide analogues and sodium glucose co-transporter inhibitors). Furthermore, the newer agents are less likely to cause hypoglycaemia and have a potentially better cardiovascular safety profile. However, the newer agents are more costly than SUs and their long-term safety is unknown. It is therefore likely that SUs will continue to be used, and more so in resource-limited settings. One may mitigate the adverse effects of weight gain and hypoglycaemia associated with the SU class by using members within this class that are less probable to cause these adverse effects. Furthermore, the specific SU must be used at the lowest effective therapeutic dose. In patients at high risk of SU-induced hypoglycaemic episodes (frail, clinically significant renal impairment), or patients in whom hypoglycaemic episodes may have devastating effects (bus drivers), newer anti-diabetic agents may be a justifiable alternative option.
On the horizon: new oral therapies for type 2 diabetes mellitus : review
Authors: Ukrainski, Melinda; Gandrabura, Tatiana ; Bischoff, Lindsay Ann ; Ahmed, Intekhab
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 2, Jun 2014
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Abstract: The first documented case of diabetes mellitus occurred earlier than 4000 BC. Since then, many of the brightest minds in medicine have dedicated their time and effort toward developing treatments that can reverse the course of this deadly disease. As our understanding of the pathogenesis of diabetes increases, so does the availability of treatment options. The fight against diabetes once only had metformin and sulfonylureas as the cornerstone of oral treatment, but now, multiple classes have been added to this armamentarium including thiazolidenediones (TZDs) and dipeptidyl peptidase IV (DDP IV) inhibitors. These therapies provide reasonable durable glycemic control but are unable to arrest the natural progression of diabetes or the eventual need for insulin. By utilizing our growing knowledge on the pathogenesis of diabetes, a number of new therapeutic agents are in development to overcome the shortcomings of current therapies. Promising options on the horizon include sodium-coupled glucose co-transport 2 (SGLT2) inhibitors, ranolazine, salicylates, second-generation peroxisome proliferator-activator receptor agonists (PPARs), and 11-beta hydroxysteroid dehydrogenase type 1 inhibitors (11-beta HSD1 inhibitors). Various molecules, including some enzymes, are also in development, particularly to address beta-cell preservation and its sensitivity to glucose, while minimising hypoglycaemia. Most of these new classes of drugs consist of daily administration, simplifying the regimen for patients and likely increasing medication compliance.
This article reviews the new agents that are advancing through clinical trials, their mechanism of actions, glucose lowering effect and possible side effects and limitations.
Treatment of diastolic heart failure in hypertensive diabetic patients: between illusion and achievements : review
Authors: Genel, Sur; Emanuela, Floca; Lucia, Sur M; Daniel, Sur G; Dan, Radulescu
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 2, Jun 2014
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Abstract: Hypertension is the most prevalent cardiovascular disease in the world. Because of associated morbidity and mortality, it is in one of the most important public health problems. Hypertension is the most important cause of heart failure with low or preserved ejection fraction. If hypertension develops concomitantly with diabetes mellitus, treatment of the two diseases becomes more complex. It is known that beta-blockers may induce type 2 diabetes, but new generation drugs such as nebivolol do not have this effect.
There are many drugs with proven efficacy in lowering blood pressure, but the optimal treatment to prevent progression to heart failure is uncertain. Beta-blockers are a class of drugs with benefits for both hypertension and heart failure. Drugs in this class have different pharmacological properties in terms haemodynamic and cardiovascular effects.
Nebivolol is a beta-blocker that causes vasodilatation mediated by nitric oxide release. This medicine lowers blood pressure, prevents endothelial dysfunction and improves coronary flow reserve and diastolic function independent of ventricular geometry changes. The action of nebivolol is superior to classic beta-blockers due to reversibility of subclinical changes in the left ventricle before the onset of heart failure.
In the early stages of heart failure with preserved ejection fraction management is not yet established. Therefore it is important to know that in these situations nebivolol has beneficial effects.
Treating diabetes with exercise: focus on the microvasculature : review
Authors:
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 2, Jun 2014
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Abstract: The rising incidence of diabetes and associated metabolic diseases, including obesity, cardiovascular disease and hypertension, have led to investigation of a number of drugs to treat these diseases. However, lifestyle interventions, including diet and exercise, remain the first line of defence. The benefits of exercise are typically presented in terms of weight loss, improved body composition and reduced fat mass, but exercise can have many other beneficial effects. Acute effects of exercise include major changes in blood flow through active muscle, and an active hyperaemia that increases the delivery of oxygen to the working muscle fibres. Longer-term exercise training can affect the vasculature, improving endothelial health and possibly basal metabolic rates. Further, insulin sensitivity is improved both acutely after a single bout of exercise and shows chronic effects with exercise training, effectively reducing diabetes risk. Exercise-mediated improvements in endothelial function may also reduce complications associated with both diabetes and other metabolic diseases. Therefore, while drugs to improve microvascular function in diabetes continue to be investigated, exercise can also provide many similar benefits on endothelial function and should remain the first prescription when treating insulin resistance and diabetes. This review will investigate the effects of exercise on the blood vessels and the potential benefits of exercise on cardiovascular disease and diabetes.
Diabetes mellitus and the brain: special emphasis on cognitive function : review
Authors: Hamed, Sherifa A
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 2, Jun 2014
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Abstract: Diabetes mellitus (DM) is a major public health problem. Cognitive deficits are common with DM which range from subclinical or subtle to severe deficits such as dementia. Both hypoglycaemia and hyperglycaemia are causes of cognitive impairment with DM. In patients with DM, not only severe hypoglycaemia but also recurrent mild or moderate hypoglyacemia have deleterious effect on the brain. Recurrent mild/moderate hypoglycaemia is associated with intellectual decline, reduced attention, impaired mental abilities and memory deficits. Hypoglycaemia may result in abnormalities of neuronal plasticity, synaptic weakening and scattered neuronal death in the cerebral cortex and hippocampus. Chronic hyperglycaemia in type 1 and type 2 DM is associated with low IQ (verbal, performance and total) and abnormalities in testing for different domains of cognitive function such as verbal relations, comprehension, visual reasoning, pattern analysis, quantitation, memory, learning, mental control, psychomotor efficiency, mental and motor processing speed and executive function. The suggested mechanisms incriminated in the pathogenesis of hyperglycaemia-related cognitive dysfunction include, macro- and microvascular disease or vasculopathy, hyperlipidaemia, hypertension, insulin resistance and hyperinsulinaemia, stress response, direct toxic effect of chronic hyperglycaemia on the brain, advanced glycation end-products, inflammatory cytokines and oxidative stress. Hyperglycaemia causes oxidative stress, amyloidosis, angiopathy, abnormal lipid peroxidation, accumulation of β-amyloid and tau phosphorylation, neuro-inflammation, mitochondrial pathology, apoptosis and neuronal degeneration in the cortex and hippocampus. Depression has been identified as a risk for accelerated cognitive decline with DM. The knowledge that diagnosis at an early age, frequency of hypoglycaemia, poor glycaemic control and presence of risk factors negatively affect cognitive functions in DM will have important implications for treatment and research purposes.
Type 1 diabetes and cardiovascular disease : review
Authors: Schnell, Oliver; Cappuccio, Francesco; Genovese, Francesco; Standl, Eberhard; Valensi, Paul; Ceriello, Antonio
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 2, Jun 2014
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Abstract: The presence of cardiovascular disease (CVD) in type 1 diabetes largely impairs life expectancy. Hyperglycaemia, leading to an increase in oxidative stress, is considered to be the key pathophysiological factor of both micro- and macrovascular complications. In type 1 diabetes, the presence of coronary calcifications is also related to coronary artery disease. Cardiac autonomic neuropathy, which significantly impairs myocardial function and blood flow, also enhances cardiac abnormalities. Also hypoglycaemic episodes are considered to adversely influence cardiac performance. Intensive insulin therapy has been demonstrated to reduce the occurrence and progression of both micro- and macrovascular complications. This has been evidenced by the Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) study. The concept of a metabolic memory emerged based on the results of the study, which established that intensified insulin therapy is the standard of treatment of type 1 diabetes. Future therapies may also include glucagon-like peptide (GLP)-based treatment therapies. Pilot studies with GLP-1-analogues have been shown to reduce insulin requirements.
New guidelines address problems associated with suboptimal injection technique : best practise
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 2, Jun 2014
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Abstract: The incorrect administration of insulin injections contributes to complications associated with South Africa's growing diabetes burden and makes problems worse. But this is about to change. Earlier this year, South Africa became the sixth country worldwide and the first in Africa to benefit from the introduction of guidelines for optimal injection technique for diabetes control. 'Needles have come a long way and are shorter and thinner than in the past, which has helped us to work around doctor and patient reluctance to initiate insulin', says paediatric endocrinologist, Dr David Segal. 'These guidelines are important to ensure uniformity in respect of how patients administer insulin and how healthcare professionals advise them with regard to correct techniques.'
The South African diabetic retinopathy screening programme launches : diabetes news
Author: Cook, Stephen
From: South African Journal of Diabetes and Vascular Disease, Vol 11, Issue 2, Jun 2014
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Abstract: South Africa has not had a screening programme until recently. The Ophthalmological Society of South Africa (OSSA) has launched a diabetic retinopathy screening programme for South Africa. This has been administered and funded by the African Eye Foundation.

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