VOLUME 8 NUMBER 4 • NOVEMBER 2011
173
SA JOURNAL OF DIABETES & VASCULAR DISEASE
JOURNAL UPDATE
associations between WHtR and WHR with
known metabolic risk factors remain to be
explored in a South African population.
The present study compared the diag-
nostic ability (sensitivity and specificity) of
obesity measures (WC, WHtR, WHR and
VAT) to identify black and white South Afri-
can women with or without elevated blood
pressure, dylipdaemia and insulin resistance;
and to identify thresholds of obesity meas-
ures that best identify risk in these women.
Apparently healthy, pre-menopausal
South African women (241 black and 188
white) were assessed on basic anthropo-
metric measurements and blood pressure.
Blood sampling after an overnight fast
determined plasma glucose, serum insulin,
TC, HDL cholesterol and TG concentrations.
Insulin resistance was calculated from fast-
ing glucose and insulin levels.
There were no ethnic differences in body
weight; however, the white women were
significantly taller and had a lower BMI and
WHtR than the black women. There were no
ethnic differences in WC or WHR; although
blackwomen had less VAT thanwhitewomen.
For both black and white women there were
no differences in blood pressure, and fasting
glucose levels were within normal ranges.
The white women had higher mean fasting
glucose and lower fasting insulin levels than
black women. White women had significantly
higher TG, TC and HDL-C levels.
All measures of central obesity were
found to be better indicators of metabolic
risk in white compared to black South Afri-
can women. These findings suggest that
factors other than body composition, such
as inflammation or environmental factors,
contribute to increased metabolic disease in
black women.
Another important finding was the sig-
nificant differences in the diagnostic ability
between VAT and anthropometric measures
for identifying metabolic risk thresholds. It
was found that WC was better than VAT
for identifying black and white women
with insulin resistance. Conversely, VAT was
significantly better than WC for identify-
ing elevated TG levels in white women and
elevated blood pressure in black women.
WC and VAT thresholds were lower in black
compared to white South African women.
Considering WC and WHtR can be used
to identify equivalent metabolic risk, and
given the high cost and risks of radiation
exposure associated with CT scans, it may
be more clinically applicable to use these
simple anthropometric measures over VAT
for identifying metabolic risk variables.
Key take-home message:
Simple anthro-
pometric measures of WC, WHtR and WHR
for determining metabolic and subsequent
risk of diabetes are not as useful in black as
in white South African women.
Source: Evans J, Micklesfield L,
et al.
Diagnostic ability
of obesity measures to identify metabolic risk factors in
South African women.
Metabol Syndr Relat Dis
2011;
9
(5): 350–360. DOI: 10.1089,met.2011.0034.
Mild symptomatic hypoglycae-
mia does not adversely impact on
beliefs about diabetes or health
status over the long term
Improved glycaemic control is required to
minimise long-term complications of type 2
diabetes but carries the risk of hypoglycae-
mia. Periods of moderate to severe hypogly-
caemia and accompanying symptoms
(sweating, palpitations, tremor, cognitive
impairments, behavioural changes and coma)
are distressing and may lead to changes in
the way patients manage and think about
their diabetes. Reports on the impact of mild
hypoglycaemia are sparse, resulting in this
study, with contributions from the Division of
Endocrinology and Metabolism of the Uni-
versity of the Witwatersrand.
Beliefs about illness may unfavourably
change in response to mild hypoglycaemia
in ways modified by external social fac-
tors, education and experience. Collectively,
these may influence self-care behaviour and
adherence to medical regimen. Self moni-
toring of blood glucose has the potential
to confirm or refute subjective feelings of
hypoglycaemia, as well as identify asympto-
matic episodes of low blood glucose.
The aim of this study was to evaluate the
association betweeen experience of mild
hypoglycaemia and changes in beliefs about
diabetes, self-reported well-being, health
status and health behaviours over a period
of 12 months.
The study randomly allocated 453 well-
controlled, non-insulin dependant type 2
diabetes patients into one of three inter-
ventions: (1) standardised care with three-
monthly HbA
1c
measurements; (2) use of a
blood glucose meter with minimal educa-
tion or training and with clinician interpreta-
tion of results; and (3) use of blood glucose
meter with extensive education and training
in self interpretation and application of the
results to diet, physical activity and medica-
tion adherence. Self-reported questionnaires
assessing beliefs about diabetes, well-being,
health status and health behaviour were
collected at baseline and one year.
Experience of grade 1 hypoglycaemia (self
reported with no accompanying symptoms)
was associated with a small increase in self-
reported personal control over diabetes, but
no other significant changes in beliefs about
diabetes or self monitoring of blood glucose
were identified. There was no evidence of
long-term adverse impact on health status
from the experience of mild, symptomatic
hypoglycaemia. Previous studies have sug-
gested amuch larger impact of hypoglycaemia
on quality of life than identified in this study.
This study shows neither a significant asso-
ciation between health status and reported
experience of hypoglycaemia, nor changes in
experience of hypoglycaemia over time.
Regular monitoring with subsequent
regulation of lifestyle and medication may
add to a sense of personal involvement and
responsibility. However, those experiencing
symptoms of hypoglycaemia did not share
the same changes in personal control. The
wider benefits of increased perceptions of
personal control in supporting self manage-
ment of diabetes need further evaluation.
Key take-home message:
There is no evi-
dence of a long-term adverse impact on
beliefs about diabetes or health status in
those patients experiencing mild sympto-
matic hypoglycaemia when self monitoring
blood glucose.
Source: Malanda UL, Bot SD,
et al.
Experience of hypo-
glycaemia is associated with changes in beliefs about
diabetesinpatientswithtype2diabetes.DIABETICMedicine
2011. DOI: 10.1111/j.1464-5491.2011.03340.x.
DRUGS AND THERAPEUTIC
REGIMENS
Addition of alogliptin to metformin
and pioglitazone effective for inad-
equate glycaemic control in type 2
diabetes
Treatment goals of type 2 diabetes aim to
achieve and maintain glycaemic control to
mitigate the risk of microvascular and mac-
rovascular complications. Dual oral therapy
with metformin and pioglitazone is a well-es-
tablished treatment option for patients with
type 2 diabetes. Metformin lowers blood glu-
cose, primarily by increasing hepatic insulin
sensitivity. Pioglitazone increases peripheral
and hepatic insulin sensitivity and potentially
preserves
β
-cell function.
Largely due to progressive decline of
β
-cell
function, most patients initially achieving
treatment goals eventually experience a dete-
