Criteria for type 2 diabetes mellitus,nephrogenic diabetes insipidus in dogs treatment,difference between type1 and type 2 diabetes insulin exercise - Try Out


Chronic complications common to all forms include retinopathy, nephropathy, neuropathy and cardiovascular disease. Diagnosis of diabetes has historically been by measuring fasting plasma glucose (FPG) or performing an oral glucose tolerance test (OGTT); specific threshold values are required to categorize an individual as pre-diabetic (increased risk for diabetes) and diabetic (Table 1).
In 2010, hemoglobin A1c (A1c) was added as a diagnostic tool for individuals with type 2 diabetes. Individuals with type 1 diabetes may have a rapid onset of symptoms, and frequently present with ketoacidosis, obviating the diagnostic need for A1c measurement. The ADA Standards of Medical Care for 2010 for GDM do not endorse A1c as a diagnostic test during pregnancy, but refer to the Hyperglycemia and Adverse Pregnancy Outcomes Study and conversations the ADA is having with the International Association of Diabetes and Pregnancy Study Groups (IADPSG) about reclassification of GDM. The IADPSG has recommended stricter criteria for classification of GDM, but for 2010, the criteria remain those shown in Table 2. Email, first name, comment and security code are required fields; all other fields are optional.
Discuss various statistics regarding diabetes mellitus, including its prevalence in the United States. Differentiate between type 1 and type 2 diabetes, including pathogenesis and prevalence for each type.
List and explain the various tests and methodologies used for the identification of diabetes. Discuss various features of hemoglobin A1c and other glycated proteins, including fructosamine and glycoalbumin and their use in the detection of diabetes. Explain long-term monitoring of diabetes mellitus, including the use of estimated average glucose.
Although simply defined on the basis of hyperglycemia, diabetes mellitus today is known to be a highly heterogeneous disease. In the past, the diagnosis of diabetes was based on either fasting plasma glucose or two-hour plasma glucose level in the oral glucose [75 g] tolerance test (OGTT). The glycation of hemoglobin occurs at several amino acid residues and, as a result, several adducts of hemoglobin A (HbA) and various sugars are formed by the nonenzymatic post-translational glycation process.
Various methods for the measurement of HbA1c have been described and reviewed.6 These methods can be classified in two major categories. Because of their ability to process a large number of samples and their superior precision, automated HPLC and automated immunoassays are among the most widely used methods. Besides the standardization of various methods, one may also be aware of the clinical situations in which HbA1c may not provide an accurate estimation of glycemic control. Several assays designed to measure glycated serum proteins (fructosamine and GA) have been described.
Despite these limitations, measuring fructosamine or GA provides some advantages over measuring glycohemoglobin A1c as they are not affected by RBC life span, and the glycated protein levels respond more quickly to changes in glycemic control than glycohemoglobin A1c. The effective clinical management of diabetes requires accurate measurement and monitoring of blood glucose levels.
Several studies have explored the relationship between HbA1c and chronic glycemia and have supported the association of HbA1c with average glucose levels over the preceding five to 12 weeks.17 These studies have relied on infrequent measures of capillary glucose levels, calling into question the validity of their assessment of chronic glycemia. Recently, HbA1c has been incorporated into diabetes diagnosis, and is recommended by the International Expert Committee based on advances in instrumentation and standardization that make it an accurate and precise marker. International expert committee report on the role of the A1c assay in the diagnosis of diabetes. Diseases of the kidney are a common finding in people with diabetes, with up to half demonstrating signs of kidney damage in their lifetime (1–3). The classic description of diabetic nephropathy is of a progressive increase in proteinuria in people with longstanding diabetes followed by declining function that eventually can lead to end stage renal disease (ESRD) ( Figure 2 ) (1,9,10). The earliest stage of diabetic nephropathy is hyperfiltration, where the glomerular filtration rate (GFR) is significantly higher than normal. It is important to note that the rate of progression can vary between individuals, and that the clinical markers of the disease (i.e. People with diabetes (particularly type 2 diabetes) often develop kidney diseases other than diabetic nephropathy.
Screening for kidney disease in people with diabetes involves an assessment of urinary albumin excretion and a measurement of the overall level of kidney function through an estimation of the GFR.
When screening for albuminuria, the test of choice is the random urine albumin-to-creatinine ratio (urinary ACR).
The serum creatinine is the most common measurement of kidney function; however, it can inaccurately reflect renal function in many scenarios, particularly in extremes of patient age or size (33,34).
The eGFR is useful for assessing chronic changes in renal function but should not be used in situations where kidney function is changing rapidly.
Urinalysis findings of red blood cell casts are not a common finding in renal disease due to diabetes, and white blood cell casts or heme-granular casts are not compatible with a diagnosis of kidney disease due to diabetes. Although 24-hour collections are not needed for routine screening in diabetes, they can be useful when there is doubt about the accuracy of an eGFR, when screening for nonalbumin urinary proteins (e.g.
People with diabetes should undergo annual screening for the presence of kidney disease when they are clinically stable and not suspected of having acute kidney injury or nondiabetic renal disease. Screening for CKD in people with diabetes should be performed with a random urine ACR and a serum creatinine that is then converted into an eGFR (Figure 3 ).
Once a diagnosis of CKD has been made, a urine sample for dipstick and microscopy should be ordered. Optimal glycemic control established as soon as possible after diagnosis will reduce the risk of development of diabetic nephropathy (38–42). All people with CKD are at risk for cardiovascular (CV) events and should be treated to reduce these risks (see Vascular Protection chapter, p.
The progression of renal damage in diabetes can be slowed through intensive glycemic control (38) and optimization of BP (55). In CKD from causes other than diabetic nephropathy, ACE inhibition has been shown to reduce proteinuria, slow progressive loss of glomerular filtration rate and delay the need for dialysis (70,71). A variety of strategies to more aggressively block the RAAS have been studied in kidney disease, including combining RAAS blockers or using very high doses of a single RAAS blocker. Several classes of medications used commonly in people with diabetes can reduce kidney function during periods of intercurrent illness and should be discontinued when patients are unwell, in particular when they develop significant intravascular volume contraction due to reduced oral intake or excessive losses due to vomiting or diarrhea.
Drugs that block the RAAS reduce intraglomerular pressure, which, in turn, leads to a rise in serum creatinine of up to 30%, which then stabilizes (79). Mild-to-moderate hyperkalemia can be managed through dietary counselling, Diuretics, in particular furosemide, can increase urinary potassium excretion. As the use of RAAS blockers during pregnancy has been associated with congenital malformations, women with diabetes of childbearing age should avoid pregnancy if drugs from these classes are required (84).
Many medications need to have their dose adjusted in the presence of low kidney function, and some are contraindicated in people with significant disease.
Most people with CKD and diabetes will not require referral to a specialist in renal disease.
Shading shows how adjusted relative risk is ranked for 5 outcomes from a meta-analysis of general population cohorts: all-cause mortality, cardiovascular mortality, kidney failure treated by dialysis and transplantation, acute kidney injury, and progression of kidney disease. 39 Anonymous Effect of intensive therapy on the development and progression of diabetic nephropathy in the Diabetes Control and Complications Trial. 40 Anonymous Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). 41 Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of intensive therapy. 43 Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.
Science, Technology and Medicine open access publisher.Publish, read and share novel research. Socio-Ecological Approach to Self-Management of Type 2 Diabetes: Physical Activity and Dietary InterventionRashid M. A Beck, J Scott, P Williams, et al1997A randomized trial of group outpatient visits for chronically older HMO members: the cooperative health care clinic. R Ewing, T Schmid, R Killingsworth, 2003Relationship between urban sprawl and physical activity, obesity, and morbidity.
H Frumkin, L Frank, R Jackson, 2004Urban Sprawl and Public Health: Designing, Planning, and Building for Healthy Communities. D Haire-joshu, 1996Management of Diabetes Mellitus: Perspectives of care across the lifespan.
Feel free to take a look around, meet the Waverunners, and see how the foundation is being set in place, by building a softball powerhouse in Indiana! Furthermore, due to the short prodromal period, the A1c value may be lower than expected if measured at diagnosis.5 Therefore, A1c is not recommended as a diagnostic tool for type 1 diabetes. The IADPSG advocates testing pregnant women at their first obstetrics visit for the presence of overt diabetes.
Behan is associate professor and director, Clinical Laboratory Sciences Program, School of Allied Health and Life Sciences, University of West Florida, Pensacola.
With the exception of email, any information you provide will be displayed with your comment. Recently, the International Expert Committee (2009) and the ADA Clinical Practice Guidelines (just published in 2013) recommended the use of glycated hemoglobin (HbA1c) to diagnose diabetes.2-3 This article will review the current state of the laboratory testing with special focus on the role of  HbA1c and other emerging glycated protein biomarkers, including fructosamine and glycated albumin (GA), in the diagnosis and long-term monitoring of diabetes. For decades the diagnosis of diabetes mellitus (type 1 and type 2) was made on the basis of an elevated fasting glucose level. Furthermore, in spite of standardization, many factors, including noncompliance for fasting and inability to tolerate the glucose load, among many other factors, influence the final test outcome. Glycemic biomarkers are important tools to monitor glycemic control.5 Measurement of glycated proteins, primarily HbA1c, has been widely used for routine long-term monitoring of glucose control and as a measure of risk for the development of diabetes complications.
Hemoglobin A1c was first discovered in 1969 as an abnormal hemoglobin fraction in blood from diabetes patients. This process involves the formation of a labile Schiff base intermediate followed by the Amadori rearrangement.
One category is based on separation and detection of HbA1c on the basis of charge differences and includes ion-exchange chromatography, high performance liquid chromatography (HPLC), and agar gel electrophoresis.
Glycation of HbA1c not only depends on average glycemia but also on the rate of production or destruction of RBCs.
Like glycohemoglobin, glucose molecules are joined to protein molecules through a nonenzymatic glycation mechanism to form stable ketoamines termed fructosamine. However, these assays are currently used only to complement glycohemoglobin A1c assays to manage diabetic patients when the detection of short-term metabolic changes is required.
Traditionally, plasma glucose has been the lab test used for monitoring the patient with diabetes. More recently, an international multicenter study examined the relationship between average glucose, as assessed with a combination of continuous glucose monitoring and frequent finger-stick capillary glucose testing and HbA1c levels over time, and demonstrated a close relationship between the two.
Currently HbA1c is widely used as a glycemic marker for long-term monitoring of diabetes, as it provides valuable information about the degree of glucose control during the previous eight to 12 weeks. Repeatability of the oral glucose tolerance test for the diagnosis of impaired glucose tolerance and diabetes mellitus. Effects of hemoglobin variants and chemically modified derivatives on assays for glycohemoglobin. Defining the relationship between plasma glucose and HbA1c in the Diabetes Control and Complications Trial.
Progression of diabetic nephropathy can be slowed through the use of medications that disrupt the renin-angiotensin-aldosterone system. Key risk factors for diabetic nephropathy include long duration of diabetes, poor glycemic control, hypertension, male gender, obesity and cigarette smoking. Identification of hyperfiltration is not clinically useful, as it is difficult to determine from routine testing. Kidney biopsy series in type 2 diabetes have found that nondiabetic glomerular disease, particularly hypertensive or ischemic nephropathy, is as common as diabetic nephropathy in people with diabetes (7). Persistent abnormalities of either urinary albumin excretion or GFR, or significant urinalysis abnormalities, lead to the diagnosis of kidney disease in people with diabetes. Indeed, in people with diabetes, the GFR usually will be less than half of normal before the serum creatinine exceeds the lab normal range (35). For this reason, a variety of methods have been developed to better estimate the level of glomerular filtration by combining the patient's serum creatinine with factors such as age, weight, and gender. Dehydration and other conditions that lead to intravascular volume contraction can lead to a transient decline in renal function.
Although persistent microscopic hematuria can occur in about 20% of people with diabetic nephropathy, its presence should lead to the consideration of other urological or nephrological conditions. Screening should be delayed in the presence of conditions that can cause transient albuminuria ( Table 3 ) or a transient fall in eGFR. This can be delayed 5 years from the onset of type 1 diabetes but should begin immediately at the time of diagnosis of type 2 diabetes. In the absence of any significant abnormalities other than proteinuria, then a presumptive diagnosis of kidney disease due to diabetes is made. Optimal BP control also appears to be important in the prevention of diabetic nephropathy, although the results have been less consistent (41,43–45). Progression of diabetic nephropathy can be slowed through the use of an ACE inhibitor or ARB (56), independent of their effect on BP, and these 2 medication classes appear to be equally effective for cardiorenal protection (57,58).
The issue of whether ARBs and ACE inhibitors are similarly effective in CKD that is not caused by diabetic nephropathy remains controversial (72,73). These strategies reduce proteinuria but have not been proven to improve patient outcomes in diabetic nephropathy (74–77) and come at a risk of increased acute renal failure, typically when a patient develops intravascular volume contraction (78). Diuretics can exacerbate intravascular volume contraction during periods of intercurrent illness.


Although these drugs can be used safely in patients with renovascular disease, these patients may have an even larger rise in serum creatinine when these drugs are used (80–82).
Sodium bicarbonate (500 to 1300 mg orally twice a day) can also increase urinary potassium excretion, especially amongst individuals with a metabolic acidosis as demonstrated by a low serum bicarbonate level.
If a woman with diabetes receiving such medications wishes to become pregnant, consideration should be given to their discontinuation prior to conception.
Appendix 6 lists some medications commonly used in people with diabetes and how they should be used if kidney dysfunction is present. However, specialist care may be necessary when renal dysfunction is severe, when there are difficulties implementing renal-protective strategies or when there are problems managing the sequelae of renal disease (85).
In adults, screening for CKD in diabetes should be conducted using a random urine ACR and a serum creatinine converted into an eGFR [Grade D, Consensus]. All patients with diabetes and CKD should receive a comprehensive, multifaceted approach to reduce cardiovascular risk (see Vascular Protection, p. People with diabetes on an ACE inhibitor or an ARB should have their serum creatinine and potassium levels checked at baseline and within 1 to 2 weeks of initiation or titration of therapy and during times of acute illness [Grade D, Consensus].
Combination of agents that block the renin-angiotensin-aldosterone system (ACE inhibitor, ARB, DRI) should not be routinely used in the management of diabetes and CKD [Grade A, Level 1 (89,90) ]. Diabetes Criteria for patientsAll the participants will adhere to their usual medications as recommended by their doctors. M Ansari, 2009Effect of physical activity and obesity on type 2 diabetes in middle-aged population. A Brown, 1990Studies of educational interventions and outcomes in diabetic adults: A meta-analysis revisited. P French, V Senior, J Weinman, et al2001Causal attributions for heart disease: a systematic review. H Jafar, N Chaturvedi, G Pappas, 2006Prevalence of overweight and obesity and their association with hypertension and diabetes mellitus in an Indo-Asian population. These are type 1 (formerly called insulin dependent or juvenile diabetes), type 2, gestational diabetes mellitus (GDM) and diabetes due to other causes. Other advantages to using A1c as the diagnostic test for diabetes are that, unlike plasma glucose and oral glucose tolerance, A1c does not require fasting. It is not cost-effective to screen for type 1 diabetes; however, individuals known to be at increased risk based on family history or prior transient hyperglycemia may be tested for presence of islet autoantibodies. This measurement can be done with FPG, A1c or random plasma glucose13 using criteria shown in Table 1.
The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus.
Intensive blood-glucose control with sulphonylureas or Insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Glucose Determination in Plasma and Serum: Potential Error Related to Increased Hematocrit. Effects of Hemoglobin Variants and Chemically Modified Derivatives on Assays for Glycohemoglobin. International Association of Diabetes and Pregnancy Study Groups Recommendations on the Diagnosis and Classification of Hyperglycemia in Pregnancy. Challenges in HbA1c analysis and reporting: An interesting case illustrating the many pitfalls. Type 1 diabetes is characterized by absolute insulin deficiency due to autoimmunity leading to ?-cell destruction and can be identified by serological markers of autoimmunity (islet cell autoantibodies). The ADA proposes that fasting plasma glucose (FPG) should be measured in all asymptomatic people ?45 years of age and screening should be considered at a younger age in individuals at increased risk for diabetes.
Based on current recommendations from the National Diabetes Data Group, the OGTT must be done after three days on a diet containing a minimum of 150 g of carbohydrates per day. The test accurately assesses the mean blood glucose level during the preceding two to three months; therefore, it complements the more traditional measures of glucose control (blood or urine glucose testing). It was later shown that glucose binds to hemoglobin in red blood cells, and the term “glycohemoglobin” is applied to a number of chemically distinct hemoglobin components that are generated when glucose binds to hemoglobin.
The reaction is slow, continuous, and irreversible, and the reaction rate depends on the ambient glucose concentration. There is no convincing data to show that one method is superior to the other, as practically all commercial methods are standardized to a common reference standard.
Findings from the Diabetes Control and Complication Trial demonstrate that maintaining blood glucose close to normal reduces diabetes complications.17 This study compared the standard versus intensive blood glucose control on the complications of diabetes.
It is also being used as a primary treatment target, as it has been shown to have close association with diabetes complications. However, it should be reiterated that there are some limitations, and HbA1c may not provide accurate information in certain clinical situations that affect RBC life span—for example, certain hemoglobulinopathies (hemoglobin S, C, or E), anemia, and renal dysfunction. Kidney disease can be a particularly devastating complication, as it is associated with significant reductions in both length and quality of life (5,6). Persistent albuminuria is considered the earliest clinical sign of diabetic nephropathy ( Table 1 ). Additionally, aggressive control of blood pressure (BP) and glycemia, and the use of renal protective drugs can slow or stop progression of diabetic nephropathy. People with type 1 diabetes are not expected to have kidney disease at the time of onset of diabetes, so screening can be delayed until the duration of diabetes exceeds 5 years.
The random urine for albumin is insufficient, as the urinary albumin concentration can vary due to urine concentration (24). When such conditions are present, screening for kidney disease should be delayed to avoid false positives. When such conditions are present, assessment of the level of kidney function may be clinically necessary but should not be used to assess the stage of CKD. Table 2 lists other clinical clues that may point to a renal diagnosis other than kidney disease due to diabetes. An abnormal screening test should be confirmed by repeat testing of the eGFR within 3 months, and 2 more random urine ACRs ordered during that interval.
The presence of clinical or laboratory abnormalities suggesting nondiabetic kidney disease indicates the need for appropriate workup or referral. Blockade of the renin-angiotensin-aldosterone system (RAAS) with either an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) can reduce the risk of diabetic nephropathy independent of their effect on BP. The degree of risk of CV events or progression to ESRD increases as albuminuria levels rise, and as eGFR falls, with the combination of albuminuria and low eGFR predicting a very high level of risk ( Figure 4 ) (53,54).
In type 1 diabetes, ACE inhibitors have been shown to decrease albuminuria and prevent worsening of nephropathy (59), and ARBs have been shown to reduce proteinuria (60). Blockers of the RAAS interfere with the kidney's response to intravascular volume contraction, namely, the ability of angiotensin II to contract the efferent arteriole to support glomerular filtration during these periods.
In the case of severe renovascular disease that is bilateral (or unilateral in a person with a single functioning kidney), RAAS blockade can precipitate renal failure. Screening should commence at diagnosis of diabetes in individuals with type 2 diabetes and 5 years after diagnosis in adults with type 1 diabetes and repeated yearly thereafter.
In order to assess the effectiveness of this intervention, it was advised not to modify the medications during this trial.
Statistical analysis The primary outcome will be analysed by an un-paired sample t-test (mean difference between baseline and final HbA1c). V Hedges, 1994Predicting metabolic control in diabetes: a pilot study using meta-analysis to estimate a linear model.
X Zhang, K Merrell, et al1998Diabetes in the African-American Medicare population: morbidity, quality of care, and resource utilization.
A Brownson, O Tool, ML et al2005Ecological approaches to self-management: The case of diabetes.
H Jensen, et al2003Multifactorial intervention and cardiovascular disease in patients with Type 2 diabetes. A Strycker, D Toobert, J et al2000The Chronic Illness Resources Surveys: A social-ecologic approach to assessing support for disease self-management.
G Eakin, et al1997Quality of life and associated characteristics in a large diverse sample of adults with diabetes.
E Glasgow, L Strycker, 2000Beliefs versus feelings: a comparison of personal models and depression for predicting multiple outcomes in diabetes. R Evenson, P Bors, et al2003Neighbourhood environment, access to places for activity, and leisure-time physical activity in a diverse North Carolina population.
We pride ourselves on hard work, dedication, and improvement; while enjoying the game of fastpitch softball. The three-to-five hour oral glucose tolerance test, once the gold standard for diagnosing diabetes, is currently not recommended either by the ADA or the International Expert Committee.2-3 However, both the ADA and International Expert Committee continue to recommend use of the two-hour oral glucose challenge test, especially in gestational diabetes mellitus (GDM). The clinical utility of insulin measurement is limited, primarily because when fasting glucose is elevated, ?-cell responsiveness decreases, and when the fasting glucose level is normal, late hyperinsulinism may occur in type 2 diabetes or in the early phase of type 1 diabetes. In addition to hemoglobin, other proteins in blood can also be glycated, and glycated proteins such as fructosamine and glycoalbumin (GA) can also be measured and used as an estimation of glucose control.5 Today the use of HbA1c is also recommended by the ADA and other organizations for diabetes screening and diagnosis.
Minor components of HbA were first recognized because of the differences in their electrical charges and were called “fast hemoglobin” as they migrated at a faster rate than an entire HbA molecule when placed in an electrical field.
Albumin is the most abundant serum protein, and it contains multiple lysine residues, all of which can be glycated.
There are clinical situations in which fructosamine or GA should not be used, such as for thyroid disease (as in thyrotoxic or hypothyroid patients in whom protein turnover is increased or decreased).
Now HbA1c levels can be expressed and reported as eAG for most patients with type 1 or type 2 diabetes.
Furthermore, its value can be translated into eAG values, providing valuable information to clinicians in monitoring patients with diabetes. If a discrepancy between blood glucose and HbA1c is observed, one must consider the measurement of extracellular glycated proteins (fructosamine or GA), as these are not affected by RBC life span or iron status.
A variety of forms of kidney disease can be seen in people with diabetes, including diabetic nephropathy, ischemic damage related to vascular disease and hypertension, as well as other renal diseases that are unrelated to diabetes ( Figure 1 ) (7,8). Initially, small amounts of albumin are leaked, below the detection threshold of a urine dipstick. While these biopsy series are biased (biopsies are usually done in people with diabetes when nondiabetic renal disease is suspected), other studies have suggested that half of everyone with diabetes and significant kidney function impairment do not have albuminuria (15). As the delay between onset and diagnosis of type 2 diabetes can be many years and as nondiabetic kidney disease is common, significant renal disease can be present at the time of diagnosis of type 2 diabetes (21,22), so screening should be initiated immediately at the time of diagnosis in this group.
A random urine ACR predicts 24-hour urinary albumin excretion sufficiently well and is the test of choice for screening for albuminuria (23,25–27).
Furthermore, diagnosing a person as having albuminuria requires the elevated urinary albumin level to be persistent.
This equation requires knowledge of the patient's age, sex, serum creatinine and race and is automatically computed and reported by many labs whenever a serum creatinine is ordered.
Because renal function can be transiently depressed, a persistent reduction in eGFR is required before it is considered to be abnormal.
If either the eGFR remains low or at least 2 of the 3 random urine ACRs are abnormal, then a diagnosis of CKD is confirmed.
This protective effect has been demonstrated in people with diabetes and hypertension (46) but not in normotensive people with diabetes (47–49).
In type 2 diabetes, ACE inhibitors and ARBs have been shown to decrease albuminuria and prevent worsening of nephropathy, and ARBs have been shown to delay the time to dialysis in those with renal dysfunction at baseline (61–64). Nonsteroidal anti-inflammatory drugs cause constriction of the afferent arterioles, which can further reduce blood flow into the glomerulus in patients who are volume contracted. Myers Evolution of incipient nephropathy in type 2 diabetes mellitus Kidney Int 58 2000 1228 1237 Published erratum appears in Kidney Int. Pieringer Clinical versus histological diagnosis of diabetic nephropathy: is renal biopsy required in type 2 diabetic patients with renal disease? Sharon The urine protein to creatinine ratio as a predictor of 24-hour urine protein excretion in type 1 diabetic patients with nephropathy.
Lang Proteinuria, renal impairment, metabolic control, and blood pressure in type 2 diabetes mellitus. Pogue Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients.
In addition, participants will be advised not to take any other new treatments for the management of type 2 diabetes during this study. The statistical analysis, using STATA will be carried out on an intention to treat basis and that will subject to the availability of data at follow up (after 90 days) as well as at entry level for individual patients.
R Brown, et al2000Promoting physical activity in rural communities: walking trail access, use and effects. W Sokol, D Hallett, 2003Personal persistence, identity development, and suicide: a study of Native and Non- native North American adolescents. L Schmid, 2003Health and Community Design: The Impact of the Built Environment on Physical Activity. J Barrera, et al2005The Chronic Illness Resources Survey: cross-validation and sensitivity to intervention. W Terry, et al1984Effects of labelling on income, work and social function among hypertensive employees. C Brownson, et al2002The effectiveness of interventions to increase physical activity: a systematic review. Our goal as a team is to develop as softball players and build character within ourselves as well as represent our communities as responsible and classy individuals. Fasting, 1-, 2- and 3-hour measurements are taken and compared to specific glucose values for those time points. Today, diabetes-associated complications remain the leading cause of heart disease- or stroke-related deaths and are associated with long-term damage including the failure of organs such as eyes and kidneys.


Type 2 diabetes is caused by insulin resistance and lack of compensatory insulin secretory response. However, it has some limitations, indicating the need for the use of other glycated protein biomarkers. Also, HbA1c levels can be false high in situations that increase the production of RBCs, as in patients with chronic kidney disease who receive erythropoietin for anemia or in patients who receive a blood transfusion.11 In brief, HbA1c levels are shown to be positively associated with hemoglobin levels and are negatively associated with erythropoietin dose. Levels are also influenced by low albumin levels, as seen in patients with protein-losing enteropathy, nephritic syndrome, or liver failure. Today, use of HbA1c is accepted as a long-term monitoring tool for the management of diabetic patients and is used in conjunction with plasma or finger-stick glucose testing.
The calculated eAG level gives healthcare providers a more useful index of chronic glycemia. However, their relationship to average glucose and their prognostic value to diabetes complications are not clear, as in the case of HbA1c.
In this chapter, we will discuss how to screen for and diagnose chronic kidney disease (CKD) in people with diabetes, how to treat them with an aim to slow progression of CKD and discuss the impact of CKD on other aspects of diabetes management. These studies suggest that testing for albuminuria may be insufficient in identifying all patients with diabetes who have renal disease. At least 2 of 3 urine samples over time exhibiting elevations in urinary albumin levels are required before it is considered to be abnormal. A rapid decline in eGFR or development of severe hypertension would suggest prompt referral to a specialist.
The exception to this approach is when the random urine ACR indicates albuminuria in the overt nephropathy range, as this level of proteinuria rarely resolves spontaneously, so confirmatory testing is usually unnecessary. In type 2 diabetes, ACE inhibitors have also been shown to reduce the chance of developing new nephropathy (46,61).
For these reasons, all of these drugs can reduce kidney function during times of intercurrent illness. For these reasons, the serum creatinine and potassium should be checked between 1 and 2 weeks after initiation or titration of a RAAS blocker (82).
All participants will be contacted again after 90 days (3-months) to give their blood sample for HbA1c testing, their weight will be taken and BMI will be calculated. In contrast to type 1 diabetes, type 2 diabetes is highly prevalent and accounts for 90% to 95% of all diabetes cases.
The most important HbA component in diabetes is HbA1c, which has glucose attached at the N-terminal-amino groups of both ? chains of hemoglobin. Just like glycohemoglobin, fructosamine and GA measurements serve as an index of the mean concentration of glucose in the blood during the preceding several weeks.
Portable glucose meters are routinely used either in physician offices or by patients at home.
In addition to measurements of urinary albumin excretion, estimations of the level of kidney function and urinalyses are required to identify patients with kidney disease other than diabetic nephropathy.
Kidney diseases of all forms can be staged based on the degree of impairment of eGFR (Table 4 ). These renal-protective effects also appear to be present in proteinuric individuals with diabetes and normal or near-normal BP.
In patients in whom a significant change in creatinine or potassium is seen, further testing should be performed to ensure that these results have stabilized. However, because of rapid turnover of serum proteins compared to hemoglobin, the fructosamine and GA levels reflect glucose control over a shorter period of two to three weeks rather than six to 10 weeks for glycohemoglobin. The current recommendation, therefore, is to normalize fructosamine results to a given serum albumin or total protein concentration. Day-to-day management as guided by self-monitoring of blood glucose by patients with the use of glucose meters is a common practice today. In most cases, the risk of ESRD in diabetes does not appear to matter whether the renal diagnosis is one of diabetic nephropathy or an alternative diagnosis as management is the same (16). ACE inhibitors have been shown to reduce progression of diabetic nephropathy in albuminuric normotensive individuals with both type 1 (65–68) and type 2 diabetes (69). A number of additional medications need to be dose adjusted in patients with renal dysfunction, so their usage and dosage should be reevaluated during periods where kidney function changes.
Study population and randomizationInitially 325 patients with type 2 diabetes will be invited to pre-randomized interview, out of which only 210 patients will be included in the actual trial. Also, with a colorimetric analysis, bilirubin, hemolysis, and lipemia will likely interfere in the measurement. Thus, significant renal dysfunction is not usually seen until late in the course of diabetic nephropathy (13). For the purpose of this trial, it is expected that out of the 325 patients, 93 patients will not meet the inclusion criteria and 22 patients might refuse to participate in the trial. Data analysis methodIn this study, the thematic analysis of data will be adopted for analysing the data because the method was developed to meet the needs of investigating the experiences, meanings and the reality of the participants (Braun and Clarke, 2006). Of special note here is that GGT in the upper half of the population range increased the risk of diabetes by 100% in normal BMI ranges, by 150% in the overweight BMI range and by 268% in the obese BMI ranges (after adjusting for several relevant factors).
In that case, two hundred and ten (210) patients will agree to participate and will be required to sign informed consent documents at the clinic where they usually visit for their usual medical care for diabetes. The method also allows the study to adopt the element from constructionist notions – to investigate the ways in which events, realities, meanings, experiences are the effects of a range of discourses operating within a society. Therefore, 105 patients will be randomized to intervention group (Physical Activity and Diet) and 105 to the control group (usual medical care).
Sample size estimationThe study sample size was determined based on the assumption of the estimation of Standard Deviation (SD). This RCT trial will not be double-blinded as the participants receiving the education on lifestyle modifications in the community and healthcare clinics would know that they are on the active intervention.
Therefore, the study design was selected to detect an effect size of 0.5 SD lowering of HbA1c. Once the randomization phase is completed, all patients will be instructed to follow-up the usual medical care for their diabetes for the duration of the 90 days trial. It was assumed that 10% patients might be lost to follow-up in control group over the period of three months and only 5 % patients will be lost to follow-up in intervention group. The patients will not be allowed to adjust their usual medications and follow their previous prescriptions recommended by their doctors.
This assumption was based on impact of education and advice on lifestyle behavioural modifications to patients and overall popularity of this approach among the diabetic patients in sub-continent to manage their glycemic control.
In addition, each patient will be asked to go for blood test for HbA1c on day 1 and then return to give blood sample after 90 days. In addition, participants will be advised not to take any other new treatments for the management of type 2 diabetes during the trial periods. The sample size (N) for each group was =105; therefore, the total, N=210 patients were recruited to participate in both the groups. Higher serum GGT levels were positively associated with diabetes mellitus, independent of, alcohol consumption, body mass index, hypertension and other confounders.
Those patients randomized to usual medical care (control group) will be instructed to take their normal medicines and follow-up with their doctor as per their normal schedule. At that time, a questionnaire will be sent via e-mail to participants in intervention group to assess the progress of the physical activity and diet intervention and to control group to assess the progress of the treatment with normal medical care only. Minimizing the bias It is possible that the outcome measures associated with physical activity and diet interventions will be subject to bias particularly when treatment will be in progress or just afterwards. The main difference between usual medical care alone for the patients and usual medical care with physical activity and dietary interventions will occur after 3 months period of trial. According to glucose tolerance test, 153 were normal and 217 and 181 were diabetic and prediabetic respectively.
Measurement The factors which will be measured in this study are the physical activity of participants (an intervention), hemoglobin (HbA1c – primary outcome variable), blood pressure and weight (secondary outcome) whereas the body mass index (BMI) is a calculated variable. In order to reduce the bias, the questionnaire will be sent to patients at home or via e-mail to minimize any chance that their answers might be affected by actual or perceived influence by medical practitioners at clinic. The linear regression analysis will be performed after three months between HbA1c and on the blood glucose results to see the reliability of measurement data and to observe any relationship between the two variables. Physical activity is a key component of lifestyle modification that can help individuals prevent or control type 2 diabetes. Discussions The results of this randomized controlled trial will support the research question that lifestyle interventions (physical activity and diet) with usual medical care for type 2 diabetes is more effective than the usual medical care alone.
It is considered that diet is probably more important in the initial phases of weight loss, incorporating exercise as part of a weight loss regimen helps maintain weight and prevent weight regain (Klein et al. The higher % age of lost to follow up throughout this trial (Figure 2) in those patients with usual medical care (10%) than in those in intervention group (5%) suggests greater satisfaction with physical activity and dietary education and advice. The difference at 3 months follow up is the mean change in HbA1c levels for the intervention group minus the mean change of HbA1c for the control group. In this study, the message will be given to participants to do 30 minutes of moderate physical activity daily (approximately 8000 step count) and it may offer greater benefits to these patients in managing their diabetes (Wright and Royson, 1996).For measurement of physical activity, the method of step count using pedometer will be used as it has been demonstrated to have a superior validity of step counts over a questionnaire approach in predicting health markers such as BMI and waist circumference (Ewald et al.
The participants will be given pedometer for a week for the measurement of physical activities (step counts). At 3 months follow-up, the patients would show significantly greater improvement and lower values of HbA1c by 1%. These participants will be instructed to wear the pedometer on a waist belt, either side and wear it from the early morning till they go to bed in the night. This would support the hypothesis 1 that the lifestyle interventions (physical activity and diet) in patients with poorly controlled diabetes will lead to reduction of 1% hemoglobin (HbA1c) in 90 days trial.
The participants will record the start and end time for each day wearing the pedometer and in the evening record the step count showing on the display without resetting the counter. Table 2 shows the baseline characteristics of participants in intervention and control group.
Testing Hypothesis 2 (Secondary outcome variable)The hypothesis 2 will be supported if we can provide evidence that the type 2 diabetic patients after the 90 days trial would reduce 5% weight and consequently the BMI as compared to the these values at baseline.
The polynomial regression analysis will be used to generate the reference range models as these models do not make assumptions about linearity of step count with age (Wright and Royson, 1996).
The changes in BMI from the base line values will determine the level of reduction in weight and BMI based on physical activity, diet and exercise.16. Ethical consideration The scientific validity of the study is a fundamental ethical protection and this study has a scientific merit and clinical value as it aims at using the socio-ecological approach to self-management of type 2 diabetes and will help diabetic patients to control their hemoglobin (HbA1c) and help them to understand the importance of physical activity and healthy diet and to enjoy a healthy lifestyle.All the patients will be provided clear instruction about the study and informed consent will be obtained and ethical clearance will be taken from a legal authority before conducting this study.
Finally, the main contribution of this trial is to provide health professionals (diabetes care providers) and patients with type 2 diabetes an insight into the ways in which diabetes is viewed and managed in that region of Pakistan which will help them in the self-management and treatment of type 2 diabetes.17. Conclusion It has been demonstrated in this study that the level of HbA1c (primary outcome) will reduce by 1% in the patients of poorly controlled type 2 diabetes after the 90 days trial of physical activity and dietary interventions and hence will support the hypothesis and the research question. This study will enhance the relationship between the medical practitioner and the patients of diabetes and will improve the health care system in that region of the country in managing and treating the patients with chronic disease such as diabetes. Adjusted odds ratios (ORs) and 95% CIs of newly recognized diabetes (205 cases) by category of BMI and quartiles (Q) of serum GGT. Supporting this hypothesis, cross-sectional investigation of background exposure to POPs in the National Health and Nutrition Examination Survey showed relationships similar to those observed for GGT, including a powerful association with prevalent diabetes and no association between obesity and diabetes for very low POP concentrations.
The association between BMI and the incidence of DM (diabetes mellitus) was enhanced by increased GGT levels in women. HRs were calculated and adjusted for age, family history of diabetes, smoking habits, baseline glucose type, alcohol consumption and ALT. After 72h, despite the similarities in triglyceride accumulation, LPON treatment, but not oleate, dramatically affected mitochondrial function as evidenced by decreased respiration, increased mitochondrial membrane potential and ROS formation with concomitant enhanced ketogenesis.
Gamma-glutamyltransferase activities of males and persons older than 45 years were significantly higher than each counterpart. Gamma-glutamyltransferase levels increased significantly with the number of cigarettes smoked per day and the frequency of alcohol consumption except for the persons who did not take alcohol.
We have been established in the area for several years and have helped to teach young ladies the skills needed to become champions on and off the field.
The investigators concluded, "These findings suggest that a raised serum GGT level is an independent risk factor for NIDDM. As noted in other more recent studies on this page, the relationship of GGT to diabetes still exists when appropriate adjustments are made for fat. The more recent studies suggest this relationship is most likely mediated by oxidative stress. The next article on this page (#18) is a letter to the editor written b by two of the same authors of the editorial (article #2) on our IRON-Diabetes page.
As shown in Table 1 (see below), the concentrations of FPG and triglycerides markedly increased among the GGT categories. Such individuals might benefit from a more intensive therapeutic approach to decrease their global cardiovascular risk, regardless of potential unmeasured effects of lifestyle or obesity. Conceivably, the significant association of serum GGT concentrations with FPG and triglycerides, observed in our investigation, may be biologically explained by some underlying mechanisms such as hepatic steatosis, insulin resistance, and increased oxidative stress. GGT was significantly associated with the 3-year incidence of individual components of the MetS.
The investigators studied the incidence of impaired fasting glucose (IFG) and type 2 diabetes over a seven year period.



Type 2 diabetes foods to eat list banana
Diabetes miracle cure video ara?a




Comments

  1. PUBLIC_ENEMY

    Common disorder and is of many strokes, but thankfully they are a more rare cause.

    28.05.2015

  2. TELEBE_367a2

    Check out these earlier than-and-after photos atkins, a lot of people.

    28.05.2015

  3. EXPLOD

    Pieces from simple potatoes to Moroccan-fashion hen to what she calls Intense setting health goals the.

    28.05.2015

  4. pobrabski

    Food, Nutrition, Type 2 Diabetes, warning reduction benefit nonetheless, it's thought and it is time.

    28.05.2015