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• Study protocol
• Open access
• Published: 05 January 2012

Living with diabetes: rationale, study design and baseline characteristics for an Australian prospective cohort study

• Maria Donald 1 , 3 ,
• Jo Dower 1 ,
• Robert Ware 1 ,
• Bryan Mukandi 1 ,
• Sanjoti Parekh 1 &
• Christopher Bain 2  

BMC Public Health volume  12 , Article number:  8 ( 2012 ) Cite this article

32 Citations

28 Altmetric

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Diabetes mellitus is a major global public health threat. In Australia, as elsewhere, it is responsible for a sizeable portion of the overall burden of disease, and significant costs. The psychological and social impact of diabetes on individuals with the disease can be severe, and if not adequately addressed, can lead to the worsening of the overall disease picture. The Living With Diabetes Study aims to contribute to a holistic understanding of the psychological and social aspects of diabetes mellitus.

Methods/Design

The Living With Diabetes Study is a 5-year prospective cohort study, based in Queensland, Australia. The first wave of data, which was collected via a mailed self-report survey, was gathered in 2008, with annual collections thereafter. Measurements include: demographic, lifestyle, health and disease characteristics; quality of life (EQ-5D, ADDQoL); emotional well-being (CES-D, LOT-R, ESSI); disease self-management (PAM); and health-care utilisation and patient-assessed quality of care (PACIC). 29% of the 14,439 adults who were invited to participate in the study agreed to do so, yielding a sample size of 3,951 people.

The data collected by the Living With Diabetes Study provides a good representation of Australians with diabetes to follow over time in order to better understand the natural course of the illness. The study has potential to further illuminate, and give a comprehensive picture of the psychosocial implications of living with diabetes. Data collection is ongoing.

Peer Review reports

Diabetes mellitus currently affects about 285 million adults worldwide, and this figure is expected to rise to over 400 million adults by 2030 [ 1 ]. Based on self-reported data, the prevalence of diagnosed diabetes among Australian adults is 4.4% [ 2 ]. It is possible that the true prevalence is as much as twice that, and likely to increase further given an aging population, more sedentary lifestyles, rising rates of obesity, and a reduction in the rates of diabetes-related mortality [ 3 – 5 ].

The day to day management of diabetes is demanding and can take a heavy psychological and social toll, which may in turn result in poor control of blood glucose levels and an increased risk of complications [ 6 , 7 ]. From the patient's perspective, minimising the burden imposed by diabetes requires an approach that ensures services are integrated, accessible and affordable. They should also be patient-centred, with a strong emphasis on supporting patients' confidence and ability to effectively manage their illness [ 8 , 9 ]. To this end, patient reported outcomes such as quality of life and assessments of quality of care are becoming more widely used indicators of health care systems, and are now commonly considered to be critical to the evaluation of the responsiveness of health systems in meeting the needs of their users [ 10 – 12 ].

There is a growing literature on the interaction between various patient-reported outcomes, demographic factors, the self-management of patients with chronic illnesses, and medical outcomes [ 13 , 14 ]. For instance, diabetes patients with higher levels of active self-management enjoy better health outcomes [ 15 , 16 ]; more engaged, informed, confident, and skilled patients are more likely to perform activities that will promote their own health, and are more likely to have their health care needs met [ 17 ]. Fostering patients to take on a meaningful role in their own care is therefore central to improving quality of care and health outcomes.

There is a need to better understand the realities of living with diabetes in order to tailor adequate and appropriate medical and psychosocial interventions [ 18 , 19 ]. Many studies have focused on quality of life [ 20 , 21 ], patient activation [ 15 , 16 ], resource utilisation [ 22 , 23 ], or the clinical aspects of diabetes [ 24 , 25 ], but there has not been a concerted effort to simultaneously address all of these in order to gain a more holistic understanding. The Living With Diabetes Study (LWDS) described here extends the focus of previous research into diabetes beyond medical endpoints to encapsulate a broader range of outcomes that contribute to good health and improved quality of life. In particular the LWDS considers: how diabetes affects participants' quality of life, including their mental health and well-being; how satisfied people with diabetes are with the range of health services they use; how people with diabetes manage their condition; and the natural progression of diabetes over time. The findings from the LWDS will provide a more comprehensive picture of the everyday experiences of people living with diabetes and inform health policy planning and service delivery.

Study design and sampling scheme

The LWDS is a 5-year, prospective cohort study being conducted in the state of Queensland, Australia. Data are collected via a mailed self-report questionnaire. Baseline data were collected in 2008 and follow-up measurement waves occur annually.

Participants were recruited from the National Diabetes Services Scheme (NDSS), a government initiative administered by Diabetes Australia that delivers diabetes-related products at subsidised prices to registrants. In order to register with the NDSS, an individual must receive certification of a diagnosis of diabetes from a doctor or diabetes educator. The NDSS is estimated to cover 80%-90% of the Australian population diagnosed with diabetes [ 26 ].

People were eligible to participate in the LWDS if they: were aged 18 years or older; had been diagnosed with type 1 or type 2 diabetes (gestational diabetes was excluded); had a valid Queensland postal address recorded with the NDSS; and indicated on their NDSS registration that they were interested in receiving information about opportunities to participate in research. The final criterion reduced the population available for sampling from 133,851 to 58,504.

The LWDS sampling scheme oversampled in three areas of policy interest in Queensland: an outer metropolitan area, a new suburban development and a coastal agricultural community. These areas of policy interest contain approximately 7% of potential participants. While the focus of the LWDS is on documenting the lived experience of diabetes for the entire cohort, differences between these three geographically distinct areas of interest will be provided to the local state health authority for policy and planning purposes. Where appropriate findings from the cohort are weighted to adjust for the oversampling.

The sample size was calculated based on detecting an absolute change in the percentage of participants with poor health-related quality of life of at least 2.5% between the start and the end of the study. The prevalence of poor health-related quality of life among Queenslanders with diabetes at study initiation was estimated at 30% [ 27 ]. To detect an absolute change of 2.5% or greater with 90% power and alpha = 0.05 we calculated we required 3,457 participants to remain in the study at completion. To achieve this, and assuming 2% of addresses on the database would be invalid, 40% of individuals invited to enter the study at baseline would participate, and that each year 10% of participants would leave the study, we were required to invite 14,350 eligible individuals to participate in the LWDS. All eligible individuals from the three areas of policy interest were invited to participate (45% of all invitees), the remainder of invitees were from the rest of Queensland.

Follow-up, retention and participant tracking

In order to encourage people with diabetes to participate in the study at baseline, a multi-stage follow-up procedure was used following the initial survey package mail-out. Approximately 3 weeks after the initial mail-out, all potential participants were sent a letter designed to thank those people who had returned the survey and prompt those who had not yet returned the questionnaire. Six weeks after the initial mail-out, potential participants who had still not returned a survey were sent a replacement survey package. No further follow-up at baseline was permitted by the NDSS.

In order to minimise non-response for subsequent annual data collection waves, in addition to the thank you/reminder letter and targeted replacement survey mail-outs, targeted reminder letters are sent to those participants who have still not returned a survey 3 weeks after the replacement survey mail-out (i.e. 9 weeks after the initial mail-out). In 2010, due to concerns about the retention rate, targeted reminder telephone calls were also made to those participants who had still not returned a survey after the replacement surveys were sent out.

In order to further maximise retention of cohort participants following recruitment, a range of additional strategies and procedures are also used. For the annual follow-up data collections, all participants are sent a small incentive with the questionnaire (e.g. $1 'scratch-it' ticket in 2009 and a pen in 2010), and those who return the questionnaire go into a draw to win one of five $1,000 cash prizes. Other strategies include recording the contact details of two alternative contacts for each participant at baseline to assist with tracking; a study website and freecall 1800 number which allows people to update their contact details; biannual study newsletters for participants providing study findings as well as a reminder to update contact details; the inclusion of study synopses in relevant consumer-based organisations' newsletters; and a reminder package, which includes a postage-paid change of address card, sent 4 weeks before the annual survey mail-out.

A participant tracking system involves contacting alternative contacts for participants whose survey packages are 'returned to sender' (RTS) or who are unable to be contacted by telephone during follow-up. If no alternative contacts have been provided an online electronic phonebook is used in an attempt to track the participants. Data linkage to Australia's National Death Index (NDI) occurs annually prior to each data collection to identify deceased LWDS participants.

Response rates

The participation rate at baseline was 29% after notified deaths and RTS were omitted (5.6%; n = 813). A study flow chart is presented in Figure 1 . The retention rate in 2009 was 88% after notified deaths and RTS were omitted from calculations. This figure was 86% for the 2010 data collection.

Flow chart of study design and response rates .

Participants versus non-participants

A previous analysis, using aggregated data provided by NDSS, compared the study's participants with non-participants, as well as the study's participants with all other NDSS registrants in Queensland including those who on their NDSS registration form did not consent to research participation [ 28 ]. The findings showed that participants were more likely than non-participants to be aged 50 to 69 years and to be non-indigenous Australians (see Table 1 ). The analyses comparing study participants with the broader population of NDSS registrants showed that the study's participants were more likely than NDSS registrants to be male, aged 50-69 years, be recently registered with the NDSS scheme and be non-indigenous Australians. In addition, there was an underrepresentation of patients with type 1 diabetes among study participants (4.8%) compared to NDSS registrants (14.5%).

Measures and instruments

The study collects information on a range of issues, including the primary outcomes of interest--quality of life and quality of care. Clinical outcomes such as the onset of diabetes complications and HbA1c are also measured. An overview of the components of the survey is provided in Table 2 . Information relating to 347 primary variables was collected in the 2008 LWDS questionnaire. A copy of the questionnaire is available from the authors on request or can be downloaded from the study's website at http://www.lwds.org.au .

The NDI will be used to identify premature deaths, and cause of death data will be accessed at the completion of the study. In addition, a proposed data linkage to Australia's Medical Benefits Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS) has also gained ethics approval and will provide information about individual participant's use of government subsidised health services and medications. Access to these administrative data will not only provide information to verify self-report health care utilisation data, but will also allow for more detailed examination of the timing of services and health outcomes.

Main outcomes of interest

Health-related quality of life.

The EQ-5D, developed by the EuroQoL Group, is widely used in clinical trials, observational studies and health surveys, and has been translated into most major languages [ 35 , 48 ]. The measure includes a descriptive system comprising five dimensions and a visual analogue scale. The dimensions measured are: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. To complete the visual analogue scale respondents are asked to rate their current health status on a scale from 0 to 100, where 0 is the worst imaginable health and 100 is the best imaginable health. The EQ-5D also provides a preference-based utility index where responses are converted to a single weighted score. This gives a possible 243 health states, 245 when unconscious and dead are included. An EQ-5D score of 1 corresponds to perfect health; 0 to indifference between death and living; and, any numbers less than 0 to a state where death is preferred.

Diabetes-specific quality of life

The ADDQoL consists of two overview items; one measures generic overall quality of life and the second measures the specific impact of diabetes on quality of life. A further 19 domains concerned with the impact of diabetes on specific aspects of life are also measured. Participants are asked to rate the impact of diabetes on each domain and the importance of the domain for their quality of life. These two scores are then multiplied to yield a weighted impact score for each domain (range -9 to +3). Finally, an average weighted impact score is then calculated for the entire scale.

Quality of care

Respondents completed the Patient Assessment of Chronic Illness Care (PACIC), which measures the extent to which patients report receiving care that is consistent with the dimensions of the Chronic Care Model (CCM) [ 49 ]. The PACIC consists of 20 items with each item scored using a five point scale, ranging from 1 being none of the time to 5 being always. The items aggregate into five sub-scales that align with the dimensions of the CCM: patient activation, delivery system design/decision support, goal setting/tailoring, problem solving/contextual, and follow-up/coordination. Patient activation assesses the extent to which the patient was motivated and supported by the physician to initiate changes. Delivery system design/decision support assesses the degree to which the patient was supported (e.g. by information sheets), and how satisfied the patient was with the organisation of that care. Goal setting/tailoring assesses to what extent general instructions and suggestions were adapted to the patient's personal situation. Problem solving/contextual addresses how the physician dealt with problems which interfered with achieving predefined goals. Finally, follow-up/coordination addresses how frequently and consistently the care process was followed-up. Each sub-scale is scored by averaging across the items within that sub-scale, with an overall PACIC score obtained by averaging across all 20 items. Higher scores indicate higher quality care.

To provide another measure of quality of care, participants completed a series of purpose-designed quality indicators based on specific aspects of care recommended in the Australian Diabetes Management in General Practice guidelines [ 42 ], by indicating whether a member of their medical team had undertaken the care activity in the preceding 12 months.

Ethics approval for the study was granted by the University of Queensland's Behavioural and Social Sciences Ethical Review Committee. Written informed consent was obtained from all individuals followed over time. Consent forms are removed from returned surveys and stored in a locked filing cabinet.

Data management and statistical analyses

After entry, data is both manually and statistically checked during the data-cleaning process. Data are verified against the returned surveys when necessary. Electronic scanned copies of all original surveys are kept on file in a password-protected data file while hard copies are destroyed.

Initially, descriptive statistics are calculated for all variables. Where appropriate proportions are weighted to adjust for the oversampling, and unweighted sample sizes and weighted percentages are reported. Change over the follow-up period will be assessed using generalised estimating equations (GEE), which will allow for the best use of all data collected as GEEs do not require balanced data sets. Using GEEs will allow the data of all individual participants to be included in analyses, irrespective of the level of questionnaire completion.

The exact final method of analysis will be outcome-dependent. However, as a rule all associations will be assessed in the following stepwise manner: (a) univariate analysis: only adding the specific independent variable to the model; (b) a multivariate model to establish the significant associations; (c) adjusting for age, gender and socio-economic indicators to explore potential confounding factors; and (d) the addition of potential effect-modifiers by using interaction terms wherever necessary.

Baseline characteristics of the sample

Baseline socio-demographic characteristics of the sample are presented in Table 3 for the purpose of assessing the potential generalisability of the findings to Australians with diabetes. Fifty-five percent of the research participants were male. Participants' age ranged from 18 to 94 years. The overall mean age was 61.4 years (SD = 12.1). Educational status varied; 13.4% of participants had completed university study, while almost half (46.5%) reported education to grade 10 (i.e. junior certificate) or lower. A large proportion of the sample (44.5%) was retired. Only 1.8% of the study population reported being of Indigenous origin. Almost two thirds of participants live in households earning less than $60,000 (AUD) per annum, while 30.6% of LWDS households earned less than $20,000 (AUD) per annum. 62.0% of LWDS participants reported that they hold a health care card which provides access to subsidised health care.

Baseline medical and lifestyle characteristics of the LWDS sample are summarised in Table 4 . The median duration of time since receiving a diagnosis of diabetes was 5 years and the mean was 6 years (range: less than 1 year to 50 years). Overall, 83% of participants reported being diagnosed within the past 8 years, with more than half (69.7%) managing their diabetes with oral hypoglycaemic drugs. Approximately one out of five participants was insulin requiring. Erectile dysfunction was the most commonly reported diabetes complication among men (41.4%), followed by diabetes related eye disease (e.g. retinopathy, cataracts, glaucoma), which was the highest among women. Overall, one in ten LWDS participants smoked daily. More than four out of five participants were overweight, with half being obese or morbidly obese.

Given established differences between males and females on several factors with likely implications for intervention, Table 4 also presents medical and lifestyle characteristics stratified by gender. Sub-group analysis by gender showed no significant differences for the diabetes-specific characteristics such as type of diabetes, length of diagnosis or HbA1c levels. However, gender specific differences were observed for several diabetes complications: including foot ulcers, cardiovascular disease and stroke. In addition, females were more likely than males to report co-morbid depressive symptomatology. With the exception of current smokers, statistically significant gender differences were observed for each of the health risk behaviours, including body mass index (BMI).

This paper describes the study rationale and procedures for the LWDS and reports the baseline characteristics of a cohort of 3951 people with diabetes. The approach of the LWDS differs from other national and international studies of diabetes in its focus on examining the natural trajectory of diabetes and its treatment from a psychosocial perspective. It is hoped that this will lead to a greater understanding of how to improve the life and quality of care of people with diabetes. The large cohort will allow for the undertaking of multivariate statistical analyses, and the longitudinal nature of the data enables the investigation of temporal effects.

Wherever possible standardised scales and questions were used in the LWDS questionnaire to measure the domains of interest. We relied on previous health services research and psychosocial research to select measures sensitive to change and with adequate face, content and construct validity. The importance of distinguishing between health-related quality of life and disease-specific quality of life has been highlighted by previous researchers [ 11 , 50 ]. On this basis, both are measured in the LWDS. Health-related quality of life measures a patient's symptoms and functioning. The EQ-5D is one of the most widely used preference-based measures of health-related quality of life [ 51 ]. Disease-specific quality of life, which captures the broader multidimensional, subjective and dynamic features of quality of life, relates more specifically to a person's perception of how a specific disease has impacted on their life [ 52 ]. Disease-specific measurement instruments include those aspects of life considered to be the most important by patients and clinicians resulting in a more detailed assessment of the issues and concerns relevant to the specific disease, its treatments and complications [ 13 , 37 , 53 ]. Several recent reviews of diabetes-specific quality of life instruments conclude that there is good evidence that the ADDQoL, used in the LWDS, is a reliable measure of disease-specific quality of life with good face and content validity [ 52 – 55 ]. A recent assessment of 37 measures of patient-assessed quality of care designed for use with people with chronic illness found the PACIC, used in the LWDS, to be the most appropriate as determined by its psychometric properties and perceived applicability and relevance [ 41 ]. The inclusion of these self-reported patient assessments of quality of life and quality of care will allow for the reliable assessment of the impact that the progression of diabetes has on these important health and well-being outcomes.

The LWDS study has the inherent limitations of self-report surveys. The reliability and validity of self-report health measures varies across behaviours and outcomes. Self-reported health service utilisation data is subject to recall bias and underreporting, especially for older adults and frequent users of primary care [ 56 , 57 ]. Cross-referencing the self-report service utilisation data with MBS data will improve the reliability and validity of this information. Self-report data on health information, such as co-morbidities, has been found to be of variable quality, but is generally satisfactory for well-known conditions [ 58 , 59 ]. Previous research has found a positive, albeit weak, correlation between self-reported HbA1c values and medical record data [ 60 ]. Self-report of treatment types including oral agents and insulin use are generally valid [ 61 ].

While recruitment at baseline was slightly lower than anticipated, it is similar to that of other studies of this nature [ 62 ] and is consistent with research showing that participation rates in large cohort studies appear to be decreasing. It is estimated that rates have declined from about 80% to 30% or 40% over the past several decades [ 63 ]. Effective participant retention is vital to the success of the LWDS and we have instituted an anti-attrition strategy to ensure as many cohort members as possible remain in the study. Past research suggests that the attrition in follow-up for postal surveys can be decreased by the provision of a monetary incentive such as a lottery ticket or a prize [ 64 ], with the magnitude less important than an incentive per se [ 65 ]. Although losses to follow-up are inevitable, the study's comprehensive retention strategy to date has been successful in limiting participant drop-out. However, it is possible that those individuals whose health deteriorates more markedly over time will discontinue study participation, biasing findings towards healthier participants.

Use of a national disease register with high coverage of the target population in the recruitment process has been effective for enrolling a large representative sample of people with diabetes, covering a broad range of socio-demographic and clinical characteristics. Specifically, the proportion of males was consistent with estimates provided by Australia's National Health Survey that 56% of Australians with diabetes are male [ 2 ]. The large proportion of LWDS participants with low levels of educational attainment is not unexpected given the older age distribution of the sample. Similarly, it is unsurprising that a large proportion of the sample (44.3%) was retired and one in 15 reported being unable to work.

In 2005-06 the average gross annual household income in Australia was around $68,000 (AUD) [ 66 ]. While it is difficult to make direct comparisons based on the income brackets used in the LWDS, the finding that 73.7% of participants live in households earning less than $60,000 (AUD) per annum indicates that overall the sample are more economically disadvantaged than the general population of Australians. This differential is consistent with what would be expected given the previously reported relationship between low socio-economic status and prevalence of diabetes [ 67 , 68 ] as well as the high levels of retirement among the LWDS participants.

A similar pattern holds for health concession cards. In Australia low income is one of the criteria for eligibility for a government health concession card. Possession of the card can significantly reduce the out-of-pocket expenses for consumers through subsidised medical care, hospital treatment and some medications. Australia's 2004-05 National Health Survey reported 35% of persons 15 years and over were covered by a government health card, a figure considerably lower than the 62.0% of LWDS participants reporting that they hold a health care card. The higher LWDS proportion will most likely be accounted for by the older age and poorer health status of people with diabetes.

Another area in which the study is not representative of the general population relates to the proportion of Indigenous Australians. Research shows that diabetes is more common among Indigenous Australians [ 69 ] than among their non-Indigenous counterparts. However, with census data showing that 2.5% of the Australian population report an Indigenous background [ 70 ] and only 1.8% of the study population reporting that they are of Indigenous origin the LWDS cannot be generalised to this population.

Less than one in 20 LWDS participants relied on diet alone as the treatment pathway for their diabetes. Previous researchers have suggested that people managing their diabetes through diet and exercise alone may not have a high level of need for the NDSS's services and would therefore be less likely to register with the scheme [ 26 ]. Our findings support this assumption. Less than 5% of the LWDS sample reported having a diagnosis of type 1 diabetes. The true prevalence of type 1 diabetes in Australia is estimated to be approximately 10% [ 2 ]. The underrepresentation of patients with type 1 diabetes is attributed to the lower likelihood of NDSS registrants with type 1 diabetes consenting to participate in research as there is not systematic updating of research consent status at the age of 18 among those registered as a child [ 28 ]. We acknowledge this as a weakness of the LWDS with implications for the generalisability of the study to people with type 1 diabetes. Future analyses of the data will stratify by diabetes type.

On the other hand, the diabetes complications reported by the LWDS participants at baseline were very much in keeping with the available Australian statistics for the Australian diabetic population as a whole [ 71 ]. For example, 2.1% of respondents reported having foot ulcers, with the available comparable figure for the entire Australian diabetic population also 2.1%. Additionally, 6.2% of the sample, compared to 6.3% of the Australian diabetic population, reported kidney disease; 5.1% of the sample compared to 5.0% of the Australian diabetic population reported having had a stroke; 8.8% of the sample versus 8.6% of the Australian diabetic population reported neuropathy; and 41.4% of men on the study reported erectile dysfunction as a complication, while 30.2% of the general male diabetic population had the same complaint. The discrepancy for erectile dysfunction may stem from the differing data collection methods used to obtain the estimates.

Lifestyle changes constitute an important aspect of the management of diabetes, in particular type 2 diabetes. For example, obesity in those with type 2 diabetes complicates management of the disease by increasing insulin resistance and with that, blood glucose concentrations. This however, is reversible, such that weight loss of just 5% of body weight may improve insulin sensitivity and glycaemic control [ 72 , 73 ]. Research undertaken with US adults found that those with diabetes were more likely to be physically inactive (61%) than those without diabetes (42%) [ 74 ]. Recent comparable physical activity rates for the Australian general population are not available. We can however compare the LWDS with the Australian Diabetes, Obesity and Lifestyle Study (AusDiab) conducted in1999 -2000 which found that 59.3% of Australians with diabetes were insufficiently active [ 75 ], which is higher than the 50.7% found for the LWDS sample. Recent suggestions of a trend towards increased levels of physical activity among Australians may explain the difference [ 76 ]. It is well established that on average people with diabetes are more likely to be overweight than people without diabetes. Both the LWDS and the AusDiab study [ 71 ] found that approximately four out of five diabetic patients are overweight or obese. The baseline estimates for health risk behaviours for participants of the LWDS suggest that there is considerable scope for behavioural lifestyle modification among Australians with diabetes.

The wide range of information collected from the LWDS participants allows for an in-depth exploration of the multidimensional nature of diabetes. The availability of longitudinal data allows the LWDS to contribute towards a deeper understanding of the dynamics of living with diabetes; and to build complex psychosocial models of the determinants of disease progression, quality of life and models of patients' assessments of the quality of their care. This will allow for the identification of key targets for intervention strategies, and will contribute to public health policy, especially as it relates to resource allocation and planning.

Shaw JE, Sicree RA, Zimmet PZ: Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010, 87 (1): 4-14. 10.1016/j.diabres.2009.10.007.

Article   CAS   PubMed   Google Scholar  

AIHW: Diabetes prevalence in Australia: Detailed estimates for 2007-08. Diabetes Series No 17 Cat no CVD 56. 2011, Canberra: Australian Institute of Health and Welfare

Google Scholar  

Cameron AJ, Welborn TA, Zimmet PZ, Dunstan DW, Owen N, Salmon J, Dalton M, Jolley D, Shaw JE: Overweight and obesity in Australia: the 1999-2000 Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Medical Journal of Australia. 2003, 178 (9): 427-432.

PubMed   Google Scholar  

Magliano DJ, Peeters A, Vos T, Sicree R, Shaw J, Sindall C, Haby M, Begg SJ, Zimmet PZ: Projecting the burden of diabetes in Australia--what is the size of the matter?. Aust New Zealand J Public Health. 2009, 33 (6): 540-543. 10.1111/j.1753-6405.2009.00450.x.

Article   Google Scholar  

Chittleborough CR, Grant JF, Phillips PJ, Taylor AW: The increasing prevalence of diabetes in South Australia: the relationship with population ageing and obesity. Public Health. 2007, 121 (2): 92-99. 10.1016/j.puhe.2006.09.017.

Wandell PE, Brorsson B, Aberg H: Psychic and socioeconomic consequences with diabetes compared to other chronic conditions. Scand J Public Health. 1997, 25 (1): 39-43. 10.1177/140349489702500109.

Article   CAS   Google Scholar  

Rubin RR, Peyrot M: Psychological issues and treatments for people with diabetes. J Clin Psychol. 2001, 57 (4): 457-478. 10.1002/jclp.1041.

Glasgow RE, Funnell MM, Bonomi AE, Davis C, Beckham V, Wagner EH: Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams. Ann Behav Med. 2002, 24: 80-87. 10.1207/S15324796ABM2402_04.

Article   PubMed   Google Scholar  

Bodenheimer T, Wagner EH, Grumbach K: Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002, 288 (15): 1909-1914. 10.1001/jama.288.15.1909.

Devlin N, Appleby J: Getting the most out of PROMS: putting health outcomes at the heart of NHS decision-making. 2010, London, United Kingdom: The King's Fund

Sundaram M, Kavookjian J, Patrick JH: Health-related quality of life and quality of life in type 2 diabetes: relationships in a cross-sectional study. The Patient: Patient-Centered Outcomes Res. 2009, 2 (2): 121-133. 10.2165/01312067-200902020-00008.

Rosenthal GE, Shannon SE: The Use of patient perceptions in the evaluation of health-care delivery systems. Med Care. 1997, 35 (11): NS58-NS68.

CAS   PubMed   Google Scholar  

Rubin RR, Peyrot M: Quality of life and diabetes. Diabetes Metab Res Rev. 1999, 15 (3): 205-218. 10.1002/(SICI)1520-7560(199905/06)15:3<205::AID-DMRR29>3.0.CO;2-O.

Leplege A, Hunt S: The problem of quality of life in medicine. JAMA. 1997, 278 (1): 47-50. 10.1001/jama.1997.03550010061041.

Hibbard JH, Mahoney ER, Stock R, Tusler M: Do increases in patient activation result in improved self-management behaviors?. Health Serv Res. 2007, 42 (4): 1443-1463. 10.1111/j.1475-6773.2006.00669.x.

Article   PubMed   PubMed Central   Google Scholar  

Mosen DM, Schmittdiel J, Hibbard JH, Sobel D, Remmers C, Bellows J: Is patient activation associated with outcomes of care for adults with chronic conditions?. J Ambulatory Care Manage. 2007, 30 (1): 21-29.

Hibbard JH, Cunningham J: HOW engaged are Consumers in their Health and Health Care, and Why Does it Matter?. 2008, October. Washington: Center for Studying Health System Change, 8:

Griffiths F, Anto N, Chow E, Manazar U, Van Royen P, Bastiaens H: Understanding the diversity and dynamics of living with diabetes: a feasibility study focusing on the case. Chronic Illn. 2007, 3 (1): 29-45. 10.1177/1742395307079194.

Paterson BL, Thorne S, Dewis M: Adapting to and managing diabetes. J Nurs Scholarsh. 1998, 30 (1): 57-62. 10.1111/j.1547-5069.1998.tb01237.x.

Koopmanschap M: Coping with type II diabetes: the patient's perspective. Diabetologia. 2002, 45: S18-S22.

Wexler D, Grant R, Wittenberg E, Bosch J, Cagliero E, Delahanty L: Correlates of health-related quality of life in type 2 diabetes. Diabetologia. 2006, 49: 1489-1497. 10.1007/s00125-006-0249-9.

Ringborg A, Martinell M, Stålhammar J, Yin DD, Lindgren P: Resource use and costs of type 2 diabetes in Sweden--estimates from population-based register data. Int J Clin Pract. 2008, 62 (5): 708-716. 10.1111/j.1742-1241.2008.01716.x.

Tomlin AM, Tilyard MW, Dovey SM, Dawson AG: Hospital admissions in diabetic and non-diabetic patients: a case-control study. Diabetes Res Clin Pract. 2006, 73 (3): 260-267. 10.1016/j.diabres.2006.01.008.

Diabetes Prevention Program Research Group: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002, 346 (6): 393-403.

Article   PubMed Central   Google Scholar  

Stratton IM, Adler AI, Neil HAW, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR: Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000, 321 (7258): 405-412. 10.1136/bmj.321.7258.405.

Article   CAS   PubMed   PubMed Central   Google Scholar  

AIHW: Diabetes Prevalence in Australia: An Assessment of National Data Sources. 2009, Canberra: Australian Institute of Health and Welfare

Johnson JA, Coons SJ: Comparison of the EQ-5D and SF-12 in an adult U.S. sample. Quality Life Res. 1998, 7 (2): 155-166. 10.1023/A:1008809610703.

David M, Ware R, Donald M, Alati R: Assessing generalisability through the use of disease registers: findings from a diabetes cohort study. BMJ Open. 2011, 1:

National Health and Medical Research Council: Dietary guidelines for Australian adults. Edited by: NHMRC. 2003, Canberra: National Health and Medical Research Council

AIHW: Statistics on Drug Use in Australia 2006. 2007, Canberra: Australian Institute of Health and Welfare

National Health and Medical Research Council: Australian guidelines to reduce health risks from drinking alcohol. 2009, Canberra: Commonwealth of Australia

AIHW: The active Australia survey. 2003, Canberra: Australian Institute of Health and Welfare

Commonwealth Department of Health and Aged Care: National physical activity guidelines for Australians. 1999, Canberra: Department of Health and Aged Care

WHO: Obesity: Preventing and Managing the Global Epidemic. 2000, Geneva: World Health Organization

Rabin R, de Charro F: EQ-5D: a measure of health status from the EuroQol group. Annals Med. 2001, 33 (5): 337-343. 10.3109/07853890109002087.

Bradley C, Todd C, Gorton T, Symonds E, Martin A, Plowright R: The development of an individualised questionnaire measure of perceived impact of diabetes on quality of life: the ADDQoL. Quality Life Res. 1999, 8: 79-91.

Bradley C, Speight J: Patient perceptions of diabetes and diabetes therapy: assessing quality of life. Diabetes Metab Res Rev. 2002, 18: S64-S69. 10.1002/dmrr.279.

Hibbard JH, Stockard J, Mahoney ER, Tusler M: Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004, 39 (4): 1005-1026. 10.1111/j.1475-6773.2004.00269.x.

Toobert DJ, Glasgow RE: Assessing diabetes self-management: the summary of diabetes self-care activities questionnaire. Handbook of Psychology and Diabetes: A Guide to Psychological Measurment in Diabetes Research and Practice. Edited by: Bradley C. 1994, Chur, Switzerland: Harwood Academic, 351-375.

Glasgow RE, Strycker LA, Toobert DJ, Eakin E: A social-ecologic approach to assessing support for disease self-management: the chronic illness resources survey. J Behavioral Med. 2000, 23 (6): 559-583. 10.1023/A:1005507603901.

Glasgow RE, Wagner EH, Schaefer J, Mahoney LD, Reid RJ, Greene SA: Development and validation of the Patient Assessment of Chronic Illness Care (PACIC). Med Care. 2005, 43 (5): 436-444. 10.1097/01.mlr.0000160375.47920.8c.

Diabetes Australia: Diabetes management in general practice: guidelines for Type 2 diabetes. 2007, Canberra: Diabetes Australia

Radloff LS: The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977, 1 (3): 385-401. 10.1177/014662167700100306.

Scheier MF, Carver CS, Bridges MW: Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a re-evaluation of the life orientation test. J Personality Social Psychology. 1994, 67: 1063-1078.

Mitchell P, Powell L, Blumenthal J, Norten J, Ironson G, Pitula CR, Froelicher ES, Czajkowski S, Youngblood M, Huber M, et al: A short social support measure for patients recovering from myocardial infarction: the ENRICHD social support inventory. J Cardiopulmonary Rehabilitation. 2003, 23 (6): 398-403. 10.1097/00008483-200311000-00001.

ABS: National health survey: users' guide--electronic publication, Australia 2004-05, Cat. No. 4363.0.55.001. 2006, Canberra: Australian Bureau of Statistics

Rehm J, Greenfield TK, Walsh G, Xie X, Robson L, Single E: Assessment methods for alcohol consumption, prevalence of high risk drinking and harm: a sensitivity analysis. Int J Epidemiol. 1999, 28: 219-244. 10.1093/ije/28.2.219.

Cheung K, Oemar M, Oppe M, Rabin R: EQ-5D User Guide: Basic Information on how to Use the EQ-5D. Version 2.0. 2009, Rotterdam: EuroQoL Group

Wagner EH: Chronic disease management: what will it take to improve care for chronic illness?. Eff Clin Pract. 1998, 1 (1): 2-4.

Bradley C: Importance of differentiating health status from quality of life. Lancet. 2001, 357 (9249): 7-8. 10.1016/S0140-6736(00)03562-5.

Tsuchiya A, Brazier J, Roberts J: Comparison of valuation methods used to generate the EQ-5D and the SF-6D value sets. J Health Econ. 2006, 25 (2): 334-346. 10.1016/j.jhealeco.2005.09.003.

Speight J, Reaney MD, Barnard KD: Not all roads lead to Rome--a review of quality of life measurement in adults with diabetes. Diabetic Med. 2009, 26 (4): 315-327. 10.1111/j.1464-5491.2009.02682.x.

El Achhab Y, Nejjari C, Chikri M, Lyoussi B: Disease-specific health-related quality of life instruments among adults diabetic: a systematic review. Diabetes Res Clin Pract. 2008, 80 (2): 171-184. 10.1016/j.diabres.2007.12.020.

Garratt AM, Schmidt L, Fitzpatrick R: Patient-assessed health outcome measures for diabetes: a structured review. Diabetic Med. 2002, 19 (1): 1-11. 10.1046/j.1464-5491.2002.00650.x.

Ostini R, Dower J, Donald M: The Audit of Diabetes Dependent Quality of Life 19 (ADDQoL): feasibility, reliability and validity in a population based sample of Australian adults. Quality life Res. 2011, DOI:10.1007/s11136-011-0043-0

Wallihan DB, Stump TE, Callahan CM: accuracy of self-reported health services use and patterns of care among urban older adults. Med Care. 1999, 37 (7): 662-670. 10.1097/00005650-199907000-00006.

Roberts RO, Bergstralh EJ, Schmidt L, Jacobsen SJ: Comparison of self-reported and medical record health care utilization measures. J Clin Epidemiol. 1996, 49 (9): 989-995. 10.1016/0895-4356(96)00143-6.

Martin LM, Leff M, Calonge N, Garrett C, Nelson DE: Validation of self-reported chronic conditions and health services in a managed care population. Am J Preventive Med. 2000, 18 (3): 215-218. 10.1016/S0749-3797(99)00158-0.

Bergmann MM, Byers T, Freedman DS, Mokdad A: Validity of self-reported diagnoses leading to hospitalization: a comparison of self-reports with hospital records in a prospective study of American adults. Am J Epidemiol. 1998, 147 (10): 969-977.

Harwell TS, Dettori N, McDowall JM, Quesenberry K, Priest L, Butcher MK, Flook BN, Helgerson SD, Gohdes D: Do persons with diabetes know their (AIC) number?. Diabetes Educator. 2002, 28 (1): 99-105. 10.1177/014572170202800111.

Fowles J, Rosheim K, Fowler E, Craft C, Arrichiello L: The validity of self-reported diabetes quality of care measures. Int J Qual Health Care. 1999, 11 (5): 407-412. 10.1093/intqhc/11.5.407.

Dunstan DW, Zimmet PZ, Welborn TA, Cameron AJ, Shaw J, de Courten M, Jolley D, McCarty DJ: The Australian diabetes, obesity and lifestyle study (AusDiab)--methods and response rates. Diabetes Res Clin Pract. 2002, 57 (2): 119-129. 10.1016/S0168-8227(02)00025-6.

Nohr EA, Frydenberg M, Henriksen TB, Olsen J: Does low participation in cohort studies induce bias?. Epidemiology. 2006, 17 (4): 413-418. 10.1097/01.ede.0000220549.14177.60.

Edwards P, Roberts I, Clark M, Di Guiseppi C, Pratap S, Wentz R, Kwan I: Increasing response rates to postal questionnaires: systematic review. Br Med J. 2002, 324: 1183-1191. 10.1136/bmj.324.7347.1183.

VanGeest J, Wynia M, Cummins D, Wilson I: Effects of different money incentives on the return rate of a national mail survey of physicians. Med Care. 2001, 39: 197-201. 10.1097/00005650-200102000-00010.

Australian Government: Families in Australia: 2008. 2008, Cabinet DotPMa. Canberra

Connolly V, Unwin N, Sherriff P, Bilous R, Kelly W: Diabetes prevalence and socioeconomic status: a population based study showing increased prevalence of type 2 diabetes mellitus in deprived areas. J Epidemiol Community Health. 2000, 54 (3): 173-177. 10.1136/jech.54.3.173.

Geiss LS, Cowie CC: Type 2 diabetes and persons at high risk of diabetes. Diabetes Public Health. 2010, 1: 15-33.

Daniel M, Rowley KG, McDermott R, Mylvaganam A, O'Dea K: Diabetes incidence in an Australian aboriginal population. An 8-year follow-up study. Diabetes Care. 1999, 22 (12): 1993-1998. 10.2337/diacare.22.12.1993.

Australian Bureau of Statistics: Population distribution, aboriginal and torres strait islander Australians, 2006. 2007, Canberra: Australian Bureau of Statistics

AIHW: Diabetes: Australian Facts 2008. 2008, Canberra: AIHW

Klein S, Sheard NF, Pi-Sunyer X, Daly A, Wylie-Rosett J, Kulkarni K, Clark NG: Weight management through lifestyle modification for the prevention and management of type 2 diabetes: Rationale and strategies. Diabetes Care. 2004, 27 (8): 2067-2073. 10.2337/diacare.27.8.2067.

Nathan DM, Buse JB, Davidson MB, Heine RJ, Holman RR, Sherwin R, Zinman B: Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. Diabetes Care. 2006, 29 (8): 1963-1972. 10.2337/dc06-9912.

Morrato EH, Hill JO, Wyatt HR, Ghushchyan V, Sullivan PW: Physical activity in U.S. adults with diabetes and at risk for developing diabetes, 2003. Diabetes Care. 2007, 30 (2): 203-209. 10.2337/dc06-1128.

Magliano DJ, Barr ELM, Zimmet PZ, Cameron AJ, Dunstan DW, Colagiuri S, Jolley D, Owen N, Phillips P, Tapp RJ, et al: Glucose indices, health behaviors, and incidence of diabetes in Australia: the Australian diabetes, obesity and lifestyle study. Diabetes Care. 2008, 31 (2): 267-272.

Vandelanotte C, Duncan MJ, Caperchione C, Hanley C, Mummery WK: Physical activity trends in Queensland (2002 to 2008): are women becoming more active than men?. Aust New Zealand J Public Health. 2010, 34 (3): 248-254. 10.1111/j.1753-6405.2010.00521.x.

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MD made a substantial contribution to the conception and design of the study as well as interpretation of the data and was involved in drafting the manuscript. JD contributed to the interpretation of the data and was involved in drafting the manuscript. RW supervised the statistical analyses and was involved in drafting the manuscript. BM contributed to interpretation of the data and was involved in drafting the manuscript. SP performed the statistical analysis and was involved in drafting the manuscript. CB contributed to the conception of the study and was involved in revising the intellectual content of the manuscript. All authors read and approved the final manuscript.

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Donald, M., Dower, J., Ware, R. et al. Living with diabetes: rationale, study design and baseline characteristics for an Australian prospective cohort study. BMC Public Health 12 , 8 (2012). https://doi.org/10.1186/1471-2458-12-8

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357 Diabetes Essay Topics & Examples

When you write about the science behind nutrition, heart diseases, and alternative medicine, checking titles for diabetes research papers can be quite beneficial. Below, our experts have gathered original ideas and examples for the task.

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⭐ most interesting diabetes research paper topics, ✅ simple & easy diabetes essay topics, 🎓 good research topics about diabetes, 💡 interesting topics to write about diabetes, 👍 good essay topics on diabetes, ❓ diabetes research question examples.

• Type 2 Diabetes The two major types of diabetes are type 1 diabetes and type 2 diabetes. Doctor: The first step in the treatment of type 2 diabetes is consumption of healthy diet.
• Adult-Onset Type 2 Diabetes: Patient’s Profile Any immediate care as well as post-discharge treatment should be explained in the best manner possible that is accessible and understandable to the patient.
• Living With a Chronic Disease: Diabetes and Asthma This paper will look at the main effects of chronic diseases in the lifestyle of the individuals and analyze the causes and the preventive measures of diabetes as a chronic disease.
• Leadership in Diabetes Management Nurses can collaborate and apply evidence-based strategies to empower their diabetic patients. The involvement of all key stakeholders is also necessary.
• Diabetes in Adults in Oxfordshire On a national level, Diabetes Research and Wellness Foundation aims to prevent the spread of the decease through research of the causes and effective treatment of diabetes 2 type.
• Case Study of Patient with DKA and Diabetes Mellitus It is manifested by a sharp increase in glucose levels and the concentration of ketone bodies in the blood, their appearance in the urine, regardless of the degree of violation of the patient’s consciousness.
• Intervention Methods for Type 2 Diabetes Mellitus An individual should maintain a regulated glycemic control using the tenets of self-management to reduce the possibility of complications related to diabetes.
• Relation Between Diabetes And Nutrition Any efforts to lessen and eliminate the risk of developing diabetes must involve the dietary habit of limiting the consumption of carbohydrates, sugar, and fats. According to Belfort-DeAguiar and Dongju, the three factors of obesity, […]
• Diabetes Mellitus: Symptoms, Types, Effects Insulin is the hormone that controls the levels of glucose in the blood, and when the pancreas releases it, immediately the high levels are controlled, like after a meal.
• Health Promotion: Diabetes Mellitus and Comorbidities This offers a unique challenge in the management of diabetes and other chronic diseases; the fragmented healthcare system that is geared towards management of short-term medical emergencies often is not well prepared for the patient […]
• Type 2 Diabetes as a Public Health Issue In recent years, a steady increase in the incidence and prevalence of diabetes is observed in almost all countries of the world.
• Diabetes Management: Case Study Type 1 and Type 2 diabetes contrast based on their definitions, the causes, and the management of the conditions. Since the CDC promotes the avoidance of saturated fat and the increase of fiber intake for […]
• Diabetes Mellitus Management in the Elderly Diabetes mellitus is a health complication involving an increase in the concentration in the concentration of blood sugar either due to a failure by cells to effectively respond to the production of insulin in the […]
• A Study of Juvenile Type 1 Diabetes in the Northwest of England The total number of children under seventeen years living with type 1 diabetes in North West England by 2009 was 2,630.
• Diabetes Prevention: The Sanofi-Aventis Leaflet Review Using the Flesh formula, it can be concluded that the leaflet has a good level of readability, but it can be improved in case it is shorter because a few sections of it are better […]
• Gestational Diabetes in a 38-Year-Old Woman The concept map, created to meet B.’s needs, considers her educational requirements and cultural and racial hurdles to recognize her risk factors and interventions to increase her adherence to the recommended course of treatment.B.said in […]
• Type 2 Diabetes Mellitus and Its Implications You call an ambulance and she is taken in to the ED. Background: Jean is still very active and works on the farm 3 days a week.
• Development of Comprehensive Inpatient and Outpatient Programs for Diabetes Overcoming the fiscal and resource utilization issues in the development of a comprehensive diabetes program is essential for the improvement of health and the reduction of treatment costs.
• Healthcare Cost Depending on Chronic Disease Management of Diabetes and Hypertension A sufficient level of process optimization and the presence of a professional treating staff in the necessary number will be able to help improve the indicators.
• Improving Glycemic Control in Black Patients with Type 2 Diabetes Information in them is critical for answering the question and supporting them with the data that might help to acquire an enhanced understanding of the issue under research. Finally, answering the PICOT question, it is […]
• Shared Decision-Making That Affects the Management of Diabetes The article by Peek et al.is a qualitative study investigating the phenomenon of shared decision-making that affects the management of diabetes. The researchers demonstrate the racial disparity that can arise in the choice of approaches […]
• Managing Obesity as a Strategy for Addressing Type 2 Diabetes When a patient, as in the case of Amanda, requires a quick solution to the existing problem, it is necessary to effectively evaluate all options in the shortest possible time.
• Tests and Screenings: Diabetes and Chronic Kidney Disease The test is offered to patients regardless of gender, while the age category is usually above 45 years. CDC1 recommends doing the test regardless of gender and is conducted once or twice to check the […]
• Obesity Management for the Treatment of Type 2 Diabetes American Diabetes Association states that for overweight and obese individuals with type 2 diabetes who are ready to lose weight, a 5% weight reduction diet, physical exercise, and behavioral counseling should be provided.
• COVID-19 and Diabetes Mellitus Lim et al, in their article, “COVID-19 and diabetes mellitus: from pathophysiology to clinical management”, explored how COVID-19 can worsen the symptoms of diabetes mellitus.
• The Importance of Physical Exercise in Diabetes II Patients The various activities help to improve blood sugar levels, reduce cardiovascular cases and promote the overall immunity of the patient. Subsequently, the aerobic part will help to promote muscle development and strengthen the bones.
• Diabetes Education Workflow Process Mapping DSN also introduces the patient to the roles of specialists involved in managing the condition, describes the patient’s actions, and offers the necessary educational materials.
• Diabetes: Treatment Complications and Adjustments One of the doctor’s main priorities is to check the compatibility of a patient’s medications. The prescriptions of other doctors need to be thoroughly checked and, if necessary, replaced with more appropriate medication.
• The Type 2 Diabetes Mellitus PICOT (Evidence-Based) Project Blood glucose levels, A1C, weight, and stress management are the parameters to indicate the adequacy of physical exercise in managing T2DM.
• Chronic Disease Cost Calculator (Diabetes) This paper aims at a thorough, detailed, and exhaustive explanation of such a chronic disease as diabetes in terms of the prevalence and cost of treatment in the United States and Maryland.
• Diabetes Mellitus Epidemiology Statistics This study entails a standard established observation order from the established starting time to an endpoint, in this case, the onset of disease, death, or the study’s end. It is crucial to state this value […]
• Epidemiology: Type II Diabetes in Hispanic Americans The prevalence of type II diabetes in Hispanic Americans is well-established, and the search for inexpensive prevention methods is in the limelight.
• Diabetes: Risk Factors and Effects Trends in improved medical care and the development of technology and medicine are certainly contributing to the reduction of the problem. All of the above indicates the seriousness of the problem of diabetes and insufficient […]
• Barriers to Engagement in Collaborative Care Treatment of Uncontrolled Diabetes The primary role of physicians, nurses, and other healthcare team members is to provide patients with medical treatment and coordinate that care while also working to keep costs down and expand access.
• Hereditary Diabetes Prevention With Lifestyle Modification Yeast infections between the fingers and toes, beneath the breast, and in or around the genital organs are the common symptoms of type 2 diabetes.
• Health Equity Regarding Type 2 Diabetes According to Tajkarimi, the number of research reports focusing on T2D’s prevalence and characteristics in underserved minorities in the U. Adapting the program’s toolkits to rural Americans’ eating and self-management habits could also be instrumental […]
• Diabetes Mellitus: Treatment Methods Moreover, according to the multiple findings conducted by Park et al, Billeter et al, and Tsilingiris et al, bariatric surgeries have a positive rate of sending diabetes into remission.
• Diagnosing Patient with Insulin-Dependent Diabetes The possible outcomes of the issues that can be achieved are discussing the violations with the patient’s family and convincing them to follow the medical regulations; convincing the girl’s family to leave her at the […]
• Human Service for Diabetes in Late Adulthood The mission of the Georgia Diabetic Foot Care Program is to make a positive difference in the health of persons living with diabetes.
• Diabetes: Symptoms and Risk Factors In terms of the problem, according to estimates, 415 million individuals worldwide had diabetes mellitus in 2015, and it is expected to rise to 642 million by the year 2040.
• Diabetes: Types and Management Diabetes is one of the most prevalent diseases in the United States caused when the body fails to optimally metabolize food into energy.
• Type 2 Diabetes’ Impact on Australian Society Consequently, the most significant impact of the disease is the increased number of deaths among the population which puts their lives in jeopardy. Further, other opportunistic diseases are on the rise lowering the quality of […]
• Epidemiology of Diabetes and Forecasted Trends The authors note that urbanization and the rapid development of economies of different countries are the main causes of diabetes. The authors warn that current diabetes strategies are not effective since the rate of the […]
• The Aboriginal Diabetes Initiative in Canada The ADI’s goal in the CDS was to raise type 2 diabetes awareness and lower the incidence of associated consequences among Aboriginal people.
• Communicating the Issue of Diabetes The example with a CGM sensor is meant to show that doctors should focus on educating people with diabetes on how to manage their condition and what to do in extreme situations.
• Obesity and Diabetes Mellitus Type 2 The goal is to define the features of patient information to provide data on the general course of the illness and its manifestations following the criteria of age, sex, BMI, and experimental data.
• The Prevention of Diabetes and Its Consequences on the Population At the same time, these findings can also be included in educational programs for people living with diabetes to warn them of the risks of fractures and prevent them.
• Uncontrolled Type 2 Diabetes and Depression Treatment The data synthesis demonstrates that carefully chosen depression and anxiety treatment is likely to result in better A1C outcomes for the patient on the condition that the treatment is regular and convenient for the patients.
• Type 2 Diabetes: Prevention and Education Schillinger et al.came to the same conclusion; thus, their findings on the study of the Bigger Picture campaign effectiveness among youth of color are necessary to explore diabetes prevention.
• A Diabetes Quantitative Article Analysis The article “Correlates of accelerometer-assessed physical activity and sedentary time among adults with type 2 diabetes” by Mathe et al.refers to the global issue of the prevention of diabetes and its complications.
• A Type 2 Diabetes Quantitative Article Critique Therefore, the main issue is the prevention of type 2 diabetes and its consequences, and this paper will examine one of the scientific studies that will be used for its exploration.
• The Diabetes Prevention Articles by Ford and Mathe The main goal of the researchers was to measure the baseline MVPA of participants and increase their activity to the recommended 150 minutes per week through their participation in the Diabetes Community Lifestyle Improvement Program.
• Type 2 Diabetes in Hispanic Americans The HP2020 objectives and the “who, where, and when” of the problem highlight the significance of developing new, focused, culturally sensitive T2D prevention programs for Hispanic Americans.
• Diabetes Mellitus as Problem in US Healthcare Simultaneously, insurance companies are interested in decreasing the incidence of diabetes to reduce the costs of testing, treatment, and provision of medicines.
• Diabetes Prevention as a Change Project All of these queries are relevant and demonstrate the importance of including people at high risk of acquiring diabetes in the intervention.
• Evidence Synthesis Assignment: Prevention of Diabetes and Its Complications The purpose of this research is to analyze and synthesize evidence of good quality from three quantitative research and three non-research sources to present the problem of diabetes and justify the intervention to address it.
• Diabetes Mellitus: Causes and Health Challenges Second, the nature of this problem is a clear indication of other medical concerns in this country, such as poor health objectives and strategies and absence of resources.
• Diabetes Mellitus (DM) Disorder Case Study Analysis Thus, informing the patient about the importance of regular medication intake, physical activity, and adherence to diet in maintaining diabetes can solve the problem.
• Diabetes Mellitus in Young Adults Thus, programs for young adults should predominantly focus on the features of the transition from adolescence to adulthood. As a consequence, educational programs on diabetes improve the physical and psychological health of young adults.
• A Healthcare Issue of Diabetes Mellitus Diabetes mellitus is seen as a primary healthcare issue that affects populations across the globe and necessitates the combination of a healthy lifestyle and medication to improve the quality of life of people who suffer […]
• Control of LDL Cholesterol Levels in Patients, Gestational Diabetes Mellitus In addition, some patients with hypercholesterolemia may have statin intolerance, which reduces adherence to therapy, limits treatment efficacy, and increases the risk of CVD.
• Exploring Glucose Tolerance and Gestational Diabetes Mellitus In the case of a glucose tolerance test for the purpose of diagnosing GDM type, the interpretation of the test results is carried out according to the norms for the overall population.
• Type 2 Diabetes Health Issue and Exercise This approach will motivate the patient to engage in exercise and achieve better results while reducing the risk of diabetes-related complications.
• Diabetes Interventions in Children The study aims to answer the PICOT Question: In children with obesity, how does the use of m-Health applications for controlling their dieting choices compare to the supervision of their parents affect children’s understanding of […]
• Diabetes Tracker Device and Its Advantages The proposed diabetes tracker is a device that combines the functionality of an electronic BGL tester and a personal assistant to help patients stick to their diet plan.
• Disease Management for Diabetes Mellitus The selection of the appropriate philosophical and theoretical basis for the lesson is essential as it allows for the use of an evidence-based method for learning about a particular disease.
• Latino People and Type 2 Diabetes The primary aim of the study is to determine the facilitators and barriers to investigating the decision-making process in the Latin population and their values associated with type 2 diabetes.
• Diabetes Self-Management Education and Support Program The choice of this topic and question is based on the fact that despite the high prevalence of diabetes among adolescents in the United States, the use of DSMES among DM patients is relatively low, […]
• Diabetes Mellitus Care Coordination The aim is to establish what medical technologies, care coordination and community resources, and standards of nursing practice contribute to the quality of care and safety of patients with diabetes.
• Healthy Lifestyle Interventions in Comorbid Asthma and Diabetes In most research, the weight loss in cases of comorbid asthma and obesity is reached through a combination of dietary interventions and physical exercise programs.
• PDSA in Diabetes Prevention The second step in the “Do” phase would be to isolate a few members of the community who are affected by diabetes voluntarily.
• Diabetes: Statistics, Disparities, Therapies The inability to produce adequate insulin or the body’s resistance to the hormone is the primary cause of diabetes. Diabetes is a serious health condition in the U.S.and the world.
• Type 2 Diabetes Prescriptions and Interventions The disadvantage is the difficulty of obtaining a universal model due to the complexity of many factors that can affect the implementation of recommendations: from the variety of demographic data to the patient’s medical history.
• Health Education for Female African Americans With Diabetes In order to address and inform the public about the challenges, nurses are required to intervene by educating the population on the issues to enhance their understanding of the risks associated with the conditions they […]
• Diabetes Risk Assessment and Prevention It is one of the factors predisposing patients suffering from diabetes to various cardiovascular diseases. With diabetes, it is important to learn how to determine the presence of carbohydrates in foods.
• Diabetes Mellitus: Preventive Measures In addition to addressing the medical specialists who will be of service in disease prevention, it will emphasize the intervention programs required to help control the spread of the illness.
• “The Diabetes Online Community” by Litchman et al. The researchers applied the method of telephone interviews to determine the results and effectiveness of the program. The study described the value of DOC in providing support and knowledge to older diabetes patients.
• Mobile App for Improved Self-Management of Type 2 Diabetes The central focus of the study was to assess the effectiveness of the BlueStar app in controlling glucose levels among the participants.
• Type 2 Diabetes in Minorities from Cultural Perspective The purpose of this paper is to examine the ethical and cultural perspectives on the issue of T2DM in minorities. Level 2: What are the ethical obstacles to treating T2DM in ethnic and cultural minorities?
• Ethics of Type 2 Diabetes Prevalence in Minorities The purpose of this article analysis is to dwell on scholarly evidence that raises the question of ethical and cultural aspects of T2DM prevalence in minorities.
• Type 2 Diabetes in Minorities: Research Questions The Level 2 research questions are: What are the pathophysiological implications of T2DM in minorities? What are the statistical implications of T2DM in minorities?
• Improving Adherence to Diabetes Treatment in Primary Care Settings Additionally, the patients from the intervention group will receive a detailed explanation of the negative consequences of low adherence to diabetes treatment.
• An Advocacy Tool for Diabetes Care in the US To ensure the implementation and consideration of my plea, I sent a copy of the letter to the government officials so it could reach the president.
• Diabetes and Allergies: A Statistical Check The current dataset allowed us to test the OR for the relationship between family history of diabetes and the presence of diabetes in a particular patient: all variables were dichotomous and discrete and could take […]
• Type 2 Diabetes in Adolescents According to a National Diabetes Statistics Report released by the Centers for Disease Control and Prevention, the estimated prevalence of the disease was 25 cases per 10,000 adolescents in 2017. A proper understanding of T2D […]
• Analysis of Diabetes and Its Huge Effects In the US, diabetes is costly to treat and has caused much physical, emotional and mental harm to the people and the families of those who have been affected by the disease.
• Nursing: Self-Management of Type II Diabetes Sandra Fernandes and Shobha Naidu’s journal illustrates the authors’ understanding of a significant topic in the nursing profession.”Promoting Participation in self-care management among patients with diabetes mellitus” article exposes readers to Peplau’s theory to understand […]
• The Impact of Vegan and Vegetarian Diets on Diabetes Vegetarian diets are popular for a variety of reasons; according to the National Health Interview Survey in the United States, about 2% of the population reported following a vegetarian dietary pattern for health reasons in […]
• “Diabetes Prevention in U.S. Hispanic Adults” by McCurley et al. This information allows for supposing that face-to-face interventions can be suitable to my practicum project that considers measures to improve access to care among African Americans with heart failure diseases. Finally, it is possible to […]
• Diabetes Disease of the First and Second Types It is a decrease in the biological response of cells to one or more effects of insulin at its average concentration in the blood. During the first type of diabetes, insulin Degludec is required together […]
• The Trend of the Higher Prevalence of Diabetes According to the CDC, while new cases of diabetes have steadily decreased over the decades, the prevalence of the disease among people aged below twenty has not.
• Person-Centered Strategy of Diabetes and Dementia Care The population of focus for this study will be Afro-American women aged between sixty and ninety who have diabetes of the second type and dementia or are likely to develop dementia in the future.
• Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services For example, during one of my interactions with the patient, I was asked whether the hospital had the policy to avoid face-to-face interaction during the pandemic with the help of video examinations.
• Diets to Prevent Heart Disease, Cancer, and Diabetes In order to prevent heart disease, cancer, and diabetes, people are required to adhere to strict routines, including in terms of diet. Additionally, people wanting to prevent heart disease, cancer, and diabetes also need to […]
• The Centers for Diabetes’ Risks Assessment In general, the business case for the Centers for Diabetes appears to be positive since the project is closely aligned with the needs of the community and the targets set by the Affordable Care Act.
• Diabetes Mellitus as Leading Cause of Disability The researchers used data from the Centers for Disease Control and Prevention, where more than 12% of older people in the US live with the condition.
• Depression in Diabetes Patients The presence of depression concomitant to diabetes mellitus prevents the adaptation of the patient and negatively affects the course of the underlying disease.
• The Relationship Between Diabetes and COVID-19 After completing the research and analyzing the articles, it is possible to suggest a best practice that may be helpful and effective in defining the relationship between diabetes and COVID-19 and providing a way to […]
• Pre-diabetes and Urinary Incontinence Most recent reports indicate that a physiotherapy procedure gives a positive result in up to 80% of patients with stage I or SUI and mixed form and 50% of patients with stage II SUI.
• Type 1 Diabetes: Recommendations for Alternative Drug Treatments Then, they have to assess the existing levels of literacy and numeracy a patient has. Tailoring educational initiatives to a person’s unique ethnic and cultural background is the basis of cultural competence in patient education.
• Type 2 Diabetes: A Pharmacologic Update Diabetes presents one of the most common diagnoses in causes of ED visits among adults and one of the leading causes of death in the United States.
• Type 2 Diabetes and Its Treatment The main difference in type 2 diabetes is the insensitivity of the body’s cells to the action of the hormone insulin and their insulin resistance.
• Diabetes: Vulnerability, Resilience, and Care In nursing care, resilience is a critical concept that shows the possibility of a person to continue functioning and meeting objectives despite the existing challenges.
• Diabetes Prevention in the United States The analysis of these policies and the other strategies provides the opportunity to understand what role they might play in the improvement of human health. NDPP policy, on the other hand, emphasizes the role of […]
• Teaching Experience: Diabetes Prevention The primary objective of the seminar is to reduce the annual number of diabetes cases and familiarize the audience with the very first signs of this disease.
• Summary of Type 2 Diabetes: A Pharmacologic Update The authors first emphasize that T2D is one of the most widespread diseases in the United States and the seventh leading cause of death.
• Insulin Effects in a Diabetes Person I will use this source to support my research because the perception of diabetes patients on insulin therapy is essential for understanding the impact they cause on the person.
• Diabetes and Medical Intervention In the research conducted by Moin et al, the authors attempted to define the scope of efficiency of such a tool as an online diabetes prevention program in the prevention of diabetes among obese/overweight population […]
• Diabetes Mellitus Type 2 and a Healthy Lifestyle Relationship The advantage of this study over the first is that the method uses a medical approach to determining the level of fasting glucose, while the dependences in the study of Ugandans were found using a […]
• Diabetes and Its Economic Effect on Healthcare For many years, there has been an active increase in the number of cases of diabetes of all types among the global population, which further aggravates the situation.
• Diabetes: Epidemiological Analysis I would like to pose the following question: how can epidemiology principles be applied to these statistics for further improvements of policies that aim to reduce the impact of diabetes on the U.S.population? The limited […]
• Pathogenesis and Prevention of Diabetes Mellitus and Hypertension The hormone is produced by the cells of the islets of Langerhans found in the pancreas. It is attributed to the variation in the lifestyle of these individuals in these two geographical zones.
• Parental Intervention on Self-Management of an Adolescent With Diabetes Diabetes development and exposure are strongly tied to lifestyle, and the increasing incidents rate emphasizes the severity of the population’s health problem.
• Addressing the Needs of Hispanic Patients With Diabetes Similarly, in the program at hand, the needs of Hispanic patients with diabetes will be considered through the prism of the key specifics of the community, as well as the cultural background of the patients.
• Diabetes Issues: Insulin Price and Unaffordability According to the forecast of researchers from Stanford University, the number of people with type 2 diabetes who need insulin-containing drugs in the world will increase by about 79 million people by 2030, which will […]
• Diabetes: Epidemiologic Study Design For instance, the range of their parents’ involvement in the self-management practices can be a crucial factor in treatment and control.
• What to Know About Diabetes? Type 1 diabetes is caused by autoimmune reaction that prevent realization of insulin in a body. Estimated 5-10% of people who have diabetes have type 1.
• Diabetes in Saudi Arabia It is expected that should this underlying factor be discovered, whether it is cultural, societal, or genetic in nature, this should help policymakers within Saudi Arabia create new governmental initiatives to address the problem of […]
• “Medical Nutrition Therapy: A Key to Diabetes Management and Prevention” Article Analysis In the process of MNT application, the dietitian keeps a record of the changes in the main components of food and other components of the blood such as blood sugars to determine the trend to […]
• Nutrition and Physical Activity for Children With a Diabetes When a child understands that the family supports him or her, this is a great way to bring enthusiasm in dealing with the disease.
• Global and Societal Implications of the Diabetes Epidemic The main aim of the authors of this article seems to be alerting the reader on the consequences of diabetes to the society and to the whole world.
• Diabetes and Hypertension Avoiding Recommendations Thus, the promotion of a healthy lifestyle should entail the encouragement of the population to cease smoking and monitor for cholesterol levels.
• Pregnant Women With Type I Diabetes: COVID-19 Disease Management The grounded theory was selected for the given topic, and there are benefits and drawbacks of utilizing it to study the experiences of pregnant women with type I diabetes and COVID-19.
• Current Recommendations for the Glycemic Control in Diabetes Management of blood glucose is one of the critical issues in the care of people with diabetes. Therefore, the interval of the A1C testing should also depend on the condition of the patient, the physician’s […]
• Diabetes Mellitus: Types, Causes, Presentation, Treatment, and Examination Diabetes mellitus is a chronic endocrinologic disease, which is characterized by increased blood glucose concentration.
• Diabetes Problem at Country Walk Community: Intervention and Evaluation This presentation develops a community health nursing intervention and evaluation tool for the diabetes problem affecting Country Walk community.
• The Minority Diabetes Initiative Act’s Analysis The bill provides the right to the Department of Health and Human Services to generate grants to public and nonprofit private health care institutions with the aim of providing treatment for diabetes in minority communities.
• Communication Challenges Between Nurses and Patients With Type 2 Diabetes According to Pung and Goh, one of the limitations of communication in a multicultural environment is the language barrier that manifests itself in the direct interaction of nurses with patients and in the engagement work […]
• Diabetes Type 2 from Management Viewpoint Demonstrate the effects of type 2 diabetes and provide background information on the disease; Discuss the management plans of diabetes centers and critically analyze the frameworks implemented in the hospitals; Examine the existing methodology models […]
• Nursing Plan for the Patient with Diabetes Type 2, HTN, and CAD The health of the population is the most valuable achievement of society, so the preservation and strengthening of it is an essential task in which everyone should participate without exception.
• Diagnosis and Classification of Diabetes Mellitus Diabetes is a serious public health concern that introduces a group of metabolic disorders caused by changes in the sugar blood level.
• Diabetes Mellitus Type II: A Case of a Female Adult Patient In this presentation, we are going to develop a care plan for a 47-year-old woman with a 3-year-old history of Diabetes Mellitus Type 2 (also known as Type II DM).
• Diabetes Insipidus: Disease Process With Implications for Healthcare Professionals This presentation will consider the topic of Diabetes Insipidus (DI) with a focus on its etiology and progress.
• The Nature of Type 1 Diabetes Mellitus Type 1 diabetes mellitus is a chronic autoimmune disease that has an active genetic component, which is identified by increased blood glucose levels, also known as hyperglycemia.
• Imperial Diabetes Center Field Study The purpose is to examine the leadership’s practices used to maintain and improve the quality and safety standards of the facility and, using the observations and scholarly research, offer recommendations for improvement.
• Diabetes Risk Assessment After completing the questionnaire, I learned that my risk for the development of diabetes is above average. Modern risk assessment tools allow identifying the current state of health and possibilities of developing the disease.
• The Role of Telenursing in the Management of Diabetes Type 1 Telemedicine is the solution that could potentially increase the coverage and improve the situation for many t1DM patients in the world.
• Health Issues of Heart Failure and Pediatric Diabetes As for the population, which is intended to participate in the research, I am convinced that there is the need to specify the patients who should be examined and monitored.
• Juvenile Diabetes: Demographics, Statistics and Risk Factors Juvenile diabetes, also referred to as Type 2 diabetes or insulin-dependent diabetes, describes a health condition associated with the pancreas’s limited insulin production. The condition is characterized by the destruction of the cells that make […]
• Diabetes Mellitus: Pathophysiologic Processes The main function of insulin produced by cells within the pancreas in response to food intake is to lower blood sugar levels by the facilitation of glucose uptake in the cells of the liver, fat, […]
• Type 2 Diabetes Management in Gulf Countries One such study is the systematic review on the quality of type 2 diabetes management in the countries of the cooperation council for the Arab states of the Gulf, prepared by Alhyas, McKay, Balasanthiran, and […]
• Patient with Ataxia and Diabetes Mellitus Therefore, the therapist prioritizes using the cushion to the client and persuades the patient to accept the product by discussing the merits of the infinity cushion with a low profile in enabling the customer to […]
• Diabetes Evidence-Based Project: Disseminating Results In this presentation, the involvement of mentors and collaboration with administration and other stakeholders are the preferred steps, and the idea to use social networking and web pages has to be removed.
• The Problem of Diabetes Among African Americans Taking into consideration the results of the research and the information found in the articles, the problem of diabetes among African Americans has to be identified and discussed at different levels.
• Childhood Obesity, Diabetes and Heart Problems Based on the data given in the introduction it can be seen that childhood obesity is a real problem within the country and as such it is believed that through proper education children will be […]
• Hypertension and Antihypertensive Therapy and Type 2 Diabetes Mellitus In particular, Acebutolol impairs the functions of epinephrine and norepinephrine, which are neurotransmitters that mediate the functioning of the heart and the sympathetic nervous system.
• Diabetes: Diagnosis and Treatment The disease is characterized by the pancreas almost not producing its own insulin, which leads to an increase in glucose levels in the blood.
• How to Manage Type 2 Diabetes The article is significant to the current research problem as the researchers concluded that the assessment of metabolic processes in diabetic patients was imperative for adjusting in the management of the condition.
• Type 2 Diabetes Analysis Thus, type 2 diabetes has medical costs, or the difficulties of coping up with the illness, economic ones, which are the financial costs of managing it, and the organizational ones for the healthcare systems.
• Clinical Trial of Diabetes Mellitus On the other hand, type II diabetes mellitus is caused by the failure of the liver and muscle cells to recognize the insulin produced by the pancreatic cells.
• Diabetes: Diagnosis and Related Prevention & Treatment Measures The information presented on the articles offers an insight in the diagnosis of diabetes among various groups of persons and the related preventive and treatment measures. The study identified 3666 cases of initial stages of […]
• Reinforcing Nutrition in Schools to Reduce Diabetes and Childhood Obesity For example, the 2010 report says that the rates of childhood obesity have peaked greatly compared to the previous decades: “Obesity has doubled in Maryland over the past 20 years, and nearly one-third of youth […]
• The Connection Between Diabetes and Consuming Red Meat In light of reporting the findings of this research, the Times Healthland gave a detailed report on the various aspects of this research.
• Synthesizing the Data From Relative Risk Factors of Type 2 Diabetes Speaking of such demographic factors as race, the white population suffers from it in the majority of cases, unlike the rest of the races, the remaining 0.
• Using Exenatide as Treatment of Type 2 Diabetes Mellitus in Adults Kendal et al.analyzed the effects of exenatide as an adjunct to a combination of metformin and sulfonylurea against the combination of the same drugs without the adjunct.
• Enhancing Health Literacy for People With Type 2 Diabetes Two professionals, Andrew Long, a professor in the school of heath care in the University of Leeds, and Tina Gambling, senior lecturer in the school of health care studies from the University of Cardiff, conducted […]
• The Scientific Method of Understanding if Coffee Can Impact Diabetes The hypothesis of the experiment ought to be straightforward and understandable. The control group and the experiment group for the test are then identified.
• Gestational Diabetes Mellitus: Review This is because of the current patterns that show an increase in the prevalence of diabetes in offspring born to mothers with GDM.
• Health Service Management of Diabetes During the task, Fay makes a countless number of short calls and often takes water irrespective of the time of the day or the prevailing weather conditions.
• Necrotizing Fasciitis: Pathophysiology, Role of Diabetes In the event of such an infection, the body becomes desperate to get rid of the intruders. For WBC, zero is given if the count is below 15cells/mm3, one is given if the count lies […]
• The Benefits of Sharing Knowledge About Diabetes With Physicians
• Gestational Diabetes Mellitus – NSW, Australia
• Health and Wellness: Stress, Diabetes and Tobacco Related Problems
• 52-Year-Old Female Patient With Type II Diabetes
• Healthy People Project: Personal Review About Diabetes
• Nursing Diagnosis: Type 1 Diabetes & Hypertension
• Nursing Care For the Patient With Diabetes
• Nursing Care Development Plan for Diabetes and Hypertension
• Coronary Heart Disease Aggravated by Type 2 Diabetes and Age
• Diabetes as the Scourge of the 21st Century: Locating the Solution
• Psychosocial Implications of Diabetes Management
• Gestational Diabetes in a Pregnant Woman
• Diabetes Mellitus: Prominent Metabolic Disorder
• Holistic Approach to Man’s Health: Diabetes Prevention
• Holistic Image in Prevention of Diabetes
• Educational Strategies for Diabetes to Patients
• Diabetes and Obesity in the United Arab Emirates
• Epidemiological Problem: Diabetes in Illinois
• Diabetes as a Chronic Condition
• Managing Diabetes Through Genetic Engineering
• Diabetes, Functions of Insulin, and Preventive Practices
• Treating of Diabetes in Adults
• Counseling and Education Session in Type II Diabetes
• Diabetes II: Reduction in the Incidence
• Community Health Advocacy Project: Diabetes Among Hispanics
• Community Health Advocacy Project: Hispanics With Diabetes
• Hispanics Are More Susceptible to Diabetes That Non-Hispanics
• Rates Diabetes Between Hispanics Males and Females
• Diabetes Mellitus and HFSON Conceptual Framework
• Prince Georges County Community Health Concern: Diabetes
• Fats and Proteins in Relation to Type 2 Diabetes
• Alcohol Interaction With Medication: Type 2 Diabetes
• Diabetes Management and Evidence-Based Practice
• Critical Analysis of Policy for Type 2 Diabetes Mellitus in Australia
• The Treatment and Management of Diabetes
• Obesity and Diabetes: The Enemies Within
• Impact of Diabetes on the United Arab Emirates’ Economy
• Childhood Obesity and Type 2 Diabetes
• Health Nursing and Managing Diabetes
• Diabetes Management: How Lifestyle, Daily Routine Affect Blood Sugar
• Diabetes Management: Diagnostics and Treatment
• Diabetes Mellitus Type 2: The Family Genetic History
• Diabetes Type II: Hormonal Mechanism and Intracellular Effects of Insulin
• Social, Behavioral, and Psychosocial Causes of Diseases: Type 2 Diabetes
• Supportive Intervention in the Control of Diabetes Mellitus
• Enhancing Foot Care Practices in Patients With Diabetes
• Community Health Promotion: The Fight Against Diabetes in a Community Setting
• Diabetes in Australia and Saudi Arabia
• Diabetes: The Advantages and Disadvantages of Point of Care Testing
• Diabetes Mellitus Type 2 or Non-Insulin-Dependent Diabetes Mellitus
• Qualitative Research in Diabetes Management in Elderly Patient
• Diabetes Prevention Measures in the Republic of the Marshall Islands
• Impact of Diabetes on Healthcare
• Gestational Diabetes: American Diabetes Association Publishers
• Gestational Diabetes: Child Bearing Experience
• Diabetes Mellitus Effects on Periodontal Disease
• Diabetes Type II Disease in the Community
• The Relationship of Type 2 Diabetes and Depression
• Glycemic Control in Individuals With Type 2 Diabetes
• The Diagnosis of Diabetes in Older Adults and Adolescents
• Physical Activity in Managing Type-2 Diabetes
• High Risk of Developing Type 1 and Type 2 Diabetes Mellitus
• Children With Type 1 Diabetes in Clinical Practice
• Type 2 Diabetes Treatment Analysis
• Type 2 Diabetes Mellitus: Revealing the Diagnosis
• The Type 2 Diabetes Prevention: Lifestyle Choices
• Indigenous and Torres Strait Population and Diabetes
• Interpretation of the Diabetes Interview Transcript
• Type 1 Diabetes: Using Glucose Monitoring in Treatment
• Managing Type 2 Diabetes Patients’ Blood Sugar Prior to and After Surgical Procedures
• Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes: Medical Terminology Definition
• Modern Diabetes Treatment Tools
• Diabetes: Encapsulation to Treat a Disease
• Current Dietary for the Treatment of Diabetes
• Diabetes: Discussion of the Disease
• Stranahan on Diabetes Impairs Hippocampal Function
• A Clinical-Based Study of Young Adults Who Have Diabetes
• Panax Ginseng for Diabetes Treatment
• Depression and Diabetes Association in Adults
• Is There Anu Cure For Diabetes?
• Diabetes Self-Management: Evidence-Based Nursing
• Diabetes Type 2 in Children: Causes and Effects
• Type 1 Diabetes Mellitus Case
• Health, Culture, and Identity as Diabetes Treatment Factors
• Diabetes Prevention in Chinese Elderly in Hunan
• “Experiences of Patients With Type 2 Diabetes Starting Insulin Therapy” by Phillips
• Type 2 Diabetes: Nursing Change Project
• Diabetes and Health Promotion Concepts
• Type 2 Diabetes Project Results Dissemination
• Type 2 Diabetes in Geriatric Patients
• Type 2 Diabetes and Geriatric Evidence-Based Care
• Cultural Empowerment. Diabetes in Afro-Americans
• Diabetes Self-Management: Relationships & Expectations
• Diagnosis and Classification of Diabetes Mellitus
• Improving Comprehensive Care for Patients With Diabetes
• Diabetes Impact on Cardiovascular and Nervous Systems
• Side Effects of Metformin in Diabetes Treatment
• Type 2 Diabetes and Drug Treatments
• Diabetes Mellitus and Health Determinants
• Nursing Leadership in Diabetes Management
• Diabetes Education for African American Women
• Latent Autoimmune Adult Diabetes
• Obesity: Epidemiology and Health Consequences
• Diabetes in Urban Cities of United States
• Diabetes in Australia: Analysis
• Type 2 Diabetes in the Afro-American Bronx Community
• Type 2 Diabetes From Cultural and Genetic Aspects
• Type 2 Diabetes in Bronx: Evidence-Based Practice
• Type 2 Diabetes in Bronx Project for Social Change
• Cardiovascular Care in Type 2 Diabetes Patients
• Ambition Diabetes and Diet on Macbeths’ Example
• Diabetes as Community Health Issue in the Bronx
• Diabetes Management Plan: Diagnosis and Development
• Diabetes Treatment and Care
• Transition from Pediatric to Adult Diabetes Care
• Diabetes Awareness Program and Strategic Planning
• Diabetes: Disease Control and Investigation
• Diabetes Pain Questionnaire and Patient Feedback
• Perception of Diabetes in the Hispanic Population
• Clinical Studies of Diabetes Mellitus
• Diabetes Mellitus and Problems at Work
• Diabetes in the US: Cost Effectiveness Analysis
• Diabetes Investigation in Space Flight Research
• Diabetes Care Advice by Food and Drug Administration
• Artificial Intelligence for Diabetes: Project Experiences
• Diabetes Patients’ Long-Term Care and Life Quality
• Chronic Care Model for Diabetes Patients in the UAE
• Diabetes Among British Adults and Children
• Endocrine Disorders: Diabetes and Fibromyalgia
• Future Technologies: Diabetes Treatment and Care
• Epidemiology of Type 1 Diabetes
• Diabetes: Treatment Technology and Billing
• Pathophysiology of Mellitus and Insipidus Diabetes
• Cure for Diabetes: The Impossible Takes a Little Longer
• Stem Cell Therapy as a Potential Cure for Diabetes
• Stem Cell Therapy and Diabetes Medical Research
• Type II Diabetes Susceptibility and Socioeconomic Status
• Diabetes Mellitus Type 2: Pathophysiology and Treatment
• Obesity and Hypertension in Type 2 Diabetes Patients
• Strongyloides Stercoralis Infection and Type 2 Diabetes
• Socioeconomic Status and Susceptibility to Type II Diabetes
• Diabetes Mellitus: Differential Diagnosis
• Diabetes Disease in the USA Adults
• Education for African Americans With Type 2 Diabetes
• Diabetes Treatment and Funding in Fulton County
• Diabetes Care: Leadership and Strategy Plan
• Diabetes Mellitus’ New Treatment: Principles and Process
• Diet and Nutrition: European Diabetes
• Preventing the Proliferation Diabetes
• Diabetes: Symptoms, Treatment, and Prevention
• Diabetes and Cardiovascular Diseases in Medicine
• Ecological Models to Deal with Diabetes in Medicine
• Different Types of Diabetes Found in Different Countries
• Analysis of Program “Prevent Diabetes Live Life Well”
• The Effect of Physical, Social, and Health Variables on Diabetes
• Micro and Macro-Cosmos in Medicine and Care Models for Prevention of Diabetes
• Why Qualitative Method Was Chosen for Diabetes Program Evaluation
• Humanistic Image of Managing Diabetes
• Diabetes mellitus Education and hemoglobin A1C level
• Obesity, Diabetes and Heart Disease
• Illuminate Diabetes Event Design
• Cause and Diagnosis of Type 2 diabetes
• Patient Voices: Type 2 Diabetes. Podcast Review
• Type I Diabetes: Pathogenesis and Treatment
• Human Body Organ Systems Disorders: Diabetes
• Age Influence on Physical Activity: Exercise and Diabetes
• Hemoglobin A1C Test for Diabetes
• Why Injury and Diabetes Have Been Identified as National Health Priority?
• What Factors Are Involved in the Increasing Prevalence of Type II Diabetes in Adolescents?
• Does the Socioeconomic Position Determine the Incidence of Diabetes?
• What Are the Four Types of Diabetes?
• How Fat and Obesity Cause Diabetes?
• How Exercise Affects Type 2 Diabetes?
• How Does the Treatment With Insulin Affect Type 2 Diabetes?
• How Diabetes Does Cause Depression?
• Does Diabetes Prevention Pay For Itself?
• How Does Snap Participation Affect Rates of Diabetes?
• Does Overeating Sugar Cause Diabetes, Cavities, Acne, Hyperactivity and Make You Fat?
• Why Diabetes Mellitus and How It Affects the United States?
• Does Alcohol Decrease the Risk of Diabetes?
• How Does a Person With Diabetes Feel?
• Does Periodontal Inflammation Affect Type 1 Diabetes in Childhood and Adolescence?
• How Can the Paleolithic Diet Control Type 2 Diabetes?
• How Does Insulin Help Diabetes Be Controlled?
• Does Economic Status Matter for the Regional Variation of Malnutrition-Related Diabetes?
• How Can Artificial Intelligence Technology Be Used to Treat Diabetes?
• What Are the Main Causes and Treatments of Diabetes?
• What Evidence Exists for Treatments Depression With Comorbid Diabetes Using Traditional Chinese Medicine and Natural Products?
• Why Was Qualitative Method Chosen for Diabetes Program Evaluation?
• What Are the Three Types of Diabetes?
• How Does Poverty Affect Diabetes?
• What Is the Leading Cause of Diabetes?
• How Is Diabetes Diagnosed?
• What Are the Main Symptoms of Diabetes?
• How Diabetes Adversely Affects Your Body?
• What Are the Most Common Symptoms of Undiagnosed Diabetes?
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• Sex differences in risk of incident microvascular and macrovascular complications: a population-based data-linkage study among 25 713 people with diabetes
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• http://orcid.org/0000-0001-8750-9720 Alice A Gibson 1 , 2 ,
• Emma Cox 1 , 2 ,
• Francisco J Schneuer 1 , 2 , 3 ,
• Jacob Humphries 4 ,
• Crystal MY Lee 5 ,
• Joanne Gale 1 ,
• Steven Chadban 2 , 6 ,
• Mark Gillies 7 ,
• Clara K Chow 2 , 8 , 9 ,
• Stephen Colagiuri 2 , 4 ,
• Natasha Nassar 1 , 2 , 3
• 1 Menzies Centre for Health Policy and Economics, Sydney School of Public Health, Faculty of Medicine and Health , The University of Sydney , Sydney , New South Wales , Australia
• 2 Charles Perkins Centre , The University of Sydney , Sydney , New South Wales , Australia
• 3 Child Population and Translational Health Research, The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health , The University of Sydney , Sydney , New South Wales , Australia
• 4 Faculty of Medicine and Health , The University of Sydney , Sydney , New South Wales , Australia
• 5 School of Population Health , Curtin University , Perth , Western Australia , Australia
• 6 Department of Renal Medicine, Kidney Centre , Royal Prince Alfred Hospital , Camperdown , New South Wales , Australia
• 7 Discipline of Ophthalmology and Eye Health, Save Sight Institute, Faculty of Medicine and Health , The University of Sydney , Sydney , New South Wales , Australia
• 8 Westmead Applied Research Centre, Faculty of Medicine and Health , The University of Sydney , Sydney , New South Wales , Australia
• 9 Department of Cardiology , Westmead Hospital , Westmead , New South Wales , Australia
• Correspondence to Dr Alice A Gibson, Menzies Centre for Health Policy and Economics, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; alice.gibson{at}sydney.edu.au

Background The global prevalence of diabetes is similar in men and women; however, there is conflicting evidence regarding sex differences in diabetes-related complications. The aim of this study was to investigate sex differences in incident microvascular and macrovascular complications among adults with diabetes.

Methods This prospective cohort study linked data from the 45 and Up Study, Australia, to administrative health records. The study sample included 25 713 individuals (57% men), aged ≥45 years, with diabetes at baseline. Incident cardiovascular disease (CVD), eye, lower limb, and kidney complications were determined using hospitalisation data and claims for medical services. Multivariable Cox proportional hazards models were used to assess the association between sex and incident complications.

Results Age-adjusted incidence rates per 1000 person years for CVD, eye, lower limb, and kidney complications were 37, 52, 21, and 32, respectively. Men had a greater risk of CVD (adjusted hazard ratio (aHR) 1.51, 95% CI 1.43 to 1.59), lower limb (aHR 1.47, 95% CI 1.38 to 1.57), and kidney complications (aHR 1.55, 95% CI 1.47 to 1.64) than women, and a greater risk of diabetic retinopathy (aHR 1.14, 95% CI 1.03 to 1.26). Over 10 years, 44%, 57%, 25%, and 35% of men experienced a CVD, eye, lower limb, or kidney complication, respectively, compared with 31%, 61%, 18%, and 25% of women. Diabetes duration (<10 years vs ≥10 years) had no substantial effect on sex differences in complications.

Conclusions Men with diabetes are at greater risk of complications, irrespective of diabetes duration. High rates of complications in both sexes highlight the importance of targeted complication screening and prevention strategies from diagnosis.

• EPIDEMIOLOGY
• DIABETES MELLITUS
• CARDIOVASCULAR DISEASES
• COHORT STUDIES
• RECORD LINKAGE

Data availability statement

Data may be obtained from a third party and are not publicly available. This research was completed using data collected from the Sax Institute’s 45 and Up Study. Requests for access to data should be addressed to the corresponding author or the Sax Institute ( http://www.saxinstitute.org.au/ ).

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/jech-2023-221759

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WHAT IS ALREADY KNOWN ON THIS TOPIC

The absolute risk of cardiovascular disease appears to be higher in men with diabetes compared with women with diabetes. However, the evidence for sex differences in microvascular complications is limited and conflicting.

Further, there is little understanding of the potential impact of diabetes duration on sex differences in micro- and macrovascular complications.

WHAT THIS STUDY ADDS

Compared with women, men were at greater risk of incident cardiovascular disease, lower limb and kidney complications, and diabetic retinopathy.

Sex differences in rate of complications were similar for those with diabetes duration <10 years and ≥10 years.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY

Given the high rates of complication in both sexes, this study highlights the importance of targeted complication screening and prevention strategies from the time of diagnosis.

Introduction

Diabetes leads to numerous microvascular and macrovascular complications such as loss of vision, amputation, kidney failure, myocardial infarction and stroke, placing an enormous burden on individuals and their families, healthcare systems and society in general. Globally, the prevalence of diabetes continues to escalate. An estimated 537 million people aged 20–79 years were living with diabetes in 2021, which is projected to rise to a staggering 783 million by 2045. 1 In Australia, the prevalence of diabetes has tripled over the past three decades, affecting an estimated 1.3 million (5.1%) Australians in 2018–2021. 2

Although the prevalence of diabetes is similar in men and women (worldwide prevalence of 8.9% and 8.4%, respectively), 3 the incidence and progression of diabetes-related complications appears to be more sex-specific. It is well established that the absolute risk of cardiovascular disease (CVD) is higher in men with diabetes than women with diabetes. 4 However, the evidence for sex differences in microvascular complications such as retinopathy, neuropathy and nephropathy is limited and conflicting. For instance, in the UK Prospective Diabetes Study, the incidence of retinopathy was similar in men and women; however, women had a lower relative risk of retinopathy progression (RR 0.54, 95% CI 0.37 to 0.80). 5 In the prospective DiaGene cohort study of diabetes complications, the incidence of microalbuminuria (a biomarker of nephropathy) was higher in men, and men were more likely to develop two or three microvascular complications compared with women (OR 2.42, 95% CI 1.69 to 3.45). 6

Ample duration of follow-up is required to assess long-term diabetes-related complications. Multiple studies have provided strong evidence that individuals with longer diabetes duration are at greater risk of complications 7 8 ; however, there is little understanding of the potential impact of diabetes duration on sex differences in diabetes-related complications. The aim of this study was to investigate sex differences in incident micro- and macrovascular complications among a large population-based sample of people with diabetes. We also investigated whether sex differences were modified by duration of diabetes.

Study population and data sources

We used data from The Sax Institute’s 45 and Up Study, a large prospective cohort of 267 357 men and women aged over 45 years residing in the state of New South Wales (NSW), Australia. This cohort represents approximately 11% of the NSW population aged over 45. The cohort profile and research protocol have been published in detail previously. 9 Briefly, participants of the 45 and Up Study were randomly sampled from Services Australia Medicare enrolment database, between 2005 and 2009. Participants were invited by mail and agreed to participate by completing a sex-specific self-administered questionnaire and providing written consent for linkage of their survey responses to administrative health data collections. The estimated response rate was 19%. The full baseline survey questionnaires are available at https://www.saxinstitute.org.au/our-work/45-up-study/questionnaires/ .

For this study we used data from participants’ baseline questionnaires that were linked to their corresponding medical services claims (Medicare Benefits Schedule, MBS), prescription medication (Pharmaceutical Benefits Scheme, PBS), hospital admission (Admitted Patient Data Collection, APDC) and death registry data collections (Registry of Births Deaths and Marriages). Detailed information about the datasets and linkage process is provided in the online supplemental file 1 . The 45 and Up Study was approved by the University of NSW Human Research Ethics Committee, and use of linked data for this study was approved by the NSW Population and Health Services Research Ethics Committee (Cancer Institute NSW reference: 2017/HRE0206).

Supplemental material

Study sample.

The present study includes all participants in the 45 and Up Study identified with diabetes at baseline. The online supplemental file 1 provides a detailed overview of diabetes case ascertainment. In brief, we used a combination of self-report and the multiple linked administrative data sources (MBS, PBS, APDC) to ascertain diabetes status.

Study exposures

The main exposures of interest were sex and diabetes duration at baseline. Diabetes duration at baseline was calculated using the age at first diabetes diagnosis identified from the baseline survey and categorised into <10 years or ≥10 years.

Study outcomes

Study outcomes were determined following literature review and consultation with clinical experts and defined as incident hospitalisation or treatment for the following four major groups and subgroups of diabetes-related micro- and macrovascular complications 10 :

Cardiovascular complications: ischaemic heart disease, transient ischaemic attack (TIA), stroke, heart failure, diabetic cardiomyopathy

Eye complications: diabetes with ‘any ophthalmic complication’, cataract, diabetic retinopathy

Lower limb complications: peripheral neuropathy, ulcers, cellulitis, Charcot foot, osteomyelitis, peripheral vascular disease, and minor or major amputation

Kidney complications: ‘diabetes with kidney complication’, acute kidney failure, chronic kidney disease, unspecified kidney failure, dialysis, and kidney transplant.

Diabetes-related complications were primarily ascertained from hospital admission records (APDC) using principal and additional International Statistical Classification of Diseases and Related Health Problems, Australian Modification (ICD-10-AM) diagnosis or Australian Classification of Healthcare Interventions (ACHI) procedure codes. As not all diabetes-related complications included in this analysis require hospital admission, we also included out-of-hospital treatment for complications such as home dialysis for chronic kidney disease, or retinal laser. This was identified using relevant MBS treatment items. A complete list of outcomes and associated diagnosis, procedure and treatment codes are presented in online supplemental table 1 .

Self-reported sociodemographic, lifestyle and health characteristics were identified from the baseline survey. All questions, response options and categories are provided in online supplemental table 2 . Sociodemographic characteristics included age group, socioeconomic background (Index of Relative Socioeconomic Disadvantage (IRSD) quintile), household income, highest level of education, language other than English spoken at home, country of birth, and private health insurance. The IRSD is derived from income, education, unemployment, and other census data. 11

Lifestyle and health factors included body mass index (BMI), smoking status, physical activity, fruit and vegetable consumption, family history of diabetes, and previous history of CVD (including heart disease and stroke), history of high blood pressure and blood pressure treatment, and treatment for high cholesterol. Of note, previous history of CVD was not included in the CVD complications analysis, as individuals with a prior history were excluded from this analysis.

Statistical analysis

Contingency tables were used to describe the baseline characteristics of participants, grouped by sex. For all major groups and subgroups of diabetes complications, we calculated age-adjusted incidence rates of complications per 1000 person-years, based on the subpopulation at risk (time to first event, death or end of follow-up time). We used Kaplan-Meier estimators to compare age-standardised cumulative complication rates for major outcome groups stratified by sex and duration of diabetes.

Cox proportional hazards models were used to estimate crude and adjusted hazard ratios (aHR) to assess associations between sex and incident CVD, lower limb, eye, and kidney complications. For analysing each group of complications (ie, CVD, lower limb, eye, and kidney), we excluded those with a prior history of that group of complications (ie, between January 2001 and their baseline survey date). The models for each outcome were conducted adjusting for other factors in a sequential process: (1) unadjusted, (2) adjusted for age and sex, (3) adjusted for age, sex, sociodemographics, and lifestyle, and (4) adjusted for all sociodemographic, lifestyle, and health-related factors. Person-years were calculated from the date of recruitment until incident treatment or hospitalisation, death, or end of follow-up (ie, December 2019). All models account for the competing risk of death before complication. Proportionality assumptions were verified based on the methods of Lin et al . 12

Multiple imputation was performed using full conditional specification and incorporating sociodemographic, lifestyle and health factors described above. Thirty imputations were conducted and estimates from the imputed datasets were combined by calculating the mean of the parameter of interest and standard errors adjusted for the uncertainty produced by the imputation process. The missing at random (MAR) assumption required for imputation was considered reasonable based on the missingness patterns in the data ( table 1 ) and the large number of variables included in the imputation process. 13 All analyses were performed using SAS software version 9.4 (SAS Institute Inc, Cary, NC, USA).

• View inline

Baseline sociodemographic, lifestyle and health characteristics of the cohort of participants with diabetes by sex (n=25 713).

Sample characteristics

The full baseline 45 and Up sample included 267 357 participants. There were 266 471 active participants available for this analysis. We excluded participants if they did not have diabetes at baseline (n=232 535), their diabetes status was uncertain (n=8166), or there were inconsistencies in their age, death, or baseline data (n=57). Our final sample included 25 713 participants ( online supplemental figure 1 ).

Table 1 presents the baseline characteristics of the cohort by sex, with almost half of the cohort aged 60–74 years and a slightly higher proportion of females aged 45–59 years with diabetes. A higher proportion of men were overweight (38.7% in men vs 27.8% in women), had higher educational attainment, held private health insurance, and had a history of heart disease. In terms of smoking status, although a similar proportion of men and women were current smokers, a higher proportion of men were ex-smokers (51% compared with only 29% women). Of the 19 277 (75%) people with diabetes who had an age of diagnosis, 58% had a duration of diabetes <10 years and 42% had a duration of diabetes ≥10 years at baseline. There were no meaningful differences in baseline characteristics between those with and without an age of diagnosis ( online supplemental table 3 ).

Incident CVD complications

During 177 851 person-years of follow-up, the overall incidence rate of CVD complications was 37 per 1000 person-years, which was higher among men than women (43 vs 30 per 1000) ( figure 1A ). After adjustment of covariates, compared with women, the aHR for any incident CVD complication in men was 1.51 (95% CI 1.43 to 1.59) ( figure 1B ). Among the CVD complication subgroups, associations were similar to the overall result for heart failure and stroke and stronger for myocardial infarction and other coronary heart disease ( online supplemental figure 2 ). These associations are reflected in the cumulative hazard curves which show that at 10 years’ follow-up, 44.4% (95% CI 43.0% to 45.9%) of men and 30.9% (95% CI 29.7% to 32.2%) of women with diabetes experienced a CVD complication (p<0.001) ( figure 2A ). The sex difference in rate of CVD complications at 10 years was similar, although slightly greater, for those with diabetes <10 years compared with ≥10 years’ duration ( online supplemental figure 6 , online supplemental table 4 ).

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(A) Age-adjusted incidence rates per 1000 person-years of incident diabetes-related complications by sex and (B) adjusted hazards ratio (aHR) (95% CI) for association between sex and incident diabetes-related complications. Hazards ratios are calculated from Cox proportional hazard models based on multiple imputed data adjusted for age, sociodemographics (education, SEIFA, income, language, country of birth, private insurance), lifestyle (BMI, smoking, diet and physical activity) and health history (family history of diabetes, cardiovascular disease, blood pressure and treatment for high cholesterol). BMI, body mass index; SEIFA, Socio-Economic Indexes for Areas.

Cumulative incidence of macrovascular and microvascular complications by sex: (A) CVD complications; (B) eye complications; (C) lower limb complications; (D) kidney complications. Hazard function survival curves using Kaplan-Meier methods. P values in the figures represent the results for the log-rank test. CVD, cardiovascular disease.

Incident eye complications

The incidence rate of eye complications was 52 per 1000 person years and was similar for men and women (52 vs 53 per 1000) ( figure 1A ). Compared with women, men had a lower risk of any eye complication (aHR 0.94, 95% CI 0.89 to 0.98) ( figure 1B ), with results largely influenced by the lower risk of cataract surgery among men (aHR 0.90, 95% CI 0.86 to 0.95) ( online supplemental figure 3 ). In contrast, men had a slightly greater rate and risk of diabetic retinopathy (10 vs 9 per 1000 person years; aHR 1.14, 95% CI 1.03 to 1.26) ( online supplemental figure 3 ). At 10 years’ follow-up, the cumulative incidence of eye complications was 57.0% (95% CI 55.3% to 58.8%) in men and 60.9% (95% CI 58.9% to 62.9%) in women (p<0.001) ( figure 2B ); for diabetic retinopathy these rates were 9.8% (95% CI 9.2% to 10.4%) in men and 8.9% (95% CI 8.2% to 9.5%) in women. When stratified by duration of diabetes, there was no statistical sex difference in risk of diabetic retinopathy for those with diabetes <10 years (aHR 1.12, 95% CI 0.95 to 1.31) at baseline and ≥10 years’ duration (aHR 1.16, 95% CI 0.99 to 1.36) at baseline ( online supplemental figure 6 , online supplemental table 4 ).

Incident lower limb complications

The incidence rate of lower limb complications was 21 per 1000 person years and was higher among men than women (25 vs 18 per 1000) ( figure 1A ). The risk of any lower limb complication was 1.5 times higher in men than women (aHR 1.47, 95% CI 1.38 to 1.57) ( figure 1B ), and the risks of peripheral neuropathy, ulcer and cellulitis were similar. The difference was stronger for peripheral vascular disease, with the risk of complications over two times higher for men. While the incidence was low, the risk of osteomyelitis and amputation was over 2.5-fold higher in men than in women ( online supplemental figure 4 ). The cumulative incidence of lower limb complications at 10 years was higher among men at 24.6% (95% CI 23.7% to 25.5%) versus 17.8% (95% CI 16.9% to 18.7%) in women ( figure 2C ), and this pattern was relatively similar irrespective of diabetes duration ( online supplemental figure 6 , online supplemental table 4 ).

Incident kidney complications

The incidence rate of kidney complications was 32 per 1000 person years and was higher among men than women (36 vs 26 per 1000) ( figure 1A ). The risk of any kidney complication was 1.6 times higher in men than in women (aHR 1.55, 95% CI 1.47 to 1.64) ( figure 1B ), with similar risk estimates for specific subgroups, including kidney failure, chronic kidney disease and dialysis ( online supplemental figure 5 ). This pattern of a higher risk of kidney complications in men is reflected in the cumulative incidence at 10 years, which was higher among men at 35.2% (95% CI 34.0% to 36.3%) versus 25.3% (95% CI 24.3% to 26.3%) in women ( figure 2D ). The sex difference in rate of kidney complications at 10 years was similar, although slightly greater, for those with diabetes ≥10 years compared with <10 years’ duration ( online supplemental figure 6 , online supplemental table 4 ).

Our study demonstrates that men with diabetes have a higher rate and greater risk of most diabetes-related complications compared with women, and this difference remained consistent irrespective of the duration of diabetes. For every 1000 people with diabetes, our findings suggest that an average of 37, 52, 21, and 32 people will develop CVD, eye, lower limb, and kidney complications every year. Men had a 1.5-fold increased risk of CVD, lower limb, and kidney complications, and risk of diabetic retinopathy was 14% greater in men than in women. These findings are reflected in the ~1.4 times higher 10-year rates for CVD, lower limb, and kidney complications in men compared with women.

The greater risk of CVD complications observed for men in our study is consistent with other large population-based studies in France 14 and Denmark. 15 These studies reported a higher incidence of major adverse cardiovascular events including heart failure in men with diabetes compared with women with diabetes (incidence rate (IR) 96 vs 66/1000 person-years, 14 and IR 24.9 vs 19.9/1000 person-years 15 ). Men, irrespective of diabetes status, have been shown to have a greater CVD risk factor burden than women. 16–18 A recent study using nationally representative survey data from Australians aged 45–74 years showed men had a higher average BMI, waist circumference, systolic and diastolic blood pressure, total: high density lipoprotein (HDL) cholesterol ratio, triglycerides and glycated haemoglobin (HbA1c) compared with women, and a higher proportion of men were also current or ex-smokers. 17 Our study observed similar differences in baseline characteristics, with men more likely to be overweight, have a history of heart disease or stroke, and be previous smokers. Men may also be less likely to adopt primary prevention strategies, such as healthy lifestyle change and medication use, 16 19 and to engage in health seeking behaviours, such as preventative health checks. 20 21 Further, women are known to be at lower risk of CVD complications compared with men due to the protective effects of reproductive factors such as breastfeeding and the use of hormone replacement therapy within 10 years of menopause. 22 There are important age-specific sex differences in CVD complications. Women have an older age of CVD onset compared with men, 23 and experience lower rates of CVD up until the age of 80 years. 18 It is possible that the sex differences in CVD complications observed in our study may resolve if the cohort were to be followed for a longer time.

Evidence for sex differences in microvascular diabetes complications is less conclusive than for macrovascular complications. A meta-analysis of 10 studies (nine cohort) reported an elevated, but non-significant, increase in incident chronic kidney disease among women compared with men (adjusted women-to-men relative risk ratio (WMR) 1.14, 95% CI 0.97 to 1.34), with risk particularly higher for end stage renal disease (adjusted WMR 1.38, 95% CI 1.22 to 1.55). 24 In contrast, studies from the Netherlands and UK found a higher baseline prevalence and risk of incident microalbuminuria in men. 6 25 Although no studies have examined overall lower limb complications, the risk of amputation has been shown to be greater in men than in women. 26 27 Similarly, a meta-analysis of 20 studies found that men with diabetic foot have an approximate 50% increased amputation risk compared with women. 28 In contrast to the results for CVD, kidney and lower limb complications, our study found that women with diabetes were at greater risk of eye complications. This appeared to be largely driven by the inclusion of cataracts as a sub-group, which are more prevalent in women compared with men. 29 30 Considering diabetic retinopathy specifically, our results indicate a 14% greater risk of incident retinopathy in men which is consistent with a study from Italy which showed the incidence of diabetic retinopathy to be associated with the male sex (HR 1.31, 95% CI 1.05 to 1.63). 31 The mechanisms for sex differences in microvascular complications remains under-researched, 32 but possible factors include worse glycaemic and blood pressure control and treatment, 18 and an underutilisation of medical care for microvascular complications 28 in men compared with women. Large-scale studies examining sex differences in adherence to guideline-recommended processes of care, including medication adherence and healthy lifestyle behaviours, are needed to understand these findings better.

It is well understood that individuals with longer diabetes duration are at greater risk of complications. The UK Biobank study showed that with each 5 year increase in diabetes duration, there was a 20% increase in excess risk of CVD complications for both men and women. 7 Despite the greater complication-risk with longer disease duration, we observed a similar sex difference in risk of complications for those with diabetes duration <10 years compared with those with diabetes duration ≥10 years. Few studies have examined the effect of diabetes duration on sex differences in risk of complications; however, Duarte et al found that the magnitude of the association between duration of diabetes and glycaemic control was stronger for women compared with men. 33 Only individuals with age of diagnosis reported in the baseline survey could be included in our analysis stratified by disease duration (approximately two-thirds of the full sample), which may have influenced our findings.

The strengths of this study include the large population-based sample, the long follow-up time, and use of objective linked data to identify incident diabetes-related complications, avoiding issues of loss to follow-up and self-report. The data in our study did not include diabetes complications not requiring hospitalisation, with the exception of diabetic retinopathy and home dialysis. While our analyses took into account competing risk of CVD-related death before hospitalisation, these numbers were small (n=163), with no meaningful sex differences that might have had an impact on our results ( online supplemental table 5 ). Given that diabetic kidney disease is frequently asymptomatic, unknown to patients, 34 and requires laboratory testing for detection, it is likely that the incidence of early-stage chronic kidney disease was underestimated in our study. On the other hand, as we excluded those with a prior history of complications to capture incident complications, this may have not allowed enough time for the development of end stage complications, such as limb amputations or requirement for kidney replacement therapy with dialysis or transplantation. As such, the absolute rates of complications should be interpreted with caution. The 45 and Up Study provides detailed information on sociodemographic, health and lifestyle covariates which we were able to adjust for in the analysis. However, we did not take into account all potential confounding/effect-modifying factors including glycaemic, lipid and blood pressure control, medication use 35 and adherence which may have impacted the strength of the association between sex and risk of complications. We were also not able to differentiate between type 1 and type 2 diabetes in our study, precluding an analysis by type of diabetes. Although the 45 and Up cohort are broadly representative of the Australian population aged ≥45 years, the sample does overrepresent higher income earners, people aged 80 and over, and residents of rural and remote areas, 36 which may limit the generalisability of the results. Although men have a higher absolute risk of CVD complications, studies in patients with diabetes compared to those without diabetes have shown that the relative CVD risk conferred by diabetes is greater in women. 37–39 Sex differences in relative risk of diabetes complications was not assessed in our study.

In conclusion, although men with diabetes are at greater risk of developing complications, in particular CVD, kidney and lower-limb complications, the rates of complications are high in both sexes. The similar sex difference for those with shorter compared with longer diabetes duration highlights the need for targeted complication screening and prevention strategies from the time of diabetes diagnosis. Further investigation into the underlying mechanisms for the observed sex differences in diabetes complications are needed to inform targeted interventions.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants. The 45 and Up Study was approved by the University of NSW Human Research Ethics Committee, and use of linked data for this study was approved by the NSW Population and Health Services Research Ethics Committee (Cancer Institute NSW reference: 2017/HRE0206). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

This research was completed using data collected through the 45 and Up Study (www.saxinstitute.org.au). The 45 and Up Study is managed by the Sax Institute in collaboration with major partner Cancer Council NSW and partners the Heart Foundation and the NSW Ministry of Health. We thank the many thousands of people participating in the 45 and Up Study. We also acknowledge the support of the NSW Centre for Health Record Linkage (CHeReL; http://www.cherel.org.au ).

• International Diabetes Federation
• Australian Institute of Health and Welfare
• Karuranga S , et al
• Huebschmann AG ,
• Huxley RR ,
• Kohrt WM , et al
• Stratton IM ,
• Kohner EM ,
• Aldington SJ , et al
• Roeters-van Lennep JE ,
• Lemmers RFH , et al
• de Jong M ,
• Woodward M ,
• Morton JI ,
• Lazzarini PA ,
• Polkinghorne KR , et al
• Bleicher K ,
• Summerhayes R ,
• Baynes S , et al
• Gibson AA ,
• Gale J , et al
• Australian Bureau of Statistics
• Sterne JAC ,
• Carlin JB , et al
• Angoulvant D ,
• Ducluzeau PH ,
• Renoult-Pierre P , et al
• Malmborg M ,
• Schmiegelow MDS ,
• Nørgaard CH , et al
• Walli-Attaei M ,
• Rosengren A , et al
• Joshy G , et al
• Peters SAE ,
• Muntner P ,
• Sep SJS , et al
• Galdas PM ,
• Cheater F ,
• Randhawa G , et al
• O’Kelly AC ,
• Michos ED ,
• Shufelt CL , et al
• Leening MJG ,
• Ferket BS ,
• Steyerberg EW , et al
• Sun J , et al
• Retnakaran R ,
• Thorne KI , et al
• Xu P , et al
• Hoffmeister L ,
• Román R , et al
• Semeraro F ,
• Parrinello G ,
• Cancarini A , et al
• Kautzky-Willer A ,
• Leutner M ,
• Harreiter J
• G Duarte F ,
• da Silva Moreira S ,
• Almeida M da CC , et al
• Polkinghorne KR ,
• Cass A , et al
• Humphries J , et al
• Komorita Y ,
• Peters SAE , et al

Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Contributors AAG, NN and SC conceived the idea for the study. All authors contributed intellectual content to the study design and interpretation of the findings. FS, JH, and JG conducted the analysis. AAG, EC, NN and JG drafted the manuscript and all authors provided edits and comments. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. All authors have approved the final article. AAG is the guarantor of this work.

Funding This work was supported by an Australian Diabetes Society Servier Research Grant, an Australian Diabetes Research Trust Grant and a NSW Health EMCR CVD Capacity Grant. AAG is supported by an Australian National Health and Medical Research Council Emerging Leader 1 Investigator Grant (APP1173784). AAG is also grateful to the NSW Cardiovascular Research Network for a Professional Development Award. NN is supported by Financial Markets Foundation for Children and by an Australian National Health and Medical Research Council Leadership 2 Investigator Grant (APP1197940). Mark Gillies is supported by an NHMRC Level 3 Investigator grant. Clara K Chow is supported by an NHMRC Leadership Investigator grant (APP1195326). Funding bodies were not involved in the study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Hypertension in Diabetes: An Update of Basic Mechanisms and Clinical Disease

Guanghong jia.

Department of Medicine-Endocrinology (G.J., J.R.S.), University of Missouri School of Medicine, Columbia.

Dalton Cardiovascular Research Center, University of Missouri, Columbia (G.J., J.R.S.).

James R. Sowers

Department of Medical Pharmacology and Physiology (J.R.S.), University of Missouri School of Medicine, Columbia.

Epidemiological studies have documented that insulin resistance and diabetes not only constitute metabolic abnormalities but also predispose to hypertension, vascular stiffness, and associated cardiovascular disease. Meanwhile, excessive arterial stiffness and impaired vasorelaxation, in turn, contribute to worsening insulin resistance and the development of diabetes. Molecular mechanisms promoting hypertension in diabetes include inappropriate activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, mitochondria dysfunction, excessive oxidative stress, and systemic inflammation. This review highlights recent studies which have uncovered new underlying mechanisms for the increased propensity for the development of hypertension in association with diabetes. These include enhanced activation of epithelial sodium channels, alterations in extracellular vesicles and their microRNAs, abnormal gut microbiota, and increased renal sodium-glucose cotransporter activity, which collectively predispose to hypertension in association with diabetes. This review also covers socioeconomic factors and currently recommended blood pressure targets and related treatment strategies in diabetic patients with hypertension.

Individuals with metabolic disorders, including insulin resistance, diabetes, and cardiometabolic syndrome, have a high prevalence of hypertension, a powerful risk factor for cardiovascular disease (CVD), kidney disease, stroke, and microvascular complications. 1 Not only is hypertension more common in patients with diabetes but also diabetes is also more common in hypertensives than in the general population. Therefore, there is a chicken-egg relationship between hypertension and diabetes (Figure ​ (Figure1 1 ). 2 To this point, hypertension occurs in 50% to 80% of patients with type 2 diabetes, who make up over 90% of the diabetic population versus ≈30% of patients with type 1 diabetes who develop hypertension. 3 , 4 That hypertension is especially common in type 2 diabetes suggests that insulin resistance may play an important role in the pathogenesis of this hypertension. Additionally, a prospective cohort study of 12 550 adults 45 to 64 years old found that type 2 diabetes was almost 2.5 times as likely to develop in patients with hypertension as in those with normal blood pressure. 3 – 5 Data from the ARIC study (Atherosclerosis Risk in Communities), the CARDIA study (Coronary Artery Risk Development in Young Adults), and the Framingham Heart Study offspring cohort in 10 893 participants showed that hypertension is a risk factor for diabetes and often precedes the development of diabetes. 4 Our understanding of mechanisms by which insulin resistance contributes to the development of hypertension in type 2 diabetes is evolving. This review focuses on basic mechanisms and environmental factors involved in promoting hypertension in diabetes, especially type 2 diabetes. It also discusses approaches for the prevention and contemporary strategies to lessen CVD and renal disease in patients with diabetes with hypertension.

Interaction of insulin resistance, diabetes, and hypertension in metabolic syndrome. Inappropriate activation of the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system (SNS), mitochondria dysfunction, oxidative stress, inflammation, abnormal release of extracellular vesicles (EVs) and related microRNAs (miRNAs), as well as dysregulation of gut microbiota, GLP-1 (glucagon-like peptide) and SGLT2 (sodium-glucose cotransporter 2), are involved in insulin resistance and type 2 diabetes-induced vascular stiffness and hypertension. CV indicates cardiovascular; EnNaC, endothelial epithelial sodium channel; and NO, nitric oxide.

Epidemiology of Insulin Resistance and Diabetes-Related Hypertension

There are fundamental differences in type 1 and type 2 diabetes-related hypertension. Although type 1 diabetes with insulin deficiency tends to appear in childhood or adolescence, type 2 diabetes is characterized by insulin resistance and usually takes years to develop. About 80% of type 1 diabetic individuals present with microalbuminuria and have diabetic nephropathy that typically plays a major role in the development of their hypertension. 5 Resistant hypertension is more common in these patients than nondiabetic hypertensive individuals, 6 , 7 and this resistance is associated with a higher risk of diabetic nephropathy progression. 5

Patients with the much more common type 2 diabetes often present with coexisting hypertension and diabetes in the absence of clinical renal disease. Epidemiological studies indicate that there is a very high incidence of hypertension, including increases in resistant hypertension and associated CVD in patients with type 2 diabetes. 1 In the Framingham Heart Study, type 2 diabetes was associated with a 2- to 4-fold increased risk of hypertension, peripheral arterial disease, and myocardial infarction. 8 A recent analysis of the Framingham data further showed that the population with hypertension at the time of diabetes diagnosis had higher rates of mortality for all causes and CVD events compared with normotensive persons with diabetes. 9 These data support a strong relationship between coexistent type 2 diabetes and hypertension and associated increases in CVD.

Our understanding of the role of insulin resistance in the development of elevated blood pressures is evolving. A clinic observation in 1966 from 19 patients without diabetes with essential hypertension found that these patients had significantly higher plasma insulin concentrations than a normotensive control group. 10 Approximately 50% of patients with hypertension are insulin resistant, and this defect in insulin metabolic actions increasingly appears to contribute to development of hypertension and associated CVD. 11 The Framingham Offspring Study investigated the relationship between insulin sensitivity and the 4-year incidence of hypertension and blood pressure progression in 1933 nonhypertensive participants. This analysis showed that the association between insulin sensitivity/resistance and hypertension was attenuated but remained statistically significant after adjustment for increases in body mass index. 12 These findings suggest that obesity and insulin resistance are inextricably linked in promotion of hypertension including that in type 2 diabetes.

Gender, Race, Environmental, and Socioeconomic Factors Impacting Persons With Diabetes and Hypertension

Gender and race impact the relationship between insulin resistance and diabetes-related hypertension. 13 In nondiabetic individuals the prevalence of hypertension is higher in men as compared to women until the age of 64 years when the gap closes and prevalence in females reaches that of males. 9 Interestingly, women with impaired glucose tolerance and diabetes have a higher incidence of hypertension than men with equivalent impairment in glucose homeostasis. 14 Additionally, the prevalence of hypertension is different within various ethnic groups. 15 , 16 In Black populations, the incidence of hypertension is higher when compared with White people between the age of 45 and 75 years. 15 Recent data from the Jackson Heart Study further support that greater insulin resistance is associated with a greater risk of incident hypertension and progression of blood pressure elevation among Black participants. These findings suggest that increased insulin resistance may play an important role in the high prevalence of hypertension as well diabetes in Black populations.

Socioeconomic and environmental factors likely have a substantial impact on the development of hypertension in persons with obesity, insulin resistance, and diabetes. 16 – 18 For example, foods that are traditionally considered healthy and promoted as components of the dietary approach to stop hypertension diet 18 are often unavailable to people living in disadvantaged communities of color due to either lack of access or reasons of affordability. 19 Instead, they become consumers of cheap high salt and high caloric foods, leading to obesity, diabetes, and hypertension. 18 , 19 Furthermore, lack of safe outdoor spaces discourages exercise, and exposure to environmental air and water pollution also predispose to insulin resistance, diabetes, and hypertension. 19 These social and environmental disparities likely help explain the poorer outcomes with coronavirus disease 2019 (COVID-19) infections that are seen in minorities as well as those with both diabetes and hypertension. 19

Obesity Contributes to Insulin Resistance and Diabetes-Related Hypertension

Studies in primary care settings found that 60% to 76% of overweight or obese patients have hypertension, 20 suggesting that there is a positive relationship between high blood pressure and indices of obesity. The high incidence of overweight/obesity is closely related to overconsumption of inexpensive and palatable high fat and high refined carbohydrate diets. 21 Indeed, a positive association even exists between a progressive increase in body mass index within the normal and overweight range and the risk of hypertension and CVD. 22 Related to this, data from the Framingham Heart Study showed that excess body weight accounted for appropriate 26% of cases of hypertension in men and 28% in women. 23 In addition, obese children were at ≈3-fold higher risk for hypertension than nonobese children. 24 Increased visceral adipose tissue and abdominal subcutaneous adipose tissue are especially associated with obesity-related metabolic and vascular complications. 25 For instance, in a study of 382 diabetic individuals, higher visceral adipose tissue, independent of body mass index, was associated with a higher prevalence of dyslipidemia and increased the risk for hypertension, atherosclerosis, and CVD. 26 Mechanistically, proinflammatory adipokines, including leptin and aldosterone, released from visceral fat may promote systemic and vascular insulin resistance and inflammation, impaired relaxation and vascular stiffness and development of hypertension. 27

Excessive Arterial Stiffness Is Related to Insulin Resistance and Diabetes-Induced Hypertension

While hypertension induces vascular remodeling and can lead to arterial stiffness, insulin resistance and diabetes can also promote arterial stiffening and subsequent hypertension and CVD. An increase in the augmentation index, a measure of arterial stiffness, was independently associated with all-cause mortality and a composite end point of CVD and diabetes-related death in a prospective cohort of patients with type 1 diabetes, suggesting that arterial stiffness predicts both all-cause mortality and the composite end point of CVD and diabetes-related death in patients with type 1 diabetes. 28 Recent data also suggest that the hyperinsulinemia accompanying insulin resistance is an independent risk factor for arterial stiffening. 21 Another study investigated the relationships between arterial stiffness indexes and serum insulin and glucose tolerance measurements in a biracial population of 4701 men and women aged 45 to 64. Patients with borderline abnormal glucose intolerance or type 2 diabetes had stiffer arteries than their counterparts with normal glucose tolerance. 29 It was suggested that interactive effects of elevated glucose and insulin may have a synergistic impact on arterial stiffness and play an important role in the early pathophysiology of hypertension and CVD in patients with type 2 diabetes. 30

Mechanisms in Insulin Resistance/Diabetes-Induced Hypertension

While diabetic nephropathy is the major driving factor for hypertension in type 1 diabetes, inappropriate activation of the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system (SNS), mitochondria dysfunction, oxidative stress, inflammation, abnormal release of extracellular vesicles (EVs), and related microRNAs (miRs), as well as dysregulation of gut microbiota and renal SGLT2 (sodium-glucose cotransporter 2), are emerging as underlying mechanisms in the development of insulin resistance and type 2 diabetes-induced hypertension (Figure ​ (Figure1 1 ).

Inappropriate Activation of RAAS and SNS

Activation of the systemic and tissue RAAS in states of insulin resistance, obesity, and associated hyperglycemia plays an important role in the development of hypertension. In vivo and in vitro studies have shown that insulin resistance and hyperglycemia induce systemic RAAS activation in association with increased vascular resistance and arterial pressure. 31 Inhibition of the RAAS with angiotensin-converting enzyme inhibitors, AT-1R (angiotensin type 1 receptor) blockers, and MR (mineralocorticoid receptor) antagonists reduce the incidence of hypertension in patients with diabetes. 32 , 33 Inappropriate activation of the RAAS observed in insulin resistance and diabetes is likely to impair insulin signaling which contributes to development of hypertension (Figure ​ (Figure2). 2 ). To this point, angiotensin II and aldosterone increase serine phosphorylation of insulin receptor substrate proteins, leading to decreased activity of insulin downstream signaling pathways in PI3K (phosphatidylinositide 3-kinase) and Akt (protein kinase B), which leads to reduced eNOS (endothelial nitric oxide synthase) activation by insulin and reduced nitric oxide (NO) mediated vasodilation. 1

Proposed molecular mechanism in activated renin-angiotensin-aldosterone system (RAAS) and insulin resistance-related hypertension. Akt indicates protein kinase B; AT-1R, angiotensin type 1 receptor; EnNaC, endothelial epithelial sodium channel; eNOS, endothelial nitric oxide synthase; ET-1, endothelin-1; MR, mineralocorticoid receptor; NO, nitric oxide; PI3K, phosphatidylinositide 3-kinase; and SGK-1, serum and glucocorticoid regulated kinase 1.

The hyperinsulinemia associated with metabolic insulin resistance stimulates production of the vasoconstrictor ET-1 (endothelin-1) via a mitogen-activated protein kinase-dependent signaling pathway (Figure ​ (Figure2). 2 ). This contributes to vascular insulin resistance, excessive arterial stiffening, and ultimately hypertension. 1 Recently, we found that hyperinsulinemia and aldosterone increase activity of the endothelial epithelial sodium channel which leads to arterial stiffness and hypertension. 21 Related to this, both angiotensin II and aldosterone enhance SGK-1 (serum and glucocorticoid regulated kinase 1) to induce endothelial epithelial sodium channel activation leading to reduction of endothelium eNOS activity, NO production, and the development of arterial stiffening (Figure ​ (Figure2 2 ).

Inappropriate activation of the SNS is often a feature of hypertension associated with obesity and insulin resistance. In this regard, overactivity of the SNS induced, in part, by insulin resistance and hyperinsulinemia has been documented in both animal models 34 , 35 and hypertensive individuals. 36 , 37 Moreover, the presence of hypertension appears to further elevate the SNS responses to insulin. 37 Increased sympathetic tone induces stimulation of β-adrenergic receptors which promotes insulin resistance through the activation of serine/threonine kinases which blunts insulin metabolic signaling. 38 Elevated blood pressure in response to hyperinsulinemia may also be mediated by changes in baroreflex sensitivity 39 and by central nervous system hypertension promoting effects of hyperinsulinemia. 34

Role of Mitochondria Dysfunction and Excessive Oxidative Stress

The metabolic actions of insulin are dependent on normal mitochondria function, which plays a key role in energy homeostasis by metabolizing nutrients and producing ATP and cellular energy generation. Insulin resistance and diabetes are associated with mitochondrial dysfunction, characterized by reduced energy production. 40 For instance, defects in mitochondria biogenesis and dynamics in endothelial cells have detrimental consequences on their bioenergetic supply and these abnormalities contribute to endothelial dysfunction and hypertension. 40

Mitochondrial are also a major source of intracellular reactive oxygen species (ROS), and increased ROS are involved in the pathogenesis of insulin resistance, diabetes, and hypertension. 40 Related to this, almost all vascular cells, including endothelial cells, vascular smooth muscle cells, and adventitial cells, possess the ability to generate ROS. In diabetes excessive ROS production can induce damage to DNA, proteins, and lipids, leading to mitochondrial dysfunction. NADPH oxidases are also an important source of excess ROS production in the vasculature in insulin resistance and hypertension. 41 Insulin resistance and diabetes are associated with increased activation of vascular NADPH oxidases thereby inducing excessive ROS production which causes an imbalance between endothelium-derived relaxing factors and endothelium-derived contractile factors leading to associated increases in vascular tone. Excessive ROS reduce NO production and increase destruction of NO leading to diminished bioavailable NO, which contributes to arterial stiffness and hypertension. Therefore, mitochondrial dysfunction and oxidative stress are likely important instigators of hypertension in states of insulin resistance and diabetes.

Inflammation

Systemic and cardiovascular inflammation are important contributors to the development of insulin resistance, diabetes, and hypertension. For instance, enhanced TLR (Toll-like receptor)-mediated proinflammatory signaling induces activation of nuclear factor kappa B and c-Jun N-terminal kinase that promote release of inflammatory cytokines, including tumor necrosis factor alpha, interleukin-6, vascular cell adhesion molecular 1, and monocyte chemoattractant protein-1. 1 These proinflammatory cytokines can impair insulin metabolic signaling and reduce insulin-mediated NO production, leading to arterial stiffness and hypertension. Furthermore, systemic and tissue inflammation are strongly related to visceral obesity. Typically, adipose tissue is composed of a variety of immune cells, such as macrophages, dendritic cells, B cells, T lymphocytes, mast cells, and neutrophils. 42 To this point, macrophages are an important driver of adipose tissue inflammation and associated metabolic disorders and hypertension.

Perivascular adipose tissue, a special local deposit of adipose tissue surrounding blood vessels, provides mechanical protection and modulates blood vessel tone. 42 In the setting of obesity, insulin resistance, and type 2 diabetes, increased NADPH oxidase-derived ROS and proinflammatory adipokines from perivascular adipose tissue contribute to vascular insulin resistance and impaired relaxation. 42 Data from the Framingham Offspring and Third Generation cohorts support the notion that altered perivascular adipose tissue volume is linked with higher thoracic and abdominal aortic dimensions and increased stiffness even after adjusting for sex, age, and CVD risk factors, including body mass index and visceral adipose tissue volume. 43

Abnormal Release of EVs and Their miRs Contribute to Insulin Resistance, Diabetes, and Hypertension

There is emerging evidence that diabetes and hypertension are associated with abnormal release of EVs, which normally mediate cell-to-cell communications. 44 For instance, the patients with hypertension often have increased circulating endothelial and platelet EVs, 45 , 46 as well as urinary endothelial microparticles. 47 Moreover, the intraperitoneal of plasma exosomes from spontaneously hypertensive rats induced an increases of systolic blood pressure in normotensive Wistar-Kyoto rats, 48 suggesting that abnormal circulating and urinary EVs may be biomarkers associated with the pathogenesis and progression of hypertension. Importantly, EVs contain various molecular constituents, including proteins, mRNA, and miR, which can be transferred from one cell to another via membrane vesicle trafficking, thereby playing a role in the pathogenesis of hypertension and related CVD. 46 To this point, the 3 subtypes of EVs are exosomes, microvesicles, and apoptotic bodies according to their different cellular origins. Recent data suggest that exosomal miRs are involved in activation of the RAAS, oxidative stress, and inflammation, and these abnormalities may induce vascular dysfunction and hypertension. 49 , 50 Indeed, increased levels of miR-223, miR-320, miR-501, miR504, and miR1 and decreased levels of miR-16, miR-133, miR-492, and miR-373 have been related to insulin resistance and diabetes-related hypertension. 51 These data suggest that exosomal miRs are important biomarkers in patients with insulin resistance, diabetes, and hypertension.

Gut Microbiota

Emerging evidence indicates that gut microbiota changes contribute to insulin resistance, diabetes, hypertension, and CVD. In this regard, the gut flora has about 100 trillion micro-organism species, and these bacteria modulate normal metabolic activities and physiological functions. For instance, the cecal bacteria from the phylum Bacteroidetes that are regarded as good bacteria are reduced in obesity, and this reduction is accompanied by a proportional increase in bad bacteria with the phylum Firmicutes . 52 These deleterious changes in gut bacteria have also been observed in insulin resistant ob/ob 53 and db/db 54 type 2 diabetic mice. A recent study provides evidence that gut microbiota may have a causal role in insulin resistance and type 2 diabetes. 55 In that study, mice receiving a transplant from an obese twin donor developed increased adiposity compared with those receiving transplants from lean twin donors. Moreover, cohousing mice harboring an obese twin’s microbiota with mice containing the lean co-twin’s microbiota prevented the development of increased body mass and obesity-associated metabolic phenotypes in obese cage mates. 55 Furthermore, oral administration of good bacteria improves the gut barrier dysfunction and metabolic disorders in obese and type 2 diabetic mice, 56 suggesting that transmissibility of intestinal microbes and the metabolic phenotype are closely linked and that it is possible to impact obesity, insulin resistance, and associated hypertension by modulating the composition of the microbiota. To this point, one study showed that gut microbiota can produce norepinephrine, thereby promoting vascular constriction and hypertension in the insulin resistant state. 57 Moreover, Enterococcus faecalis directly contributes to hypertension and renal injury by interfering lipid metabolism. 58 Thus, alterations of gut microbiota provide a new mechanism in exploring insulin resistance and diabetes-induced hypertension.

Contribution of SGLT2 to Insulin Resistance, Diabetes, and Hypertension

Glucose homeostasis is impaired in individuals with insulin resistant associated diabetes, in part, as a consequence of an increased capacity to absorb renal glucose and via proximal tubule SGLT2, which is responsible for proximal tubule reabsorption of about 90% of filtered glucose. 59 The glucose reabsorption in the kidney normally has a maximal threshold corresponding to glucose plasma levels. However, individuals with insulin resistance and type 2 diabetes have a higher threshold due to the upregulation of SGLT2 that increases proximal tubule glucose and sodium absorption, thereby contributing to hypertension and related CVD. 59 Recent large, randomized, placebo-controlled clinical trials have shown that treatment with SGLT2 inhibitors significantly reduces hypertension and CVD events and prevent the progression of renal dysfunction in individuals with diabetes. 60

Recent Therapy in Patients With Diabetes and Hypertension

The ADA 2020 Clinical Practice Guidelines suggest that nonpharmacological measures, such as weight loss, regular physical activity, and limitation of fat and total energy intake, should always be part of any blood pressure-lowering treatment as it is the cornerstone of preventive therapy in patients with diabetes with hypertension. 61 RAAS blocker may slow progression to kidney failure and CVD, and thus angiotensin II–converting enzyme inhibitors and angiotensin II receptor blockers are appropriate for initial therapy for managing hypertension in patients with diabetes. Many patients with diabetes with hypertension manifest a resistant form of hypertension requiring the addition of MR antagonists to their combination therapy. 62 , 63 This includes nonsteroidal MR antagonists (ie, Fineronone) which has recently been shown to reduce CVD events as well as reducing advancement of renal disease in patients with diabetes and kidney disease. 64 , 65

In recent years, newer antihyperglycemic medications, such as GLP-1 (glucagon-like peptide 1) agonists and SGLT2 inhibitors, have been found to lower blood pressure as well improving glucose metabolism. For instance, exenatide, an analog of GLP-1, was evaluated in the EXSCEL trial (Exenatide Study of Cardiovascular Event Lowering) clinical trial in patients with diabetes for 5 years, and exenatide reduced systolic blood pressure and low-density lipoprotein cholesterol. 66 Consistent with these data, Semaglutide, injected once-weekly at 2 doses (0.5 or 1.0 mg) for 104 weeks in the SUSTAIN-6 (Trial to Evaluate Cardiovascular and Other Long-Term Outcomes With Semaglutide in Subjects With Type 2 Diabetes), reduced blood pressure, nonfatal myocardial infarction, and stroke in patients with type 2 diabetes at high CVD risk. 67

SGLT2 inhibition induces glycosuria and promotes natriuresis resulting in reductions in blood pressure. The EMPA-REG OUTCOME study (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients) showed that empagliflozin reduced blood pressure and major adverse CVD events, death, and hospitalization for heart failure. 68 In the DECLARE-TIMI 58 trial (Dapagliflozin Effect on Cardiovascular Events-Thrombolysis in Myocardial Infarction 58) in patients with type 2 diabetes and CVD, dapagliflozin treatment reduced blood pressure but failed to reduce major adverse CVD events. 69 Recent evidence from the CREDENCE trial (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) further found that canagliflozin reduced blood pressure and slowed diabetic nephropathy progression. 60 Therefore, both incretin-based and SGLT2 inhibitor therapy are beneficial in patients with diabetes with hypertension.

Summary and Future Perspectives

Insulin resistance and diabetes increase the prevalence of hypertension. The underlying molecular and cellular mechanisms include inappropriate activation of the RAAS and SNS, enhanced renal and endothelial sodium channel activation, mitochondria dysfunction, oxidative stress, inflammation, abnormal exosomal miRs, abnormal gut microbiota, as well as increased renal SGLT2 activity. Treatment strategies in patients with hypertension with diabetes include lifestyle interventions and the use of with pharmacological therapy, including RAAS blockade. Meanwhile, these patients may also benefit from treatment with GLP-1 agonists and SGLT2 inhibitors. However, there is a need for randomized and multiple-center clinical trials to better define the role of these medications in patients with diabetes with hypertension. Further research should be directed improving our understanding the pathophysiological role of insulin resistance, diabetes, and related metabolic abnormalities in the pathogenesis of hypertension.

Sources of Funding

G. Jia received relevant funding from the National Institute of Diabetes and Digestive and Kidney Diseases (DK124329) and an American Diabetes Association Innovative Basic Science Award (1-17-IBS-201). J.R. Sowers received relevant funding from the National Institutes of Health (R01 HL73101-01A and R01 HL107910-01).

Disclosures

Nonstandard abbreviations and acronyms.

For Sources of Funding and Disclosures, see page 1203.

A newsletter briefing on the health-care policy debate in Washington.

Covid origins in spotlight, as feds cut funding to virus hunters

with research by McKenzie Beard

Welcome to Thursday. I’m Dan Diamond, a reporter at The Washington Post, where my colleagues are hiring for a transportation, medicine and energy editor. (To be clear, that’s a single position — the Neapolitan sandwich of editing jobs.) Send your tri-flavored résumés and other delicious tips to [email protected] . Not a subscriber? Sign up here .

Today’s edition: A key senator is pushing to expand dental coverage to millions of Americans. Overdose deaths dropped slightly last year, but experts say the toll remains unacceptably high. But first …

The EcoHealth saga continues

What did the deputy director of the National Institutes of Health know, and when did he know it?

Top NIH official Lawrence Tabak is set to face off this morning with the House panel probing the coronavirus response. Expect lawmakers to focus on the agency’s oversight and funding of EcoHealth Alliance , a nonprofit organization that worked with the Wuhan Institute of Virology before the pandemic.

EcoHealth was thrown back into the spotlight Wednesday, after the Department of Health and Human Services said it was suspending funding to the organization and moving to debar the New York-based nonprofit from receiving additional funds, citing evidence EcoHealth had failed to monitor and report on risky virus experiments in China.

EcoHealth has said it is appealing the decision, but the news was hailed on Capitol Hill. Both Republicans and Democrats had called on HHS to review the organization’s funding and its NIH grants; GOP leaders have gone further and called for a criminal probe.

“Our investigation into EcoHealth and Dr. Daszak’s actions is not over,” Rep. Brad Wenstrup (R-Ohio), who chairs the House Select Subcommittee on the Coronavirus Pandemic , plans to say to Tabak today, in remarks shared with The Health 202. “This issue has highlighted broader concerns with the NIH — especially that it is up to the grantee to oversee themselves. That is a recipe for waste, fraud, abuse and deception.”

Years of questions

EcoHealth has been at the center of questions about SARS-CoV-2 ’s origins since the pandemic’s earliest days, given the organization’s ties to Wuhan, China — the epicenter of the outbreak — and its work to research and experiment with coronaviruses. Then-President Donald Trump publicly said his administration was looking into EcoHealth’s work, and Tabak was among the officials in April 2020 who moved to abruptly halt NIH funding to the organization. (It was later restored.)

The House coronavirus panel also recently grilled Peter Daszak , EcoHealth’s president, on his conflicting statements and outstanding questions, including why his organization waited nearly two years to submit a required report about the results of its research and activities leading up to the pandemic.

EcoHealth has repeatedly denied accusations that it played any role in the pandemic, and its defenders have said it’s been wrongly scapegoated. There’s no existing evidence EcoHealth, the Wuhan Institute of Virology or another organization had SARS-CoV-2 in its possession before the pandemic.

Federal and congressional officials also cautioned that the HHS decision to cut funding to EcoHealth shouldn’t be interpreted as a smoking gun about the virus’s origins or a possible lab leak. Officials on Wednesday told me the theory that the pandemic began naturally — when a virus spread from animals to humans — continues to be favored by several government agencies and many scientists.

But at minimum, federal officials had grown increasingly uneasy about EcoHealth’s work and safeguards, they said. “HHS wanted to be out of the EcoHealth business,” one official told me.

What Tabak will be pushed on today

Republicans’ line of attack was previewed in a letter to NIH last week, in which Wenstrup laid out Daszak’s claims and compared them with other officials’ statements under oath.

“The Select Subcommittee is eager to uncover the true sequence of events and has identified multiple occasions where Dr. Daszak directly contradicts NIH’s or NIAID’s assertions,” Wenstrup wrote. Republicans have hinted that they could refer Daszak to the Justice Department on perjury grounds.

Expect GOP lawmakers to probe Tabak’s conversations with Anthony S. Fauci , his longtime colleague at NIH and the center of persistent Republican attacks over his pandemic recommendations, his agency’s funding of EcoHealth and other issues. Fauci, who retired from government at the end of 2022, is set to testify in front of the panel in June.

Democrats, meanwhile, have tried to draw a line between what they characterized as bad actions by EcoHealth and Daszak, and the more sweeping charge that the organization helped spark the pandemic.

“While the Select Subcommittee’s probe has uncovered efforts by Dr. Peter Daszak to mislead his funders at the National Institutes of Health and the National Institute of Allergy and Infectious Diseases , it has not substantiated any allegations that federal grant funding for EcoHealth Alliance created the COVID-19 pandemic,” Rep. Raul Ruiz (D-Calif.), the top Democrat on the House coronavirus panel, plans to say in remarks today previewed with The Health 202.

Overdose deaths dropped slightly in 2023, but remain staggeringly high

Overdose deaths have surpassed 100,000 for the third consecutive year, a reminder that the nation remains mired in an intractable epidemic fueled by the potent street drug fentanyl, our colleague David Ovalle reports . 

By the numbers: An estimated 107,543 people died in 2023, a slight decrease from the previous year, according to provisional data from the CDC . Of these deaths, an estimated 74,702 were attributed to synthetic opioids such as fentanyl.

• The agency described it as the first annual decrease in deaths since 2018, although experts cautioned that the numbers could rise in ensuing years and that the toll remains unacceptably high.

The politics: The CDC yesterday pointed to the decrease as a sign that federal efforts to help prevent deaths and treat addiction in states are paying off. It could boost Biden as he seeks reelection and Republicans rip him over border security and the flow of fentanyl synthesized by Mexican criminal groups.

On the Hill

Sanders mounts another push for expanded dental coverage.

On tap today: The Senate Health, Education, Labor and Pensions Committee will hold a hearing on dental care accessibility and affordability, a topic long championed by Chair Bernie Sanders (I-Vt.). 

Sanders is also set to introduce a comprehensive bill aimed at extending dental insurance to all Medicare, Medicaid and Veterans Affairs beneficiaries. The legislation, outlined in a one-pager shared with The Health 202, also seeks to establish new access points for dental services, enhance the oral health workforce, improve education and authorize additional federal funding for oral health research. 

We’re expecting the independent firebrand to draw from his constituents’ experiences in navigating dental care challenges during the hearing, following a request this month that garnered over 1,000 responses, as noted by a source familiar with the senator's plans.

Why it matters: An estimated 68.5 million U.S. adults lacked dental insurance in 2023, according to the nonprofit CareQuest Institute for Oral Health . That’s more than 2.5 times the roughly 26 million Americans of all ages who lack health insurance .

The Centers for Disease Control and Prevention estimates that untreated dental disease costs the United States more than $45 billion in lost productivity annually, and it’s linked to a long list of serious health problems, including diabetes and heart disease.

Sen. Bernie Sanders (I-Vt.):

Today in America: - Over 40% of kids have tooth decay by the time they reach kindergarten - 20% of seniors are missing all their natural teeth and can't afford a full set of dentures - Nearly 50% of adults have some form of periodontal disease Let’s get our priorities straight. — Bernie Sanders (@SenSanders) May 15, 2024

In other news from the upper chamber …

New this a.m.: Sens. Edward J. Markey (D-Mass.) and Sanders are urging HHS to be prepared to offer support and regulatory flexibility to prevent any loss of care after Steward Health Care ’s bankruptcy filing, according to a letter sent to Secretary Xavier Becerra that was shared with The Health 202.  

The Senate rejected a GOP-led attempt to claw back billions of dollars in unspent coronavirus relief funds in a party-line vote yesterday. President Biden had already pledged to veto the bill, safeguarding Treasury Department guidance that gave states and municipalities more time to spend the money. 

And across the Capitol …

On our radar: The House Energy and Commerce Committee unveiled legislation to extend pandemic-era Medicare telehealth flexibilities for the next two years, which is up for a consideration today during a health subcommittee mark up . Among the other 22 bills on the agenda are proposals that seek to remove barriers for living organ donors, preserve access to treatments for rare disease patients and tackle fraud in Medicare and Medicaid. 

The House passed a bipartisan bill that would direct the Federal Aviation Administration to update aircraft emergency medical kits to include overdose reversal medication. It now heads to Biden’s desk. 

The House Committee on Oversight and Accountability voted to advance a bipartisan bill that would prohibit U.S. businesses that receive federal funding from purchasing equipment or contracting services from a list of designated foreign “companies of concern,” currently all of which are Chinese-owned biotechnology firms. 

Rep. Brad Wenstrup (R-Ohio):

My bill, the BIOSECURE Act, was reported favorably out of @GOPoversight today, the first in what I hope will be a multi-step approach to fortifying U.S. national health security and ending our dependence on foreign adversaries, like China, for genomic testing or basic… — Rep. Brad Wenstrup (@RepBradWenstrup) May 15, 2024

In other health news

• More self-collection test kit news. Yesterday, we told you about the Food and Drug Administration moving to expand screening for potentially lethal cervical cancer by allowing women to collect test samples themselves. In addition to the test by Becton, Dickinson and Company , the FDA also signed off on self-collection for an HPV test manufactured by Roche , our colleague Rachel Roubein writes. 
• The Centers for Medicare and Medicaid Services has abandoned its proposal to revise how drugmakers calculate the “best price” they must offer Medicaid, saying it will gather additional information before proceeding with any changes. 
• A first-of-its-kind service program will train hundreds of young adults to help their peers access mental health care and other support . The Youth Mental Health Corps is set to launch in Colorado, Michigan, Minnesota and Texas this fall, Maya Goldman reports for Axios . 

Health reads

Months after Maui fires, residents report troubling health problems (By Brianna Sacks | The Washington Post)

Most states receive D’s, F’s in maternal mental health report card (By Alejandra O’connell-Domenech | The Hill)

North Carolina lawmakers push bill to ban most public mask wearing, citing crime (By Makiya Seminera | The Associated Press)

Thanks for reading! See you tomorrow.