Significant challenges remain to achieve risk reduction targets for cardiovascular secondary prevention and diabetes

Objective: To examine population-level evidence treatment gaps for cardiovascular risk among rural patients with existing cardiovascular disease or diabetes.

Methods: Three population surveys were undertaken in the Greater Green Triangle region of southeastern Australia 2004-2006. Adults aged 25-84 yrs were randomly selected using age/sex stratified electoral role samples. A representative 1690 participants were recruited (48% participation rate). Anthropometric, clinical and self-administered questionnaire chronic disease risk data were collected in accordance with the WHO MONICA protocol. Detailed investigation of cardiovascular and diabetes history, key cardiovascular risk factors, medication use and health behaviours were included.

Results: After adjusting for age and sex, an estimated 12% (sample n=272) of the population had one or more of coronary heart disease, stroke, or diabetes. Blood pressure was at target (<130/80 mmHg) for 26% of these individuals, and 61% were treated with antihypertensive medications. Lipid targets were achieved by 17% for total cholesterol (<4 mmol/L), 18% for LDL cholesterol (<2 mmol/L), 77% for HDL cholesterol (>1.0 mmol/L) and 44% for triglycerides (<1.5 mmol/L); overall 6% achieved all four lipid targets and 60% reported use of lipid-lowering therapy, including 51% overall using statins. Ten percent were current smokers, and four in every five patients (82%) had suboptimal BMI (outside the range 18.5 - 25.0).

Conclusions: All participants with uncontrolled blood pressure and most with uncontrolled lipids should be taking medications. The magnitude of evidence treatment gaps suggests existing models of care need fundamental reform and renewed focus on prevention.

Research and diabetes nursing. Part 2 : process of critical review

This article is the second in a six-part series addressing research and the DSN. Crirical review is a key aspect of research and evidencebased care and, therefore, of clinical and professional practice. Critical review is an analytical and reflective process that involves judging the quality of research publicarions and their relevance to practice. This article oudines key aspects of how to review publications and conference presentations, how critical review applies to clinical care, and how this process om help develop writing and critical thinking skills. Also addressed are the general aspects of critical review, and a list of further reading and useful websites is provided. Specific considerations for particular research methods such as quantitative, qualitative, evaluation studies and audits will be addressed in later articles in the series.

Prevalence of vitamin D insufficiency and risk factors for type 2 diabetes and cardiovascular disease among African migrant and refugee adults in Melbourne

Migration to industrialised countries poses a “double whammy” for type 2 diabetes among sub-Saharan African migrant and refugee adults. This population group has been found to be at an increased risk of obesity and type 2 diabetes, which may be further aggravated by inadequate vitamin D status. Thus, this study aimed to describe the demographics of vitamin D insufficiency, obesity, and risk factors for type 2 diabetes among sub-Saharan African migrants and refugees aged 20 years or older living in Melbourne, Australia (n=49). Data were obtained by a questionnaire, medical assessment, and fasting blood samples. The mean serum 25-hydroxyvitamin D level was 27.3 nmol/L (95% CI: 22.2, 32.4 nmol/L); with 25-hydroxyvitamin D levels <50 nmol/L occurring in 88% of participants. Participants displayed a cluster of risk factors for type 2 diabetes and cardiovascular disease: 62% were overweight or obese, 47% had insulin resistance (HOMA-IR ≥2), 25% had low density lipoprotein cholesterol levels ≥3.5 mmol/L, 24.5% had high density lipoprotein cholesterol levels ≤1.03 mmol/L, 34.6% had borderline or high levels of total cholesterol (≥5.2 mmol/L), 18.2% had borderline or high levels of triglyceride (≥1.7 mmol/L), and 16% had hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg). These findings suggest that sub-Saharan African migrants and refugees may be at risk of type 2 diabetes and atherosclerosis-related diseases such as ischemic heart disease, stroke, and peripheral vascular disease. Well-designed vitamin D interventions that incorporate lifestyle changes are urgently needed in this sub-population.

Research and diabetes nursing. Part 6: writing a research article

Publishing research findings is a key component of the research process. The purpose of this article, the last of the research and diabetes nursing series, is to describe how to plan, focus, structure, and write an article and submit it to a journal for publication. It is essential that authors realise articles need to be carefully written and usually require several drafts before they are ready to submit. Understanding the submission and publication process, including peer review, can help new authors get their work published.

The spread and uptake of diabetes prevention programs around the world : a case study from Finland and Australia

Type 2 diabetes is a major public health issue in most countries around the world. Efficacy trials have demonstrated that lifestyle modification programs can significantly reduce the risk of type 2 diabetes. Two key challenges are: [1] to develop programs that are more feasible for “real world” implementation and [2] to extend the global reach of such programs, particularly to resource-poor countries where the burden of diabetes is substantial. This paper describes the development, implementation, and evaluation of such “real world” programs in Finland and Australia, the exchange between the two countries, and the wider uptake of such programs. Drawing on the lessons from these linked case studies, we discuss the implications for improving the “spread” of diabetes prevention programs by more effective uptake of lifestyle change programs and related strategies for more resource-poor countries and settings.

Predicting changes in lifestyle and clinical outcomes in preventing diabetes : The Greater Green Triangle Diabetes Prevention Project

Objectives : To analyse how psychosocial determinants of lifestyle changes targeted in the Greater Green Triangle Diabetes Prevention Project conducted in Southeast Australia in 2004–2006 predict changes in dietary behaviour and clinical risk factors.

Methods : A longitudinal pre-test and post-test study design was used. The group program was completed by 237 people at high risk of type 2 diabetes. Associations between changes in the variables were examined by structural equation modelling using a path model in which changes in psychological determinants for lifestyle predicted changes in dietary behaviours (fat and fibre intake), which subsequently predicted changes in waist circumference and other clinical outcomes. Standardised regression weights are presented, with β = ± 0.1 and β = ± 0.3 representing small and medium associations, respectively.

Results : Improvements in coping self-efficacy and planning predicted improvements in fat (β = − 0.15, p < 0.05 and β = − 0.32, p < 0.001, respectively) and fibre intake (β = 0.15, p < 0.05 and β = 0.23, p < 0.001, respectively) which in turn predicted improvements in waist circumference (β = 0.18, p < 0.01 and β = − 0.16, p < 0.05, respectively). Improvements in waist circumference predicted improvements in diastolic blood pressure (β = 0.13, p < 0.05), HDL (β = − 0.16, p < 0.05), triglycerides (β = 0.17, p < 0.01), and fasting glucose (β = 0.15, p < 0.05).

Conclusions : Psychological changes predicted behaviour changes, resulting in 12-month biophysical changes. The findings support the theoretical basis of the interventions.

Low serum 25-hydroxyvitamin D is associated with increased risk of the development of the metabolic syndrome at five years : results from a national, population-based prospective study (the Australian Diabetes, Obesity and Lifestyle Study : AusDiab)

Context: Serum 25-hydroxyvitamin D [25(OH)D] concentration has been inversely associated with the prevalence of metabolic syndrome (MetS), but the relationship between 25(OH)D and incident MetS remains unclear.

Objective: We evaluated the prospective association between 25(OH)D, MetS, and its components in a large population-based cohort of adults aged 25 yr or older.

Design: We used baseline (1999–2000) and 5-yr follow-up data of the Australian Diabetes, Obesity, and Lifestyle Study (AusDiab).

Participants: Of the 11,247 adults evaluated at baseline, 6,537 returned for follow-up. We studied those without MetS at baseline and with complete data (n = 4164; mean age 50 yr; 58% women; 92% Europids).

Outcome Measures: We report the associations between baseline 25(OH)D and 5-yr MetS incidence and its components, adjusted for age, sex, ethnicity, season, latitude, smoking, family history of type 2 diabetes, physical activity, education, kidney function, waist circumference (WC), and baseline MetS components.

Results: A total of 528 incident cases (12.7%) of MetS developed over 5 yr. Compared with those in the highest quintile of 25(OH)D (≥34 ng/ml), MetS risk was significantly higher in people with 25(OH)D in the first (<18 ng/ml) and second (18–23 ng/ml) quintiles; odds ratio (95% confidence interval) = 1.41 (1.02–1.95) and 1.74 (1.28–2.37), respectively. Serum 25(OH)D was inversely associated with 5-yr WC (P < 0.001), triglycerides (P < 0.01), fasting glucose (P < 0.01), and homeostasis model assessment for insulin resistance (P < 0.001) but not with 2-h plasma glucose (P = 0.29), high-density lipoprotein cholesterol (P = 0.70), or blood pressure (P = 0.46).

Conclusions: In Australian adults, lower 25(OH)D concentrations were associated with increased MetS risk and higher WC, serum triglyceride, fasting glucose, and insulin resistance at 5 yr. Vitamin D supplementation studies are required to establish whether the link between vitamin D deficiency and MetS is causal.

Five-year change in cardiovascular risk factors according to education level : the Australian diabetes, obesity and lifestyle (AusDiab) study

Background: Lower socioeconomic status (SES) is strongly associated with a higher prevalence of major cardiovascular risk factors, but few studies have examined changes in these risk factors over time according to SES. We aimed to determine whether SES is a predictor of the change in cardiovascular risk factor levels in a contemporary Australian adult cohort

Methods: Participants in the population-based AusDiab study aged 25+ years who attended both baseline and 5-year follow-up examinations (n=5 954) were categorised according to their level of education at baseline. Cardiovascular risk factor data at both time points were ascertained through questionnaire and physical measurement. Analysis was stratified by gender.

Results: The mean levels of systolic blood pressure, total cholesterol and the prevalence of smoking decreased between the two time points across all educational categories. Increases were also seen in mean BMI and the prevalence of diabetes. For blood pressure, the smallest decrease was seen among men with lower education (age-adjusted difference from higher education 2.8 mmHg, 95% CI 1.0 to 4.6). For total cholesterol, the decrease was greatest among women with lower education (age-adjusted difference from higher education 0.11 mmol/l, 95% CI 0.19 to 0.02). Among those "not at risk" at baseline for each risk factor, women with lower education were more likely than those with higher education to progress to being "at risk" for BMI (age-adjusted odds ratio 1.60, 95% CI 1.09 to 2.35).

Conclusion: Educational gradients narrowed for total cholesterol in women, but widened for systolic blood pressure in men and remained static for other risk factors. Lower education was also associated with an earlier onset of overweight or obesity in women. Given current socioeconomic gradients in risk factors levels, these findings suggest that social inequalities in CVD will persist and may even widen in the future.

Incidence of cardiovascular risk factors by education level 2000-2005 : the Australian diabetes, obesity and lifestyle (AusDiab) cohort study

Lower socioeconomic status (SES) is associated with a higher prevalence of major risk factors for cardiovascular disease (CVD). However, few longitudinal studies have examined the association between SES and CVD risk factors over time. We aimed to determine whether SES, using education as a proxy, is associated with the onset of CVD risk factors over 5 years in an Australian adult cohort study.

Participants in the Australian Diabetes, Obesity and Lifestyle study (AusDiab) study aged 25 years and over who attended both baseline and 5-year follow-up examinations (n=5 967) were categorised according to educational attainment. Cardiovascular risk factor data at both time points were ascertained through questionnaire and physical measurement.

Women with lower education had a greater risk of progressing from normal weight to overweight or obesity than those with higher education (age-adjusted OR 1.57, 95% CI 1.06-2.31). Both men and women with lower education were more likely to develop diabetes (age-adjusted OR from higher education 1.75, 95% CI 1.14-2.71 and 3.01, 95% CI 1.26-7.20, respectively). A lower level of education was associated with a greater number of risk factors accumulated over time in women (OR of progressing from having two or less risk factors at baseline to three or more at follow up, 2.04, 95% 1.32-3.14).

In this Australian population-based study, lower educational attainment was associated with an increased risk of developing both individual and total CVD risk factors over a 5-year period. These findings suggest that SES inequalities in CVD will persist into the future.